The Evaluation of Gastric Emptying Using the 13 C-Acetate Breath Test in Neurologically Impaired Patients - A Focus on the Stomach Function and Morphology

PURPOSE

We explored factors affecting gastric emptying in neurologically impaired (NI) patients using the 13C-acetate breath test.

METHODS

Twenty-four NI patients were classified by the presence of gastroesophageal reflux disease (GERD), which was treated by fundoplication plus gastrostomy, or the absence of GERD, which was treated by gastrostomy alone, along with gastric malposition involving cascade stomach and organoaxial gastric volvulus (OGV). Gastric emptying parameters (GEPs), which were the emptying half time (T 1/2 , minute), the lag phase time (T lag , minute), and the gastric emptying coefficient (GEC), were measured before and after surgery. We evaluated the relationship between GEPs and GERD, gastric malposition, and surgical intervention. All data were expressed as the median (interquartile range).

RESULTS

The T1/2 and GEC of patients with OGV were significantly worse than in those without OGV before surgery (T1/2 with OGV: 241.3 [154.9, 314.3] vs. T1/2 without OGV: 113.7 [105.2, 151.4], p = 0.01, GEC with OGV: 3.19 [2.46, 3.28] vs. GEC without OGV: 3.65 [3.24, 3.90], p = 0.02). GERD and cascade stomach were not associ ated with GEPs. The GEPs of all NI patients showed no significant difference between before and after surgery. The surgical change in T1/2 (ΔT 1/2 ) in the patients with OGV was significantly lower than in those without OGV (ΔT1/2 with OGV: -47.1 [-142.7, -22.1] vs. ΔT1/2 without OGV: -3.78 [-26.6, 12.0], p = 0.03).

CONCLUSION

Stomach malposition, such as OGV, seems to affect gastric emptying and may be improved by surgi cal intervention.

Tubular intestinal duplication extending from the stomach to the ileum associated with multiple intestinal atresia and situs inversus: a case report

BACKGROUND

Duplication of the alimentary tract can occur in any of its parts. For duodenal duplication, complete resection is particularly difficult when the ampulla of Vater is on the duplicated lumen and a deliberate management is necessary.

CASE PRESENTATION

A 0-day female baby was referred to our department due to abdominal distention. The X-ray examination showed dextrocardia and opacity of the liver on the left side and abdominal ultrasonogram revealed remarkable intestinal dilatation. Therefore, urgent laparotomy was performed on the day of birth. Complete situs inversus of the abdominal organs was revealed, and the origin of the jejunum was on the left side and was accompanied by tubular intestinal duplication. The origin of the duplicated intestine was at the pancreatic head's dorsal area. There were two points of type Шa atresia on the ileum. Therefore, we spared the duplicated intestine with a length of 3 cm to secure the passage of the biliary and pancreatic juices by a functional-side-to-side anastomosis with a 45-mm Endo-GIA™ camel load (Medtronic, Minneapolis, MN, USA). The ileum was transected at the distal side of the atresia point, and end-to-end jejunoileostomy was performed. Postoperative gastrointestinal series revealed remnants of the duplicated alimentary tract on the dorsal area of the stomach.

CONCLUSIONS

Identifying the position of the ampulla of Vater is crucial in the surgery of alimentary tract duplication with duodenal involvement. However, in the present case, it was difficult to identify whether the ampulla of Vater was on the true or duplicated lumen, and we had to spare the duplicated duodenum. Stapler anastomosis could be performed safely even in neonatal cases.

Influence of laparoscopy-aided gastrostomy on gastroesophageal reflux in neurologically impaired patients using multichannel intraluminal impedance pH measurements

BACKGROUND

Development of gastroesophageal reflux disease (GERD) after gastrostomy remains debatable. Therefore, this study aimed to evaluate whether laparoscopy-aided gastrostomy (LAG) influence on the occurrence of GERD in neurologically impaired (NI) patients. Furthermore, we investigated whether preoperatively excluding NI patients with GERD can reduce the number of patients requiring subsequent anti-reflux surgery (ARS) after LAG.

METHODS

This retrospective study included 35 NI patients (median age: 11.0; interquartile range 5.0-23.5 years) who underwent LAG according to our criterion from October 2012 to June 2020 and MII-pH before and after LAG. MII-pH parameters were compared in all patients and among three age groups between before and after LAG.

RESULTS

There were no significant differences in MII-pH parameters before and 1 year after LAG in all patients, and no patient underwent subsequent ARS. Only one paediatric patient with 64 number of reflux episodes before LAG required subsequent ARS 3 years after LAG.

CONCLUSIONS

Generally, LAG did not influence the postoperative GERD at 1 year after LAG, and our criteria could reduce the number of patients requiring subsequent ARS. However, paediatric NI patients with higher number of reflux episodes in preoperative MII-pH study may need careful long-term follow-up after LAG.

