Development of acquired tracheal stenosis in premature infants due to prolonged endotracheal ventilation: etiological considerations and surgical management

The aim of this study was to determine the etiology and appropriate surgical treatment for acquired tracheal stenosis that developed in patients who had undergone prolonged endotracheal mechanical ventilation as premature neonates. During the period 2000-2004, four patients aged 1-16 years were referred for tracheal stenosis characterized by stridor, choking, and recurrent pulmonary infection. All patients had undergone endotracheal mechanical ventilation for 2-5 months for respiratory distress related to prematurity (gestational age 25-29 weeks, birth weight 648-1,222 g). During this period, methicillin-resistant Staphylococcus aureus was predominantly cultured from the trachea. All patients exhibited a stenotic lesion encompassing 30-37% of the entire tracheal length on spiral CT. On palpation and inspection of the trachea during surgery, however, the stenotic segment appeared to encompass over 50% of the entire trachea. The carina was intact. Three patients underwent slide tracheoplasty with a tracheal resection and the other underwent resection and end-to-end anastomosis. Of the three patients treated by slide tracheoplasty, two are currently free of respiratory symptoms. However, one patient in this group required secondary resection of the remaining stenotic lesion with end-to-end anastomosis. This patient is currently asymptomatic. The remaining patient who underwent a resection and end-to-end anastomosis is doing well. The resected specimen showed fibrosis and degeneration of tracheal cartilage. A combination of prematurity, prolonged endotracheal mechanical ventilation and tracheal infection seem to be responsible for tracheal inflammation and stenosis. When considering surgical procedures for acquired tracheal stenosis, resection and end-to-end anastomosis are desirable. However, slide tracheoplasty with a partial tracheal resection is indicated for the treatment of stenosis involving a long tracheal segment.

A case report of glial choristoma of the tongue

Glial choristoma of the tongue is extremely rare. The authors report the case of a 9-day-old infant with a congenital lingual glial choristoma. Complete surgical excision was performed without postoperative complications or recurrence. The authors also present a review of the literature and outcome of this benign tumor.

Composite pheochromocytoma associated with adrenal neuroblastoma in an infant: a case report

A 5-year-old boy presented with headache and hypertension. Screening abdominal ultrasonography showed a 6-cm-sized mass in the left adrenal gland. Laboratory data included urine vanillylmandelic acid/creatinine (208.3 microg/mg), urine homovanillic acid/creatinine (114.3 microg/mg), serum epinephrine (237 pg/mL), and serum norepinephrine (1842 pg/mL). Metaiodobenzyl guanidine I 123 scintigram, abdominal computed tomography, and abdominal magnetic resonance imaging revealed only left adrenal tumor with no metastasis. Left adrenalectomy was performed transperitoneally, and histopathological diagnosis was an adrenal composite pheochromocytoma associated with neuroblastoma. Immunoreactivity for vimentin was positive in pheochromocytoma, which was negative in neuroblastoma. After operation, the symptom of hypertension disappeared. We should examine the identification of composite pheochromocytoma by immunohistochemistry method in patients with neuroblastomatous elements complicated by severe hypertension, and it is important to carefully monitor urine vanillylmandelic acid and urine homovanillic acid in the examination tests and hypertension in the clinical symptoms, and follow up this patient because of some risk of recurrence and metastasis.

Laparoscopic fenestration of a neonatally detected hepatic mesenchymal hamartoma

We report a case of hepatic mesenchymal hamartoma that was detected neonatally and successfully treated by laparoscopic fenestration. A baby girl was referred to our hospital 9 days after birth with a cystic lesion in her liver. Screening abdominal ultrasonography revealed a sonolucent lesion measuring 65x43x40 mm in the right lobe of the liver with a small solid area. Magnetic resonance imaging depicted the lesion as hyperintense on both T1- and T2-weighted images with no enhancement. A laparoscopic biopsy and fenestration of the lesion was performed. Histologic examination of the cyst wall led to a diagnosis of hepatic mesenchymal hamartoma. The postoperative course was uneventful and the patient is doing well at 4 years' follow-up, with no recurrence.

Communicating bronchopulmonary foregut malformation: particular emphasis on concomitant congenital tracheobronchial stenosis

A total of four patients with communicating bronchopulmonary foregut malformation were treated surgically at Kobe Children's Hospital between 1993 and 2004. Of these, three patients displayed congenital tracheobronchial stenosis and developed life-threatening respiratory distress soon after birth. In each case, anomalous bronchi arose from the lower portion of the esophagus and connected to the lower part of the ipsilateral lung. This anomaly involved the right lung in two patients, and the left lung in one patient. Tracheobronchial stenosis extended from the inlet of the thorax to the carina in one patient, and to the contralateral main stem bronchus in two patients. Surgical treatment included division of the esophageal bronchus and anastomosis of bronchus to the trachea in one patient. In the other patient, the ipsilateral lung was resected and the stenotic tracheobronchus was stented. The remaining patient underwent pneumonectomy of the ipsilateral lung. Details of this fatal anomaly and a discussion of appropriate surgical management are described herein.

Glucocorticoid receptor alpha expression in the intrahepatic biliary epithelium and adjuvant steroid therapy in infants with biliary atresia

BACKGROUND/PURPOSE

In patients with cirrhosis, proinflammatory cytokines increase progressively in relation to the severity of liver dysfunction. Proinflammatory cytokines regulate the expression of glucocorticoid receptors (GcRs). On the other hand, GcRs mediate the effects of glucocorticoid steroids on bile excretion in the biliary epithelium. Glucocorticoid receptors have 2 isoforms: a cytoplasmic glucocorticoid receptor alpha (GcRalpha) mediates their physiological effects, whereas a nuclear localized glucocorticoid receptor beta (GcRbeta) acts as a dominant negative inhibitor of GcRalpha activity. We examined the histology features of liver biopsy and the expression of GcRalpha in the intrahepatic biliary epithelium in infants with biliary atresia.