Negative-Pressure Pulmonary Edema After Difficult Endotracheal Intubation in a Patient with Juvenile Rheumatoid Arthritis Undergoing Spigelian Hernia Surgery: A Case Report

Patient: Male, 35-year-old

Final Diagnosis: Negative-pressure pulmonary edema

Symptoms: Difficult airway management

Medication:—

Clinical Procedure: —

Specialty: Anesthesiology • Critical Care Medicine

Current status of intractable pediatric gastroesophageal reflux disease in Japan: a nationwide survey

PURPOSE

A nationwide survey was conducted to investigate the current status of pediatric gastroesophageal reflux disease (GERD) in Japan, with special reference to the characteristics of intractable GERD.

METHODS

Data were collected using a questionnaire from facilities specializing in the treatment of pediatric GERD in Japan. Intractable GERD was defined as follows: I, no symptomatic improvement after 8 weeks of optimal medical treatment (OMT) plus fundoplication; II, no symptomatic improvement after 8 weeks of OMT and with no indications for fundoplication; and III, no symptomatic improvement after surgery without OMT.

RESULTS

We collected data from 3,463 pediatric patients with GERD from 91 institutions, and 81 satisfied the definition of intractable GERD. Additional clinical information was obtained from 56 patients, and 41 represented cases of definite intractable GERD. The main underlying disorders included neurological impairment (NI), esophageal atresia (EA), and congenital heart disease (CHD), which altogether accounted for 85% of patients. Of the 41 patients, 33 received fundoplication, and the remaining 8 received medical treatment alone because surgery was considered unsuitable.

CONCLUSIONS

The nationwide survey revealed that pediatric intractable GERD is rare in Japan. Three main underlying disorders-NI, EA, and CHD-were implicated in the majority of cases of intractable GERD.

Belching in children: Prevalence and association with gastroesophageal reflux disease

BACKGROUND

Excessive belching is frequently reported in adult patients with gastro-oesophageal reflux disease (GORD) and dyspepsia. Although postprandial gastric belching (GB) is considered a physiological mechanism for gastric venting, supra-gastric belching (SGB) is considered a distinct behavioural disorder. We aimed to define the prevalence of different types of belching and its association with reflux disease in paediatric patients.

METHODS

We retrospectively analysed reflux monitoring studies from 287 patients (median age: 7.0 years; interquartile range 3.0-11.3 years) with a suspicion of GORD. Based on oesophageal acid exposure time (AET) patients were divided in 3 groups: (a) physiological AET, (b) borderline AET and (c) pathological AET. MII-pH studies were manually edited and reflux disease parameters were measured together with quantification of GB and SGB.

KEY RESULTS

Two hundred one children (70.0%) had physiological AET (median: 0.8; interquartile range 0.3-1.6), 52 (18.1%) had borderline AET (median: 4.2; interquartile range 3.4-5.3) and 34 (11.9%) had pathologic AET (median: 10.7; interquartile range 9.1-14.2). Gastric belching was observed in all studies. Gastric belching related reflux was more frequently observed in patients with borderline and pathological AET (p < 0.001). This was more common in older children. SGB were observed in only 7 (2.4%) children (age range: 8-17years) in our population and all patients had Physiological AET. Only 3 (1%) patients had pathological number of SGB (>13/24 h).

CONCLUSIONS AND INFERENCES

Gastric belching related reflux is observed in children with increased AET. SGB is very rare in the paediatric population.

Quality of life of caregivers supporting neurologically impaired patients who underwent surgery

BACKGROUND

A questionnaire survey was conducted to clarify whether surgical treatments performed by a pediatric surgeon improve the quality of life (QOL) of caregivers (medical doctors, nurses, physical therapists, and nursery teachers) supporting neurologically impaired (NI) patients who work at specialized institutions.

METHODS

The questionnaire survey was conducted with caregivers who cared for NI patients who underwent an operation at the Department of Pediatric Surgery, Kurume University Hospital. Quality-of-life related responses concerning the change of care after surgical procedures in NI patients were collected in addition to the background data related to caregivers and the surgical procedures performed for them. Degrees of difficulty in caring for NI patients and of the caregivers' own QOL postoperatively were also compared.

RESULTS

There were 192 valid responses. The majority of responses were from females and nurses aged in their 40s and 50s. The surgical procedure performed most often in the NI patients was gastrostomy. Of the respondents, 77% answered that the postoperative care became easier. The degrees of difficulty in caring for NI patients and the caregivers' own QOL were significantly higher and lower, respectively, among physical therapists compared with caregivers in other occupations. Moreover, the QOL in respondents with factors related to a longstanding relationship with NI patients was significantly higher compared with the respondents without them.

CONCLUSION

This survey indicated that surgical procedures for NI patients might contribute to improved QOL for the caregiver by reducing the difficulty of caring for NI patients.

Laparoscopic identification of combined pediatric femoral hernia and ruptured abdominal cyst of the canal of Nuck: A report of an extremely rare case

A 7-year-old girl was referred to our hospital with a suspected right-sided indirect inguinal hernia. An egg-sized elastic, non-painful mass was palpated in the right inguinal region. Preoperative CT demonstrated a 30-mm simple cystic mass in the right internal inguinal canal, which we diagnosed as an abdominal cyst of the canal of Nuck. Laparoscopy revealed that the abdominal cystic component was ruptured, so we performed Pott's procedure. However, the patient's right groin swelled on postoperative day 3, necessitating re-operation. The patient's symptoms recurred again after 3 months, despite having had two surgical repairs. In the third operation, a right-sided femoral hernia was confirmed and repaired via external and laparoscopic approaches. To the best of our knowledge, there have been no reports on the combination of femoral hernia and cyst of the canal of Nuck in children. A laparoscopic approach was useful for obtaining a definitive diagnosis and conducting a safe and secure surgical repair.

De novo gastric cancer developing after liver transplantation from deceased donor for biliary atresia: a case report

BACKGROUND

Apart from Kasai's procedure, liver transplantation (LTx) has dramatically improved the outcome of children with biliary atresia (BA). However, de novo malignancy has been reported to be one of the major causes of late mortality after LTx among adults. We report a rare case of de novo gastric cancer developing after LTx for BA received during childhood.

CASE PRESENTATION

A 21-year-old male patient who had undergone LTx for BA at age 2 years occasionally visited our outpatient clinic due to symptoms of epigastric pain and dysphagia. Endoscopic examination and computed tomography revealed advanced gastric cancer at the gastroesophageal junction with multiple liver metastases. Despite systemic chemotherapy, the disease progressed, resulting in patient's death 2 years after the diagnosis.

CONCLUSIONS

De novo malignancy in the absence of post-transplant lymphoproliferative disease is rare in pediatric patients who received LTx. To the best of our knowledge, no report has been available on the development of gastric cancer after LTx for BA during childhood. Primary physicians should therefore establish a follow-up plan for patients receiving LTx for BA considering the potential for the development of de novo malignancy, including gastric cancer, despite its rarity.

Simultaneous Evaluation of Laryngopharyngeal Reflux and Swallowing Function Using Hypopharyngeal Multichannel Intraluminal Impedance Measurements in Neurologically Impaired Patients

Background/Aims

This study aims to evaluate the presence of laryngopharyngeal reflux (LPR) and to investigate the use of hypopharyngeal baseline impedance (BI) for assessing swallowing dysfunction and gastroesophageal reflux disease (GERD) using hypopharyngeal multichannel intraluminal impedance and pH (HMII-pH) monitoring in neurologically impaired patients (NIPs).

Methods

The study population in this retrospective study comprised 20 NIPs (mean age, 36.1 ± 15.0 years; age range, 13-64 years) who underwent multichannel intraluminal impedance and pH (MII-pH), HMII-pH, and laryngoscopy using the Hyodo scoring method from December 2016 to April 2019. The MII-pH and HMM-pH parameters were compared in the NIPs, whereas hypopharyngeal BI values were compared between NIPs with ≥ 5 and < 5 in Hyodo scores. Correlations between the hypopharyngeal BI values and the Hyodo score were analyzed using Spearman’s correlation coefficient. A receiver operator characteristic curve was created to determine the optimum cut-off of hypopharyngeal BI value to discriminate SD.

Results

Three NIPs were diagnosed with pathological LPR and GERD by the HMII-pH monitoring. No significant differences in parameters were observed between MII-pH and HMII-pH monitoring. The correlation analysis demonstrated a significant negative correlation between the hypopharyngeal BI values and Hyodo scores. The optimal cutoff value for hypopharyngeal BI was 1552 Ω.

Conclusions

This study demonstrated the usefulness of HMII-pH monitoring in identifying NIP with pathological LPR. Considering the difficulties in performing examinations in NIPs, HMII-pH monitoring may be a potentially useful technique for the simultaneous evaluation of swallowing dysfunction, LPR, and GERD in NIP.

Adherences to oral nutritional supplementation among hospital outpatients: An online cross-sectional survey in Japan

Oral nutritional supplements (ONS) are multi-nutrient products used to increase the energy and nutrient intakes of patients. The aim of this study was to examine whether or not the adherence of patients varies according to their receiving prescription or over-the-counter ONS. Data were obtained from an online cross-sectional survey conducted with patients in Japan. A total of 107 patients who matched the inclusion criteria for the prescription ONS group and 148 who matched the criteria for the over-the-counter ONS group were further analyzed. In the prescription and over-the-counter ONS groups, the main medical reason for ONS consumption were “malnutrition” (48 patients [44.9%] vs. 63 patients [42.6%] p = 0.798], “frailty” (29 patients [27.1%] vs. 36 patients [24.3%] p = 0.663) and “aging” (25 patients [23.4%] vs. 30 patients [20.3%] p = 0.644). The proportion of “No particular disease” for prescription ONS consumption was significantly lower than that for over-the-counter ONS (6 patients [5.6%] vs. 24 patients [16.2%] p = 0.001). The body mass index of the prescription ONS group was significantly higher than that of the over-the-counter ONS group (21.1±4.38 kg/m² vs. 19.9±3.75 kg/m², p = 0.0161). In the prescription ONS group, all patients were given medical advice by doctors or registered dietitians. In contrast, in the over-the-counter ONS group, only 46 patients (31.1%) were given advice by doctors or registered dietitians (p<0.001). In the prescription ONS group, ONS was taken significantly more times and for a longer duration than in the over-the-counter ONS group (p<0.0001). However, among patients given advice by doctors or registered dietitians, there were no significant differences between the groups. Greater support by the medical team is still needed in order to maximize adherence to supplementation, especially concerning the calories, timing and period, so that benefits can be achieved and sustained.