PATIENTS/METHODS

The patients were divided into 2 groups: patients in group 1 (n = 17) had a total bilirubin level below 1.0 mg/dL at least once after surgery, whereas patients in group 2 (n = 14) has never had bilirubin level below 1.0 mg/dL postoperatively. Liver biopsies taken from 31 infants with biliary atresia at the time of hepatic portoenterostomy between 1988 and 2002 were examined for immunohistochemistry and histology with H&E staining. The degree of GcRalpha expression in the biliary epithelium was semiquantitatively analyzed using staining scores. The histology features of the liver biopsy were also semiquantitatively analyzed by using the same scores to evaluate the liver injury. Intravenous prednisolone dosage was started with 4 mg/kg per day and tapered by a half dose every 2 days. The protocol was orally repeated during admission until the stool became constantly cholic. Statistical analysis was performed using Mann-Whitney U test and Spearman correlation coefficient by rank. Significance is set at a 95% confidence interval (P < .05).

RESULTS

There was a significant positive correlation between the liver histology and the GcRalpha scores in all patients with biliary atresia (P = .0128; r = 0.429). In group 1, there was a significant positive correlation between the GcRalpha expression scores and the total dose of prednisolone administered (P = .0063; r = 0.767).

CONCLUSIONS

The increase and degree of GcRalpha expression were associated with the severity of liver injury and may correlate with the dose of prednisolone required to sustain bile flow after successful hepatic portoenterostomy.

Ileo-caecal arterio-venous malformation associated with extrahepatic portal hypertension: a case report

This paper is a case report describing a boy with Down syndrome and a novel combination of multiple vascular anomalies: extrahepatic portal hypertension, an arterio-venous malformation (AVM) at the ileo-caecal junction, and caval/iliac vein anomalies and developing anal bleeding. We considered that the ileo-caecal AVM would be one of the causes of the repeated hematochezia. The patient underwent ileo-caecal resection with the AVM, and anastomosis of the left external iliac vein and the jejunal branch vein because of the stenosis of the superior mesenteric vein (Clatworthy mesocaval shunt). Intraoperative portal pressure measurement at the site of the right colic vein showed a moderate pressure reduction (42.5-31.5 cm H2O). On the fourth month after operation, gastrointestinal fiberscopy showed no existence of esophageal varices. One year after operation, the patient was doing well without bleeding.

Efficacy of urinary sulfated bile acids for diagnosis of bacterial cholangitis in biliary atresia

This study evaluated the efficacy of measuring urinary sulfated bile acids (USBA) for diagnosis of bacterial cholangitis in patients with biliary atresia. Eight infants with biliary atresia were recruited. The USBA level was measured when they were admitted to hospital with a fever of unknown origin. Clinical manifestations and laboratory data were reviewed. The standard USBA value for each patient (S-USBA) was defined as the level measured when they had no fever, and USBA ratio (R-USBA) was calculated as the USBA level during the febrile episode divided by the S-USBA. Then R-USBA values were compared between febrile episodes with and without cholangitis to assess the diagnostic ability of USBA. Twenty-three febrile episodes occurred in eight patients during a 15-month period. Nine episodes were diagnosed as being due to cholangitis, five were due to non-cholangitis, and nine were of undetermined origin. The R-USBA value ranged from 1.5 to 15.4 during cholangitis episodes and from 0.4 to 1.2 during non-cholangitis febrile episodes. When fever was of undetermined origin, R-USBA was found to be increased during some episodes and not in others. USBA increased immediately in patients with cholangitis. The measurement of USBA is a useful non-invasive test for cholangitis in patients with biliary atresia who had undergone Kasai's operation.

Multistaged esophageal elongation technique for long gap esophageal atresia: experience with 7 cases at a single institution

BACKGROUND/PURPOSE

Esophageal reconstruction for long gap esophageal atresia (LGEA) is still controversial. We successfully managed 7 cases of patients with LGEA by doing staged elongation of the native esophagus and subsequent end-to-end anastomosis. The technique and efficacy of this procedure are evaluated.

METHODS

During the last 10 years, 7 patients with LGEA (Gross type A, 5; B, 1; C, 1) underwent multiple extrathoracic esophageal elongations (ETEEs) of the upper esophagus and subsequent esophagoesophagostomy. Medical records were reviewed in regard to the number of ETEE before definitive esophageal reconstruction, interval between each ETEE, operation time, time before initiation of sham feeding, duration of hospital stay, and complications.

RESULTS

The definitive esophageal reconstruction was successfully achieved without major complications in all patients after 2 to 4 stages of ETEE. The interval between each ETEE was 72 days on average. The average operation time was 98 minutes. The elongation was 1 to 3.5 cm during each session. Oral sham feeding was recommenced 4.1 days after each ETEE, and the hospital stay was 9.6 days on average. Gastroesophageal reflux occurred in all patients, requiring antireflux surgery.

CONCLUSIONS

We conclude from our experience (a) that effective esophageal lengthening with preservation of the native esophagus was achieved with multiple ETEE in LGEA and (b) that this procedure allows oral sham feeding at home until esophageal reconstruction.

Thoracic neuroblastoma: outcome of incomplete resection

The prognosis for thoracic neuroblastoma has been documented as good, but the reasons have not been elucidated. We reviewed our experience of patients with thoracic neuroblastoma who were treated over the past decade. Among 102 patients treated for neuroblastoma at our hospital between December 1987 and June 1997, 20 patients had thoracic neuroblastoma (stage 1: nine, stage 2: five, stage 3: three, stage 4: three). Tumor characteristics and survival rate were compared between thoracic and nonthoracic neuroblastoma. The surgical margin was positive in 13 of the 20 patients with thoracic neuroblastoma. However, local recurrence was observed in only one patient who later underwent complete resection. All patients survived 4-14 years of follow-up. Among those over 1 year old, thoracic neuroblastoma was detected at an earlier stage than in their nonthoracic counterparts (stages 1 and 2 vs. 3 and 4: 6/3 vs. 1/17, p=0.003), and the 5-year survival rate was better than in their nonthoracic counterparts (100% vs. 44.5%, p=0.015). The incidence of ganglioneuroblastoma was significantly higher in the thoracic group at the age of >1 year ( p=0.003). In six of nine patients from the thoracic group who were >1 year old, small areas of ganglioneuroma were identified in the tumor tissue. There was a stronger tendency for the maturation of neuroblastoma into ganglioneuroma in the thoracic group. Complete resection is not required for thoracic neuroblastoma regardless of the patient's age.