Cystic biliary atresia with paucity of bile ducts and gene mutation in KDM6A: a case report

Background

Biliary atresia (BA) cases are generally not associated with congenital abnormalities. However, accurate diagnosis of BA is often challenging because the histopathological features of BA overlap with those of other pediatric liver diseases and rarely overlap with those of other genetic disorders. We experienced a rare case of BA with the histopathological finding of bile duct paucity, a gene mutation in KDM6A, and KS-like phenotypes.

Case presentation

A male baby was diagnosed with biliary atresia by intraoperative cholangiography at 4 days of age, and histological examination following a liver biopsy revealed a paucity of bile ducts and several typical clinical findings of Alagille syndrome. However, Alagille syndrome was ruled out after neither JAG1 nor NOTCH2 gene mutations were identified. Whole-exome sequencing on DNA from his parents was additionally performed to examine other possible syndromic disorders, and a mutation was identified in KDM6A. However, Kabuki syndrome was not diagnosed as a result.

The histological finding of interlobular bile duct paucity and the genetic mutation in KDM6A, as well as several clinical findings consistent with Alagille syndrome or Kabuki syndrome, made it difficult to confirm the diagnosis of BA.

Conclusions

Based on the interesting findings of the present case, we hypothesized that KDM6A is associated with hepatic malformations via a connection with the Notch signaling pathway.

Resting energy expenditure prediction using bioelectrical impedance analysis in patients with severe motor and intellectual disabilities

INTRODUCTION

Resting energy expenditure (REE) is expected to be lower in with severe motor and intellectual disabilities (SMID) patients than in healthy subjects because of their relatively low fat-free mass (FFM). Therefore, an REE predictive equation for SMID patients may be required. The aim of this study was to validate existing REE predictive weight-based equations (Harris-Benedict, WHO, Mifflin, Owen, Schofield) and FFM-based REE equations (Mifflin, Owen and Cunningham) and to develop a new SMID patient-specific FFM-based REE equation.

METHODS

Twenty-eight (22 males, 6 females) SMID patients over 18 years of age were included. The REE was measured using indirect calorimetry. FFM were measured using bioelectrical impedance analysis. A multiple linear regression analysis was used to develop a new FFM-based REE predictive equation. The accurate predictions compared the measured REE and root mean square error.

RESULTS

The median measured REE was 950 (25th,75th percentile:712.75, 1102.75) kcal/day. The new FFM-based equation was as follows: REE (kcal/day) = 550.62 + 16.62 FFM (kg). The new FFM-based REE resulted in the highest percentage of accurate predictions within 10% of measured REE (42.9%). The root mean square errors were the smallest for the new FFM-based REE and largest for Harris-Benedict (91.00 and 185.22 kcal/day).

CONCLUSION

For SMID patients, the REE cannot accurately be predicted using the existing weight-based REE equations. Furthermore, the existing FFM-based REE equations are less accurate with regard to the measured REE than the new FFM-based REE equation. The new FFM-based equation is advised for use in SMID patients.

A large retroperitoneal lipoblastoma: A case report and literature review

INTRODUCTION

Lipoblastoma is a rare benign soft tissue tumor that occurs most commonly in infants and children. However, retroperitoneal lipoblastomas are rare, occurring in <5% of cases. We report a case of large retroperitoneal lipoblastoma and the largest collection of known retroperitoneal lipoblastomas in children in the literature.

CASE PRESENTATION

A 3-year-old girl presented with left abdominal mass. Magnetic resonance imaging (MRI) revealed a soft tissue mass measuring 12 × 8 × 6 cm in the retroperitoneal region. The mass had a clearly defined margin and a reticular pattern with an interposing fat component. Based on these findings, the mass was suspected to be a soft-tissue tumor, most likely lipoblastoma.Laparotomy with resection of the retroperitoneal mass was performed. The tumor was easily dissected from the retroperitoneal space without injury to surrounding structure.A histopathological examination demonstrated the mature proliferation of adipocytes and spindle-shaped cells separated by fibrovascular septa accompanied by myxoid changes. The cells were separated into lobules by septa, and areas of immature adipocytes showing a signet-ring or multivacuolar appearance were present at the periphery. Histopathological diagnosis was lipoblastoma. Follow-up at 6 months revealed no evidence of recurrence.

CONCLUSION

Retroperitoneal lipoblastoma is rare and tends to be large in size when diagnosed at presentation. Complete resection should not be delayed, as impingement on the surrounding structures is imminent.

Analyses of the relationship between a 'number of reflux episodes' exceeding 70 and the pH index in neurologically impaired children by evaluating esophageal combined pH-multichannel intraluminal impedance measurements

BACKGROUND

The present study aimed to evaluate the characteristics associated with a number of reflux episodes (NoRE) of 70 by comparing the clinical and multichannel intraluminal impedance pH measurements (pH/MII) and pH index (pHI) in neurologically impaired (NI) children.

PATIENTS AND METHODS

NI children (1-16 years of age) in whom pH/MII had been measured for GERD study were enrolled in this study. All children were divided into NoRE >70 or ≤70 and pHI >4.0 or ≤4.0, >5.0 or ≤5.0 or >7.0 or ≤7.0. In addition, the NI children with pHI >4.0, >5.0 and >7.0 were subdivided into NoRE >70 and ≤70 groups. The clinical and pH/MII measurements were compared between each of the two groups. The cutoff values of pHI and baseline impedance (BI) (Z6) were calculated to discriminate NoRE >70 and ≤70.

RESULTS

A total of 61 NI children were enrolled in this study. There was a significant difference in the acid-related parameters, the NoRE (nonacid) and BI between NoRE >70 and ≤70, acid-related parameters and BI between pHI >4.0 and ≤4.0, >5.0 and ≤5.0 and >7.0 and ≤7.0 groups. Furthermore, a significant difference was still observed in the BI between NoRE >70 and ≤70 groups among patients with pHI >4.0, >5.0 or >7.0. The cutoff values of pHI and BI (Z6) for discriminating NoRE >70 and ≤70 were 9.2 and 1049Ω, respectively.

CONCLUSION

The present study indicates that NoRE 70 corresponds to GERD in which patients suffer severe acid exposure with pH of around 9% and esophageal mucosal damage with low BI value in NI children.

Functional assessment of the patients with perineal and vestibular fistula treated by anterior sagittal anorectoplasty

BACKGROUND

Anterior sagittal anorectoplasty (ASARP) has been a standardised operative treatment for anorectal malformation (ARM). This retrospective study was undertaken to evaluate patients with perineal fistula (PF) and vestibular fistula (VF) treated by ASARP in our institution.

PATIENTS AND METHODS

Twenty patients (PF, n = 14; male, n = 8 and female, n = 6 and VF, n = 6) were evaluated. Eighteen patients underwent primary ASARP without protective colostomy. Two patients underwent colostomy because of intestinal atresia and suspected of other type ARM. The age range of operation was from 4 months to 5.0 years. Sixteen patients (PF, n = 13; male, n = 7 and female n = 6 and VF, n = 3) over 3 years of age were evaluated according to the Krickenbeck classification.

RESULTS

Operative complications occurred in one patient. Minor wound dehiscence occurred in six patients. Mucosal prolapse occurred in two patients. According to the Krickenbeck classification, amongst male patients with PF, all patients had voluntary bowel movements (VBMs) and two patients had Grade 1 soiling, while four patients had Grade 2 constipation. Amongst female patients with PF, all patients had VBM and no soiling, one patient had Grade 1 and two patients had Grade 2 constipation. In patients with VF, one patient was continent with Grade 1 soiling. One patient had Grade 2 and two patients had Grade 3 constipation.

CONCLUSIONS

ASARP without colostomy carried a risk of wound dehiscence. The ASARP technique provided normal or moderate outcomes for VBM and soiling. However, in about half of patients, defecation management with laxative therapy was required to achieve a normal condition.

Severe Delayed Gastric Emptying Induces Non-acid Reflux up to Proximal Esophagus in Neurologically Impaired Patients

Background/Aims

The aim of this study is to investigate the degree of delayed gastric emptying (DGE) and evaluate how the severity of DGE affects gastroesophageal reflux disease (GERD) in neurologically impaired (NI) patients utilizing 24-hour multichannel intraluminal impedance pH measurements (pH/MII) and ¹³C-acetate breath test (¹³C-ABT) analyses.

Methods

¹³C-ABT and pH/MII were conducted in 26 NI patients who were referred to our institution due to suspected GERD. At first, correlation analyses were performed to investigate the correlation between the ¹³C-ABT parameters and the clinical or pH/MII parameters. Thereafter, all patients were divided into 2 groups (DGE and severe DGE [SDGE] group) according to each cut off half emptying time (t_1/2, 90-170 minutes). Each pH/MII parameter was compared between the 2 groups in each set-up cutoff t_1/2.

Results

The mean t_1/2 of all patients was 215.5 ± 237.2 minutes and the t_1/2 of 24 (92.3%) patients were > 100 minutes. Significant moderate positive correlations were observed between both t_1/2 and lag phase time and the non-acid reflux related parameters. Furthermore, the patients in the SDGE group demonstrated higher non-acid reflux related parameters than those of the DGE groups when the cutoff was t_1/2 ≥ 140 minutes.

Conclusion

The present study demonstrated that GE with t_1/2 ≥ 140 minutes was related to an increase of non-acid exposure reaching up to the proximal esophagus in NI patients, and indicating that NI patients with SDGE might have a high risk of non-acid GERD.

The characteristics of salivary pepsin in patients with severe motor and intellectual disabilities

PURPOSE

The aim of the present study was to determine the utility of measuring the salivary pepsin level (SPL) as an objective assessment of gastroesophageal reflux disease (GERD) in severe motor and intellectual disabilities (SMID) patients.