Vascular ring in an extremely low birth weight infant

Vascular rings due to aortic arch anomalies can be a major cause of tracheoesophageal obstruction in infants. But there is no report of vascular ring in an extremely low birth weight (ELBW) infant. This is a report of an infant with birth weight of 560 g, who has not diagnosed vascular ring until 6 months of age because of asymptomatic process by prolonged tracheal intubation. The patient was treated for double aortic arch with tracheomalacia surgically by simple division of the atretic left arch and the ligamentum arteriosus, aortopexy and tracheostomy before reaching full recovery at 3 years of age. We reported our management of vascular rings in the ELBW infant. This case suggested that the difficulty of extubation in ELBW infants in spite of the improvement of respiratory condition should raise a suspicion of the tracheal compression by other lesions such as vascular rings.

Supraumbilical pyloromyotomy: comparison between intracorporeal and extracorporeal approaches

We evaluated intracorporeal pyloromyotomy (ICP) as an alternative to extracorporeal pyloromyotomy (ECP) in infants with hypertrophic pyloric stenosis. From July 1994 to June 2002, 75 patients underwent ICP, and 29 patients underwent ECP through supraumbilical incisions. The medical charts were reviewed retrospectively with regard to operating time, time to return to full feeding, complications, and outcome. The average operating time in the ICP group was significantly longer than in the ECP group (56.4+/-13.6 vs. 48.7+/-16.3 min; p=.004). However, the average time to return to full feeding in the ICP group was significantly shorter than in the ECP group (2.1+/-1.6 vs. 2.9+/-1.9 days; p=.002). Extension of the skin and/or fascial incision was necessary in two of 75 patients in the ICP group, compared with 11 of 29 patients in the ECP group ( p<.0001). There were four (5.3%) wound infections and one (1.3%) mucosal perforation in the ICP group, compared with two (6.9%) wound infections in the ECP group. ICP allows patients to return to full feeding earlier than ECP does, resulting in a shorter hospital stay. ICP through a supraumbilical incision is superior to the ECP technique.

Transection of the innominate artery for tracheomalacia caused by persistent opisthotonus

Patients with cerebral palsy often develop opisthotonus. The trachea may be pinched between the innominate artery and the cervical spine. This compartmentalized thoracic inlet results in severe tracheomalacia. We successfully released tracheal compression by transection of the innominate artery. In case 1, a 4-year-old girl with cerebral palsy and opisthotonus was admitted due to respiratory distress. Bronchoscopy revealed severe tracheomalacia 2 cm above the carina. An endotracheal stent was placed through a tracheostomy. Two months later, she developed tracheal bleeding and bronchoscopy demonstrated a trachea-innominate artery fistula. Magnetic resonance brain angiography showed the presence of Willis' circle, and transection of the innominate artery was justified. This was done through a low cervical skin incision. In case 2, a 6-year-old boy with cerebral palsy and opisthotonus had long-standing respiratory distress. Ventilatory support did not resolve the symptoms. The innominate artery was transected in the same fashion as in the first case. Case 1 has been free from respiratory distress for 4 months and case 2 for 3 years. Our experience suggests that the combination of tracheomalacia, opisthotonus causes severe respiratory distress. Transection of the innominate artery is a useful therapeutic strategy to release airway obstruction in this condition.

Sonographic diagnosis of biliary atresia in pediatric patients using the "triangular cord" sign versus gallbladder length and contraction

OBJECTIVE

A retrospective review was performed to evaluate the importance of the "triangular cord" sign in comparison with gallbladder length and contraction for the diagnosis of biliary atresia in pediatric patients.

MATERIALS AND METHODS

Fifty-five fasting infants with cholestatic jaundice were examined on sonography. The examinations focused on the visualization of the triangular cord sign and assessment of gallbladder length and contraction. The diagnosis of neonatal hepatitis or of other causes of infantile cholestasis was made if symptom resolution occurred during follow-up.

RESULTS

A triangular cord sign was found in 27 of 29 infants with biliary atresia and in one of 26 infants with neonatal hepatitis or other causes of infantile cholestasis. The diagnostic accuracy was 95%, sensitivity was 93%, and specificity was 96%. The gallbladder was thought to be abnormal if it was less than 1.5 cm long, was not detectable, or was detectable but had no lumen. The gallbladder was abnormal in 21 of 29 infants with biliary atresia, whereas it was abnormal in eight of 26 infants with neonatal hepatitis or other causes of infantile cholestasis. The diagnostic accuracy was 71%, sensitivity was 72%, and specificity was 69%. The gallbladder was detectable on sonography in 13 infants with biliary atresia and 26 infants with neonatal hepatitis or other causes of infantile cholestasis. Gallbladder contraction was not confirmed in 11 of 13 infants with biliary atresia and seven of 26 infants with neonatal hepatitis or other causes of infantile cholestasis. The diagnostic accuracy was 77%, sensitivity was 85%, and specificity was 73%.

CONCLUSION

The triangular cord sign was a more useful sonographic finding for diagnosing biliary atresia than gallbladder length and contraction.

Tracheoplasty for long segment congenital tracheal stenosis: analysis of 29 patients over two decades

PURPOSE

The authors determined the long-term outcome of patients who underwent surgical repair of long-segment congenital tracheal stenosis (LCTS) and compared the quality of cartilage graft and slide tracheoplasty techniques.

METHODS

Twenty-nine patients underwent surgical repair of LCTS at 29 days to 9 years of age. In 26 patients, more than 50% of the entire length of the trachea was involved. The early 12 patients (1981 through 1992) were treated with a costal cartilage graft for tracheal reconstruction. The remaining 17 patients (1997 through 2002) were treated with slide tracheoplasty. For both procedures, a median sternotomy was preferred because of convenience when using extracorporeal circulation and for simultaneous repair of associated cardiovascular anomalies.

RESULTS

Of the 12 patients who underwent a costal cartilage graft, 8 survived (66%). Six of these patients are free of disease, but 2 have persistent airway problems. Three patients died of residual stenosis and 1 of unrelated disease. Of the 17 patients who underwent slide tracheoplasty, 13 survived (76%), and 10 are free of disease. Three patients continue to require a stent because of tracheomalacia and granulation. Two patients died of cardiac failure, 1 of granulation, and 1 of aspiration pneumonia.

CONCLUSIONS

The authors challenged LCTS with a unique surgical approach and succeeded in making an incurable disease curable. When the cartilage graft technique is compared with slide tracheoplasty, however, the latter is preferable because it preserves native tracheal tissue with less frequent complications.

Laryngotracheal separation for intractable aspiration pneumonia in neurologically impaired children: experience with 11 cases

PURPOSE

Laryngotracheal separation (LTS) with or without end-to-side laryngoesophagostomy was performed as an antiaspiration procedure for intractable aspiration pneumonia in 11 children. The effectiveness of LTS for preventing aspiration was investigated.

METHODS

Eleven children aged from 9 months to 16 years with intractable aspiration pneumonia underwent LTS with (n = 8) or without (n = 3) laryngoesophagostomy at our institution over the last 2 years. Of these 11 patients, 7 underwent fundoplication with or without gastrostomy for gastroesophageal reflux (GER) before LTS (n = 5) or concurrently with LTS (n = 2). The effectiveness of LTS was evaluated by chart review and follow-up phone questionnaires.

RESULTS

LTS decreased the frequency of performing suction from an average of once every 30 minutes to once every 4.5 hours in all patients. In 5 patients who underwent fundoplication with gastrostomy before LTS, aspiration pneumonia remained unless they underwent LTS. Two patients who underwent LTS with or without laryngoesophagostomy tolerated oral feeding postoperatively. All parents rated LTS as excellent or good in terms of improving the quality of life.

CONCLUSIONS

LTS can be recommended for neurologically impaired children with intractable aspiration as a primary surgical intervention. If patients show impaired swallowing and GER, LTS could be performed simultaneously with fundoplication and gastrostomy.

Successful salvage of a long-standing collapsed lung by bronchoplasty in three children

BACKGROUND

The authors report successful salvage of the ipsilateral lung by a bronchoplastic procedure in 3 patients with a long-standing, totally collapsed lung.

METHODS

The 3 patients were 1, 5, and 6 years of age, and the left lung had been collapsed totally for periods of 13 months to 5 years. The origin of atelectasis was congenital in 2 patients and traumatic in one patient. Bronchoscopy showed complete obstruction of the left main bronchus. In each patient, the left lung was small and appeared as a liverlike organ. Entire length of the main bronchus was resected. The left lung was not aerated in spite of aggressive bagging through an endotracheal tube inserted into the distal bronchial stump. The bifurcation of the upper and lower segmental bronchi was anastomosed to the trachea by interrupted sutures. Histology of the resected bronchus in the cases of congenital origin showed bronchial rings represented by islands of immature cartilage.

RESULTS

Chest x-ray showed complete aeration of the left lung at 3, 4, and 5 months, respectively, after surgery in the 3 children. Bronchoscopy disclosed a well-reconstructed airway in all patients. Two of the 3 patients have been free from respiratory distress during a 3- to 4-year follow-up. The latest patient to have this surgery is undergoing home ventilation because of chronic lung disease.

CONCLUSIONS

A long-standing collapsed lung in children may reexpand if bronchial continuity is restored. Insufficient inflation of the lung at surgery is not an indication for pneumonectomy. When at all possible, a child's lung should be preserved.

Primary repair of pulmonary artery sling with double outlet right ventricle and distal tracheal stenosis

The fate of patients with pulmonary artery sling depends on associated tracheal lesions. Distal tracheal stenosis involving the carina frequently results in lethal obstruction due to secretion or inflammatory edema. Further-more, associated complex cardiac anomalies with excessive pulmonary flow make the situation more complicated. We present a case of successful simultaneous one-stage repair of pulmonary artery sling, double outlet right ventricle and distal tracheal obstruction. Pulmonary artery sling was relieved by relocation of the left pulmonary artery (left pulmonary artery to main pulmonary artery) and a tracheoplasty (resection and end-to-end anastomosis). We advocate early aggressive simultaneous repair of pulmonary artery sling with tracheal stenosis and concomitant repair of intracardiac anomalies whenever possible.

Surgical management for intractable cholangitis in biliary atresia

BACKGROUND/PURPOSE

The efficacy of antireflux surgical procedures involving the Roux-en-Y jejunal limb for cholangitis was evaluated retrospectively in patients with biliary atresia (BA).

METHODS

From July 1993 to December 2001, 41 patients with BA underwent hepatic portojejunostomy with Roux-en-Y reconstruction. Of these patients, 11 had intractable cholangitis that was treated by creation of a value with or without lengthening of the Roux-en-Y limb.

RESULTS

Among the 11 patients, the first episode of cholangitis occurred within 6 months after portojejunostomy in 10 patients and at the age of 4 years in one patient. Cholangitis developed at various intervals from once every week to once every 2 months requiring hospitalization each time. All patients underwent valve creation at 2 months to 5 years postoperatively, whereas 2 had an additional lengthening of the limb. Cholangitis resolved completely after surgery in all cases. Two patients underwent liver transplantation, and the third patient died of an unrelated cause. The 8 survivors with native livers are doing well after 1 to 8 years of follow-up.

CONCLUSION

Early surgical intervention could control intractable cholangitis in all patients, both delaying the time of liver transplantation and improving the quality of life.

Urinary sulfated bile acids: a new simple urine test for cholestasis in infants and children

BACKGROUND/PURPOSE

Measurement of urinary sulfated bile acid (USBA) has been reported as a simple urine test that reflects the degree of cholestasis. The authors report the diagnostic value of this new laboratory test in various cholestatic conditions affecting infants and children.

METHODS

A urine sample was collected from 4 surgical neonates with parenteral nutrition-induced cholestasis and 48 patients with biliary atresia (BA). USBA was measured by direct enzymatic assay.