SUBJECTS AND METHODS

This prospective study included 26 SMID patients who underwent simultaneous 24-h multichannel intraluminal impedance pH measurement (pH/MII) and SPL evaluation. The enrolled patients were divided into GERD (+) or GERD (-) groups according to the pH/MII findings. The age, gender and pH/MII parameters were compared between the two groups. A correlation analysis was also conducted for the SPL following early-morning fasting and post-enteral feeding and the age, gender, presence of gastrostomy and tracheostomy and pH/MII parameters. The SPL was compared between the two sampling groups.

RESULTS

Fifteen patients were classified as GERD (+), and 11 patients were classified as GERD (-). The mean SPL following early-morning fasting and post-enteral feeding among all patients were 104.3 (median: 38, 25th and 75th percentile: 12, 361) ng/ml and 222.2 (median: 152:0, 500) ng/ml, respectively. Regarding positivity, 76.9% and 73.1% of SPL values in early-morning fasting and post-enteral feeding SMID patients, respectively, were positive (≧16ng/ml). The SPL following early-morning fasting demonstrated a weak but significant positive correlation with age. In contrast, we noted no correlation between the pH/MII parameters and the SPL for either the early-morning fasting or post-enteral feeding patients, and no significant difference in the SPL was observed between the GERD (+) and (-) patients.

CONCLUSIONS

The present study showed that a high proportion of SMID patients had a relatively high SPL, regardless of the presence of GERD. The SPL in SMID patients might be affected by several distinctive factors in addition to gastroesophageal reflux.

The utility of a phase angle analysis in patients with severe motor and intellectual disabilities

PURPOSE

The purpose of the present study was to evaluate whether evaluating the phase angle (PhA), in a bioelectrical impedance analysis (BIA) is useful for estimating the nutritional status of severe motor and intellectual disabilities (SMID) patients.

SUBJECTS AND METHODS

This retrospective study included 31 SMID patients (mean age: 33.9±13.5years, median age: 29years (range: 18-58years), male/female: 23/8). First, each of the parameters from the total study population and the male and female SMID patients were compared with those of healthy Asian subjects. Second, correlation analyses were conducted to investigate the correlation between the PhA and the other BIA parameters (appendicular skeletal muscle mass index (ASMI), appendicular muscle mass (AMM), extracellular water (ECW)/total body water (TBW)) as well as subjective global assessment and serum nutritional markers. Finally, all patients were divided into 2 groups according to their albumin (Alb) (<3.5 or ≥3.5) values and PhA of the 2 groups were compared.

RESULTS

The mean PhA and ASMI were a considerably low, whereas ECW/TBW was considerably high in comparison to the healthy Asian subjects. Significant negative correlations were observed between the PhA and ECW/TBW, whereas there were significant positive correlations between PhA and AMM, ASMI, total protein and albumin levels. Furthermore, PhA of Alb ≥3.5 group was significantly higher than that of Alb <3.5 group.

CONCLUSIONS

The present study indicated that SMID patients demonstrate the low PhA, which were similar to sarcopenia and a certain proportion of them also potentially have nutritional disturbances.

A baseline impedance analysis in neurologically impaired children: A potent parameter for estimating the condition of the esophageal mucosa

BACKGROUND

The aim of the present study was to investigate whether the baseline impedance (BI) value is a useful parameter to evaluate the condition of the esophageal mucosa in neurologically impaired (NI) children undergoing multichannel intraluminal impedance pH measurements (pH/MII).

METHODS

The retrospective study included 55 NI patients ≤15 years. The patients were divided into acid gastroesophageal reflux disease (GERD), non-acid GERD and GERD (-) groups. Furthermore, the patients in the acid GERD group were subdivided into erosive reflux disease (ERD) and non-erosive reflux disease (NERD) groups. pH/MII parameters and BI values (Z1-6) were compared among three groups or between two groups, respectively. A Spearman's correlation analysis was used for the correlation analysis of pH/MII parameters and BI values. A receiver operator characteristic curve analysis was used to evaluate the optimum cut-off values of BI to discriminate ERD patients.

KEY RESULTS

The BI values of the proximal and the distal channels in ERD group were significantly lower than those in NERD group. The BI values of the distal channels demonstrated significant negative correlations with acid exposure related pH/MII parameters. The optimal cut off value of BI in the most distal channel was determined to be 1500 Ω.

CONCLUSIONS & INFERENCES

The present study suggested that NI children with reflux esophagitis were likely to suffer mucosal damage up to the proximal esophagus and cut-off BI values may help estimate the presence of reflux esophagitis. Baseline impedance is a potent parameter, reflecting the esophageal mucosal damage in NI children who have difficulty in undergoing endoscopic examinations.

Clinical Efficacy of Herbal Medicine for Pediatric Lymphatic Malformations: A Pilot Study

BACKGROUND

Lymphatic malformations (LMs) are congenital malformations of the lymphatic system that commonly affect the head and neck region and cause marked cosmetic and functional complications. In this pilot study, we present eight children with LMs treated using an herbal medicine for this indication.