RESULTS

In 3 patients receiving parenteral nutrition, USBA increased with caloric gains. For one surgical patient, a decrease in calories because of liver dysfunction resulted in a decrease of USBA, closely reflecting the fluctuations of caloric intake. In patients with BA, a significant positive correlation was noted between serum bile acid and USBA (r = 0.85; P <.01). Ten of 14 febrile episodes in 6 patients with liver dysfunction and increased C-reactive protein showed elevated USBA, thus diagnosed as cholangitis. Four febrile episodes caused by viral infection showed no elevation of USBA.

CONCLUSIONS

USBA is a simple and sensitive noninvasive test reflecting the degree of cholestasis in infants and children. USBA correlated highly with serum bile acid levels and may be helpful in diagnosis of cholestasis caused by cholangitis without blood sampling.

Congenital cricopharyngeal achalasia: Diagnosis and surgical management

BACKGROUND

Congenital cricopharyngeal achalasia is a rare condition in which a newborn presents with dysphagia, choking, nasal reflux, and salivation. Awareness of this condition is important because simple myotomy of the cricopharyngeus muscle often solves the problem.

METHODS

The diagnosis and the surgical management of cricopharyngeal achalasia were reviewed based on 4 cases experienced over the last 13 years.

RESULTS

The severity of the symptoms and the age of onset were dependent on the severity of achalasia. The cine-fluoroscopic swallow is an important diagnostic procedure. Surgery should be performed early enough for infants to learn how to swallow properly. The surgical procedure involves complete myotomy of cricopharyngeus, allowing the submucosa of the esophagus to bulge out in the posterior midline region. Postoperatively, nasopharyngeal reflux may resolve immediately or decrease over several months, depending on the timing of surgical intervention and the patient's ability to learn the act of swallowing.

CONCLUSIONS

Early surgical intervention for this disease is recommended to achieve early recovery from dysphagia and to establish buccopharyngeal swallowing during the appropriate period of development.

Congenital esophageal stenosis: Therapeutic strategy based on etiology

BACKGROUND/PURPOSE

The diagnosis and treatment of congenital esophageal stenosis (CES) can be a vexing clinical problem. This study aims at determining the ideal therapeutic strategy for the management of CES.

METHODS

Medical records of patients with CES were reviewed retrospectively with regard to diagnostic method, therapy, and outcome.

RESULTS

During the last 29 years, 36 patients, aged 1 month to 9 years, were found to have CES. Diagnosis was made by fluoroscopy, esophagoscopy, endoscopic ultrasonography (EUS), and pathologic examination. Of the 36 patients, 15 had tracheobronchial remnants (TBR), 13 had fibromuscular stenosis (FMS), 5 had membranous stenosis (MS), and 3 had multiple stenoses (MPS). EUS was diagnostic in distinguishing TBR from FMS. All patients with TBR underwent operative repair in which 13 patients had resection and anastomosis with or without preoperative dilation. The 14th patient had enucleation and the 15th underwent myotomy. Postoperative dilation was needed 2.2 times for 2.1 months on average in this group of patients. Ten patients with FMS were treated by dilation only (a mean of 4.7 dilations was required for a duration of 2.6 years), whereas 3 patients underwent open surgical intervention. Most patients with MS or MPS were treated by dilation (with or without endoscopic resection of the membranes), whereas 2 patients had surgical intervention. All patients in this study are doing well after a mean follow-up period of 5.3 years (range, 0.5 to 25 years) without any further operative interventions.

CONCLUSIONS

If the etiologic diagnosis of CES is unclear, EUS is useful in distinguishing TBR from FMS. This distinction is critical, because patients with TBR should undergo surgical resection, whereas most cases of FMS, MS, and MPS can be treated with esophageal dilation alone.

Multistaged extrathoracic esophageal elongation procedure for long gap esophageal atresia: Experience with 12 patients

PURPOSE

This study evaluates the multistaged extrathoracic esophageal elongation procedure performed on 12 babies with long gap esophageal atresia over 15 years.

METHODS

Eight babies had pure esophageal atresia, 2 had proximal tracheoesophageal fistula (TEF), and 2 had distal TEF. The gaps ranged between 2 and 7 vertebral bodies. Proximal esophagostomy, TEF ligation, and gastrostomy were performed initially. The proximal esophagus is elongated 2 to 3 cm each time by translocating the esophagostomy distally along the anterior chest wall at 2- to 3-month intervals. Sham-fed milk is collected in an ostomy bag and refed via the gastrostomy. The definitive esophageal reconstruction is performed at 5 to 24 months of age.

RESULTS

Only one elongation was required in 4 babies, 2 were needed in 5, 3 in 2, and 5 in 1 patient. All patients tolerated sham feeding well. After esophageal restoration, 3 patients had minor leakage. All (12 of 12) patients had anastomotic stenosis requiring multiple dilatations, of which, 3 needed resection of stricture. Eleven patients had gastroesophageal reflux that required fundoplication. Follow-up was possible in 11 patients for 4 months to 14 years after esophageal restoration. Seven early patients are eating normally.

CONCLUSION

Multistaged extrathoracic esophageal elongation is effective in stretching the proximal esophagus to bridge 2 to 7 vertebral bodies.

A new volumetric evaluation of partial splenic embolization for hypersplenism in biliary atresia

BACKGROUND/PURPOSE

Partial splenic embolization (PSE) has become an important therapeutic modality in the management of hypersplenism in biliary atresia (BA). Fifty percent to 80% of spleen is usually devascularized by embolization. The functional outcome, however, has not been correlated with embolized volume of the spleen. The authors propose a new, reliable method of predicting functional outcome using nonembolized volume of the spleen (NEVS) as an index.

METHODS

Between January 1993 and July 2000, 11 children with BA (2 boys and 9 girls, aged 5 to 10 years) underwent 12 PSE procedures. The follow-up period ranged from 6 to 77 months. The NEVS was calculated by enhanced computed tomography (CT) images, and an index was calculated by dividing NEVS with the predicted splenic volume for body weight (standardized NEVS ratio) 2 weeks after PSE.

RESULTS

Splenic volumes before PSE ranged from 312 to 1,201 cm(3) (mean, 875.8 cm(3)). NEVS ranged from 140 to 485 cm(3) (mean, 340 cm(3)). Standardized NEVS ratio ranged from 2.21 to 7.22 (mean, 4.25). The platelet counts with standardized NEVS ratio below 5.0 (group I) and above 5.0 (group II) were 15.1 x 10(4)/mm(3) and 7.2 x 10(4)/mm(3) at 6-month follow-up, respectively.

CONCLUSIONS

(1) Nonembolized volumetric evaluation is useful in predicting the functional outcome of PSE. (2) Reembolization is indicated for the patients with standardized NEVS above 5.0.

Posterior sagittal anorectoplasty for failed imperforate anus surgery: lessons learned from secondary repairs

PURPOSE

The aim of this study was to evaluate secondary operations using a posterior sagittal approach in patients with fecal incontinence and impaction after primary repair of anorectal malformations.

METHODS

Twenty patients (14 boys, 6 girls) who had previous failed surgery for imperforate anus underwent secondary operations. The indications for surgery included fecal incontinence (n = 16) and fecal impaction (n = 4). Patients ranged in age from 2 to 30 years (mean, 11 years), with 4 over the age of 20 years. The primary procedures included abdominosacroperineal (n = 7), sacroperineal (n = 10), and perineal (n = 3) pull-throughs. At surgery, none of the patients underwent a diverting colostomy. The rectum was mobilized from the surrounding structures through a posterior sagittal approach. The surgical findings included anteriorly displaced anus (n = 17), laterally displaced anus (n = 3), mesenteric fat surrounding the rectum (n = 4), mega-rectosigmoid (n = 2), and others (n = 3). The rectum underwent reconstruction, which involved relocation of the rectum and anus to surround them with the muscle complex.

RESULTS

Patients underwent follow-up for periods ranging from 8 months to 6 years after surgery (mean, 3 years). To evaluate the functional results, fecal continence scores (Templeton and Ditesheim) were calculated for incontinent patients. Of the 16 incontinent patients, 12 achieved continence and 4 some improvement. Of the 4 patients with fecal impaction, 2 achieved daily voluntary bowel movement, whereas the other 2 have mild constipation and need occasional enemas.

CONCLUSIONS

Our study suggests that (1) a secondary operation through a posterior sagittal approach can restore fecal continence and is efficacious even in adolescents and adults and (2) a posterior sagittal procedure can be safely performed without a diverting colostomy.

The evaluation of meconium disease by distribution of cathepsin D in intestinal ganglion cells

Meconium disease (MD) results in intestinal obstruction in the neonate where tenacious meconium is found in the distal ileum and proximal colon. The obstructive symptoms improve at several days of age after some of the meconium is passed. We observed premature infants with MD who underwent ileostomy for intestinal obstruction due to tenacious meconium. Afterward, meconium was passed well and the clinical symptoms improved. After closing the ileostomy, growth and defecation became normal. The MD in our cases was documented by histologic changes in the maturation of ganglion cells observed at the time of ileostomy creation and closure. For an objective evaluation of the maturation of intestinal ganglion cells (IGC), we attempted to distinguish immature from mature cells by the expression of cathepsin D. We examined the distribution of cathepsin D in IGC in patients with MD to test the hypothesis that ganglion-cell immaturity might be related to MD. In ganglion cells at the time of ileostomy, cathepsin D was detected in the perinuclear cytoplasm (immature staining pattern), while at the time of ileostomy closure it was detected in intense granules throughout the cytoplasm (mature staining pattern). We propose that it would be possible to evaluate the maturation of IGC by the intracellular distribution of cathepsin D in MD and suggest that immaturity of IGC might be the cause of MD.

Ingested ring-pull causing bronchoesophageal fistula and transection of the left main bronchus: successful salvage of the left lung and esophagus five years after injury

A 6-year-old girl with a history of ingestion of a ring-pull of a can and a transient episode of stridor had been asymptomatic 3 years before admission when left lung atelectasis with severe respiratory distress developed. Fluoroscopy and 3-dimensional computed tomography scan showed bronchoesophageal fistula and the ring-pull around the left main bronchus. At operation, the ring-pull, which transected the left main bronchus, was extracted. The left main bronchus was reconstructed by end-to-end anastomosis in spite of insufficient inflation of the collapsed left lung. The esophageal defect was repaired. The patient's respiratory distress gradually disappeared, and the x-ray films 3 months after operation showed complete expansion of the left lung. This case shows the risk of the long-term retained esophageal foreign body and the possibility of pulmonary salvage after long-term total atelectasis of the lung.

Surgical repair of rectovestibular fistula with normal anus

PURPOSE

The aim of this study was to evaluate the authors' surgical approach and technique in patients with congenital rectovestibular fistula with a normal anus (CRF).

METHODS

During the period between 1981 and 1995, 19 girls from 2 months to 13 years of age were treated surgically for CRF by a primary perineal approach. After appropriate bowel preparation, the patient was placed in a lithotomy position. A probing catheter was placed in the fistula. A perineal transverse skin incision was made on the midpoint between the posterior commissure and the anus, and the underlying tissue was dissected. The fistula was divided, and the both ends were closed by interrupted sutures. The external sphincter muscle was mobilized to interpose between the vestibular and rectal stumps of the fistula. Postoperative feeding was begun on day 6.

RESULTS

A protecting colostomy was created in the early 4 patients. Fifteen patients underwent a primary fistula division without colostomy. In those without colostomy, 1 patient had a reopening of the fistula 6 days after the primary repair. In this patient, colostomy was created, and the fistula was divided 6 months later by the same approach. After a follow-up of 3 to 17 years, all patients have normal bowel habit.

CONCLUSION

A primary perineal approach is appropriate for the treatment of CRF.