METHODS

Between January 2009 and May 2014, eight children (four boys, four girls) with LMs were treated using oral administration of an herbal medicine, Eppikajyutsuto (TJ-28; Tsumura, Tokyo, Japan), as monotherapy.

RESULTS

Four of the cases were macrocystic and four were mixed micro- and macrocystic. The mean treatment duration was 7.2 ± 2.9 months (range 5-12 mos). The mean LM volume shrinkage on magnetic resonance imaging was 54.5 ± 38.3% (macrocystic 73.6 ± 27.0%; mixed micro- and macrocystic 35.4 ± 41.5%). One of four macrocystic lesions had a marked reduction, two had a moderate reduction, and one had no response. A marked reduction was observed in three of the four mixed micro- and macrocystic cases; the other mixed cystic case had no response. The treatment was well tolerated, without severe adverse events.

CONCLUSIONS

This preliminary study demonstrates the beneficial effects of TJ-28. Further evaluations of this therapeutic modality are warranted.

Near-infrared fluorescence cholangiography with indocyanine green for biliary atresia. Real-time imaging during the Kasai procedure: a pilot study

INTRODUCTION

Hepatoportoenterostomy (HPE) with the Kasai procedure is the treatment of choice for biliary atresia (BA) as the initial surgery. However, the appropriate level of dissection level of the fibrous cone (FC) of the porta hepatis (PH) is frequently unclear, and the procedure sometimes results in unsuccessful outcomes. Recently, indocyanine green near-infrared fluorescence imaging (ICG-FCG) has been developed as a form of real-time cholangiography.

METHODS

We applied this technique in five patients with BA to visualize the biliary flow at the PH intraoperatively. ICG was injected intravenously the day before surgery as the liver function test, and the liver was observed with a near-infrared camera system during the operation while the patient's feces was also observed.

RESULTS

In all patients, the whole liver fluoresced diffusely with ICG-containing stagnant bile, whereas no extrahepatic structures fluoresced. The findings of the ICG fluorescence pattern of the PH after dissection of the FC were classified into three types: spotty fluorescence, one patient; diffuse weak fluorescence, three patients; and diffuse strong fluorescence, one patient. In all five patients, the feces evacuated after HPE showed distinct fluorescent spots, although that obtained before surgery showed no fluorescence. One patient with diffuse strong fluorescence who did not achieve JF underwent living related liver transplantation six months after the initial HPE procedure. Four patients, including three cases involving diffuse weak fluorescence and one case involving spotty fluorescence showed weak fluorescence compared to that of the surrounding liver surface.

CONCLUSION

We were able to detect the presence of bile excretion at the time of HPE intraoperatively and successfully evaluated the extent of bile excretion using this new technique. Furthermore, the ICG-FCG findings may provide information leading to a new classification and potentially function as an indicator predicting the clinical outcomes after HPE.

Successful balloon dilatation for postoperative caval stenosis caused by primary venorrhaphy for traumatic retro-hepatic caval injury in a three-year-old child: Report of a case

Inferior vena cava injuries are highly lethal. We experienced a case of retrohepatic inferior vena cava injury as a result of blunt trauma in a three-year-old female. Because the site of bleeding of the IVC was identified, we repaired it with running sutures. An attempt at primary repair resulted in postoperative narrowing of the vena cava. There was pressure gradient of the right atrium and inferior vena cava, and collateral circulation developed. Since it was also found that the haemodynamics was unstable, the child underwent another intervention before the stenosis of the IVC was fixed. To the best of our knowledge, there have been no previous reports of therapeutic radiological intervention for stenosis that developed after treatment of a traumatic IVC injury. The IVC in the present case recovered enough patency so that the collateral venous flow could be decreased after balloon dilatation angioplasty.

Intestinal neuronal dysplasia-like histopathology in infancy

The present patient was delivered at a gestational age of 27 weeks. She had abdominal bloating with symptoms of respiratory distress. We suspected Hirschsprung disease (HD) or small intestinal stricture, but examinations were not definitive. Exploratory laparotomy was performed at 97 days of age. Intraoperative findings showed no evidence of small intestinal stricture or changes in intestinal caliber. A transanal drainage tube was inserted, and decompression therapy and intestinal lavage were started. Rectal mucosal biopsy was performed at 184 days of age, and HE and acetylcholinesterase staining showed intestinal neuronal dysplasia (IND)-like pathological findings. At 15 months, giant ganglia were no longer present on follow-up rectal mucosal biopsy, and the pathological diagnosis was normoganglionosis. It should be recognized that while the enteric nervous system is developing, IND-like pathological findings may be seen as a pathological condition during the maturation process.