The mechanism of focal intestinal perforations in neonates with low birth weight

Among 36 neonates with intestinal perforations (IP) between 1975 and 1996, 5 had necrotizing enterocolitis (NEC IP) and 10 had focal IPs (FIP). A histologic review of the bowel near the perforations was made to see if there was any difference between cases of NEC IP and FIP. In 1 case of NEC IP, a defect in the musculature was found in addition to disappearance of the mucosal villi and dilated vessels or hemorrhage in the submucosa. Thinning or absence of the intestinal musculature and short villi in the mucosa was observed in 3 cases of FIP, but the acute ischemic changes in FIP were much less than in NEC IP. Hypothesizing that the defective musculature in FIP may be acquired by a vascular accident either before or after birth, we examined the histology of the latest consecutive infants diagnosed as having meconium peritonitis (MP) due to in-utero volvulus and perforation. In the tissue near the perforation, there was an identical focus of thinning and interruption of the musculature while the acute ischemic changes were minimal. We speculate that thinning or absence of the intestinal musculature in FIP may be a result of a transient ischemic event occurring in-utero and that FIP may develop in the damaged intestine after birth when it is fully dilated.

Postoperative intussusception after surgery for malrotation and appendicectomy in a newborn

Postoperative intussusception in the newborn is an infrequent condition. A 17-day-old female with duodenal stenosis and malrotation underwent excision of the membrane in the duodenum and incidental appendicectomy. Postoperatively, a ceco-colic type of intussusception occurred, necessitating a right hemicolectomy. We speculate that the causative factors are twofolds: the embedded appendiceal stump, a polyp-like protrusion that became a lead point, and the non-fixation of the ileocecal mesentery, which facilitated a ceco-colic type of invagination.

Jejunoileal atresia: a 27-year experience

PURPOSE

In this study, the authors review cases of jejunoileal atresia (JIA) to evaluate their surgical treatment strategy.

METHODS

Eighty-eight neonates who underwent surgical repair for JIA were divided into four groups for the type of lesion: group 1, membranous (n = 23), group II, interrupted (n = 49), group III, multiple (n = 9), and group IV, apple-peel (n = 7). Group I patients were treated with membranectomy or bowel resection and anastomosis, group II with resection of the dilated bowel and one anastomosis, group III with two to six multiple anastomoses to preserve bowel length, and group IV with minimal bowel resection and bowel anastomosis. During surgery a uniform protocol was used to minimize bowel resection and to perform an end-to-end single layer anastomosis using either Halsted horizontal mattress or conventional interrupted sutures. Mortality, morbidity, days for functional recovery, and central venous nutrition (CVN) were included in the review.

RESULTS

Of 88 patients, three died of causes unrelated to operation for JIA. Nine patients underwent an additional laparotomy for leakage (n = 4) and obstruction (n = 5). Oral feeding was allowed on day 5.4+/-4.3 and full caloric intake via the enteric route on day 12.5+/-10.0. Twenty-one patients required CVN for 32.4+/-19.1 days. None required a long-term treatment for the short bowel syndrome.

CONCLUSION

This study concludes that efforts to preserve bowel length are laudable to avoid the short bowel syndrome and that an end-to-end single layer anastomosis contributes to early recovery of bowel function.

Slide tracheoplasty: a case report of successful concomitant reconstruction of extensive congenital tracheal stenosis and pulmonary artery sling

An 8-month-old infant presented with an extensive congenital tracheal stenosis with an aberrant left pulmonary artery. The patient was treated successfully by relocation of the left pulmonary artery and tracheal reconstruction with slide tracheoplasty. This patient is the first survivor cited in the literature after concomitant repair using slide tracheoplasty.

Reappraisal of lateral cervical cysts in neonates: pyriform sinus cysts as an anatomy-based nomenclature

BACKGROUND/PURPOSE

Cervical cysts in neonates are recognized as rare branchial remnants. This term includes many different derivatives of the branchial cleft and sinus.

METHODS

A retrospective review was performed in seven neonates with lateral cervical cysts seen at a single institution between 1975 and 1996. Two patients underwent simple excision of the cyst before 1987. Since 1987, five underwent complete excision of the sinus with or without esophagoscopic assistance to identify the orifice of the pyriform sinus.

RESULTS

All of the cysts were located on the left side of the neck, anterior to the sternocleidomastoid muscle. Five had large cysts containing air. In four patients, a large orifice of the pyriform sinus was identified by the esophagoscopy. In six of seven patients, the histological examination showed thyroid or thymic tissue in the wall of the cysts, which is compatible with a clinical entity of "pyriform sinus fistula" commonly seen in older children.

CONCLUSION

We propose that this anomaly be called a pyriform sinus cyst, which is an anatomic term based on their draining orifice.

[Pulmonary artery sling with tracheal stenosis--primary repair in infancy]

Between 1984 and 1996 five infants underwent surgical repair of pulmonary artery sling associated with severe congenital tracheal stenosis. All infants had symptoms of severe respiratory distress and three of them required ventilator support preoperatively ages ranged from 2 to 11 months (mean age 6 months). Complete tracheal rings were present in all patients as an associated lesion and right upper lobe tracheal bronchus in 3 patients. The length of tracheal stenosis ranged from 18 to 45 mm (median 40 mm). Three had associated intracardiac anomalies (Scimitar syndrome (1), VSD (1), double-outlet right ventricle with VSD (1), double-outlet right ventricle with pulmonary hypertension (1)). Surgical intervention was carried out through a right thoracotomy (1) or median sternotomy (4). Cardiopulmonary bypass (CPB) was used in 3 patients and extracorporeal membrane oxgenator (ECMO). In 1. All infants had reimplantation of the left pulmonary artery into the main pulmonary artery left anterior to the trachea. Four patients underwent simultaneous tracheoplasty using costal cartilage grafts and one had complete resection of obstructed trachea between the right upper lobe tracheal bronchus and carina. The length of resected trachea was about 30% of the entire length of the trachea. Three infants underwent simultaneous intracardiac repair. There was no hospital death. All were weaned from ventilatory support and extubated on 1 to 16 months (mean 4, 5 months) postoperatively. AS an additional procedure, aortopexy, removal of granulation tissue or balloon dilatation of the trachea were carried out in one patient each following tracheoplasty using cartilage grafts. There was one late death at 1 year postoperatively. Three of 4 survivors are doing well with no stridor. We adonostridor. We adovocate 1) early aggressive primary repair of pulmonary artery sling with tracheal stenosis, 2) concomitant repair of tracheal lesion and intracardiac anomalies whenever possible, 3) application of CPB or ECMO to avoid cumbersome intubation technique, and 4) utmost effort to perform tracheal resection and end-to-end anastomosis.