Infantile neuroblastoma of the urinary bladder detected by hematuria

Malignant tumors of the urinary bladder in infants are extremely rare. Rhabdomyosarcoma is the most likely tumor in this site, whereas neuroblastoma of the urinary bladder is exceedingly uncommon and is not listed as a differential diagnosis for tumors of this site. We present a case of neuroblastoma arising from the dome of the bladder wall, detected by hematuria. Only six cases of neuroblastoma originating from the bladder, including the present case have been reported. Of the cases, five arose from the dome of the bladder wall. In this report, the differential diagnosis of bladder tumors in children is discussed. A diagnosis of neuroblastoma should be taken into consideration, especially in the case of tumors arising from the dome of the bladder wall despite an uncommon location.

Pre and post-operative evaluation of gastroesophageal reflux and esophageal motility in neurologically impaired children using combined pH–multichannel intraluminal impedance measurements

BACKGROUND

Gastroesophageal reflux disease (GERD) in patients with neurological impairment (NI) has not been fully studied before and after fundoplication procedure because their characteristics such as generalized gastrointestinal dysmotility, non-acid reflux, and the proximal reflux due to feeding of enteral nutrition via a nasogastric tube prevent their GERD from being detected by 24 h pH monitoring. The aim of this study was to elucidate whether multichannel impedance-pH measurement (pH/MII) is able to detect the subtypes of GERD and the differences in the reflux episodes of the severity of GERD, the ingestion pathway, and before and after fundoplication. The second aim was to determine whether a trial evaluation of dry swallows was able to be used to assess the esophageal motility of NI patients as an alternative examination.

PATIENTS AND METHODS

The 24 h pH/MII was conducted on 20 NI children [15 were the patients before Nissen's fundoplication (BN), of whom, six were fed orally (FO) and nine were fed via nasogastric tube (NGT), and five were the patients after Nissen's fundoplication (AN)]. All reflux episodes were evaluated and compared between patients with pathological GERD (PG) and non-pathological GERD (NG) and between patients who had FO and NGT and patients between BN and AN. Dry swallows were conducted to evaluate the esophageal motility. The average bolus presence time (BPT) and total bolus transit time (TBTT) were compared between the PG and NG, FO and NGT, and the BN and AN subgroups.

RESULTS

A total of 1,064 reflux episodes were detected by pH/MII. Of those, 303 (28.5 %) were non-acid-related and 477 episodes reached the proximal esophagus. Of the 12 patients (57.1 %) showing pathological GERD, two cases (16.7 %) demonstrated predominantly weakly acidic PG. More than half of the reflux episodes of PG patients reached to the proximal esophagus. The numbers of total reflux and proximal reflux episodes in the PG were significantly higher than those in NG patients. The number of proximal reflux episodes in the FO group was significantly higher than that in the NGT groups, whereas NGT patients showed more non-acidic reflux episodes than FO patients. A trial evaluation of dry swallows demonstrated no significant differences in this study.

CONCLUSION

The pH/MII was useful to detect the subtype of GERD in NI patients which could not be detected by 24 h pH monitoring. It can, therefore, be considered to have first priority for testing NI patients who are suspected to be suffering from GERD.

Intraoperative near-infrared indocyanine green fluorescence angiography (NIR-ICG AG) can predict delayed small bowel stricture after ischemic intestinal injury: report of a case

We herein report the case of a 15-year-old male who developed delayed intestinal stricture after undergoing massive intestinal resection due to severe small intestinal volvulus. At the time of the initial surgery, the laparotomy findings showed a massive intestinal volvulus without malrotation. Most of the small intestine appeared to be necrotic; therefore, massive necrotic intestinal resection was performed. The residual intestine comprised only the proximal jejunum and short ileum, including the ileocecal valve and entire colon. After the resection, the serosal surface color of the distal part of the residual jejunum (DPRJ) initially showed a slightly darker hue than normal. However, the color improved with time, and the other clinical findings also improved, which were considered to indicate that the perfusion of the DPRJ was preserved. The perfusion of that area was therefore clinically expected to improve with time. On the other hand, repeated intraoperative near-infrared indocyanine green fluorescence angiography (NIR-ICG AG) consistently showed abnormal vascular flow patterns in the same region, which were suspected to indicate the presence of perfusion damage of the DPRJ, in spite of improvements in the clinical findings. Although the necessity of additional resection was discussed at the time of reconstruction, we finally estimated that the perfusion of the DPRJ was preserved, mainly based on the improvement of the clinical findings of the intestine. The primary anastomosis was performed without additional resection, to maximize the lengths of the residual intestine. However, after the initial surgery, the patient developed a delayed partial stricture of the residual intestine, and an additional resection was necessary on the 22nd postoperative day. The stricture segment corresponded to the area that presented abnormal findings by NIR-ICG AG. This case suggests that abnormal NIR-ICG AG findings may predict delayed intestinal ischemic complications. We believe that NIR-ICG AG can intraoperatively provide more useful real time information for the assessment of intestinal perfusion, than conventional clinical assessment methods.

Infantile juvenile xanthogranuloma of the chest wall mimicking mesenchymal hamartoma: report of a case

Juvenile xanthogranuloma (JXG) is essentially a benign neoplasm arising from any site on the body; however, there has so far been only one report of JXG located on the chest wall involving a rib. This report presents a rare case finally diagnosed as JXG based on histopathological and immunohistochemical examinations.