The colon patch graft procedure for extensive aganglionosis: long-term follow-up

PURPOSE

During the last 17 years, the authors have used the colon patch graft (CPG) procedure to treat 11 patients with extensive aganglionosis. This study evaluates the effectiveness of the CPG procedure in treating patients with this disorder.

METHODS

An initial ileostomy was created during infancy in all 11 patients. At 1 to 21 months (mean, 5.5 months) of age, an 11- to 40-cm (mean, 18 cm) side-to-side ileocolostomy (CPG) was created between the ileum and aganglionic ascending colon, (including aganglionic ileum in three patients). Ten patients later underwent a Swenson-type definitive operation, the CPG segment being brought down to the anus at 9 to 30 months (mean, 19 months) of age. These 10 patients have been followed up for growth, development, and bowel habit patterns for the subsequent 5 to 17 years (mean, 12 years).

RESULTS

Within 1 month after the CPG was created, intravenous nutrition could be discontinued and the patients treated at home until time for the definitive procedure. During this period, one patient died of aspiration. After the definitive operation, body weight for age returned to a normal range in 2 to 4 years. Currently, seven older patients have one to three bowel movements per day, whereas three younger patients have explosive diarrheal defecations. None are incontinent of stool. Iron deficiency anemia developed in four patients. Two are mentally retarded, but the others are doing well in school.

CONCLUSIONS

(1) The colon patch graft procedure effectively reduces "ileostomy diarrhea," shortening the period of intravenous nutrition to 1 month, (2) bowel habit patterns improve with the advance of time, (3) body weight for age returns to normal 2 to 4 years after the definitive procedure, and (4) during long term follow-up, patients must be evaluated for iron deficiency anemia.

[Recent advance in the treatment of congenital esophageal atresia and congenital tracheal stenosis]

Advances in anesthetic management, neonatal intensive care and cardiovascular techniques for severe cardiac defects have permitted improved survival rate for esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) during the last two decades. In the treatment of EA-TEF, primary esophageal repair without staging or preliminary gastrostomy becomes popular among pediatric surgeons. In pure EA and long-gap EA with TEF, options for esophageal reconstruction include use of the native esophagus or replacement with colon or stomach. In considering the esophageal motility in patient's whole life, native esophageal reconstruction is the procedure of choice rather than esophageal replacement. Improved survival rates are noted irrespective of the traditional Waterson criteria, which now seem outdated. The surgical treatment of congenital tracheal stenosis have started in the early '80s. Resection of the stenotic trachea with end-to-end anastomosis has been available in the stenosis ranging less than 30% of the entire trachea. However, the treatment of long segment tracheal stenosis is still controvertial. Various surgical techniques including balloon tracheal split, slide tracheoplasty, implantation of autografts of pericardium and costal cartilage have been attempted. In this review, we described our own experience in tracheoplasty using costal cartilage.

Diaphragmatic eventration in infants and children: is conservative treatment justified?

PURPOSE

The purpose of this study is to examine the justification of diaphragmatic plication to treat diaphragmatic eventration. A retrospective review of 50 patients who underwent diaphragmatic plication for phrenic nerve injury (PNI) or congenital muscular deficiency (CMD) of the diaphragm was conducted.

METHODS

During the last 26 years, 50 patients, aged 4 days to 7 years, were surgically treated for diaphragmatic eventration. Twenty-five patients had iatrogenic PNI and another 25 had CMD. Respiratory distress developed in all patients who had PNI and 10 required mechanical ventilatory support for 13 to 78 days (mean, 41 days) before operation. Respiratory symptoms developed in 17 of 25 patients who had CMD, and four required ventilatory support. In those who were asymptomatic, we justified surgical repair to optimize future lung growth. All patients underwent diaphragmatic plication by a thoracic approach. Reefing mattress sutures on pledgets were used for the plication.

RESULTS

In patients who had PNI, ventilatory support could be discontinued within 0 to 6 days (mean, 3 days) after operation, with a dramatic improvement in their respiratory status. Two patients required reoperation because the plication was not tight enough. Seven patients died in this series, but none because of the diaphragmatic plication.

CONCLUSION

This study suggests that symptomatic patients who have diaphragmatic eventration should be operated on immediately with an expected dramatic resolution of their respiratory problems.

Congenital true diverticula of the esophagus: a case report

Pseudodiverticulosis secondary to gastroesophageal reflux is a common disease in adults, but true esophageal diverticula are rare in infants and children. A 5-year-old boy was well until the age of 1 1/2 years when he started vomiting. An upper gastrointestinal series showed two diverticula bulging from the posterior right side of the middle esophagus associated with slight hiatal hernia and short esophagus. Diverticulectomy, the Collis-Nissen antireflux procedure, and pyloroplasty were performed simultaneously through a left thoracoabdominal incision. Histological examination of the diverticula showed that the wall of each diverticulum consisted of a full-thickness of esophageal wall. Because there was no tracheal remnant in the diverticula, this lesion is more likely to be a true diverticulum than a duplication.

A shape memory airway stent for tracheobronchomalacia in children: an experimental and clinical study

The authors have designed a coil airway stent using a thermal shape-memory titanium-nickel alloy (SMA) to relieve airway collapse in children. A characteristic of alloy allowed the stent to be enclosed in the thin introducer tube and to position it bronchoscopically in the collapsed airway. When the stent is warmed to 37 to 40 degrees C, it expands to the memorized diameter and stents the airway. In eight rabbits, an experimental model of potentially fatal tracheomalacia was created by fracturing the tracheal cartilages. The stents of 6 mm in diameter and 15 mm in length were placed, and then the stents were recovered to their original shape within 1 minute. All rabbits except one showed no respiratory symptoms during the follow-up period. Results of bronchoscopy performed 6 and 10 months after implantation showed satisfactory patency of the trachea. The rabbits were killed for histological evaluation 6 to 28 months after implantation. The specimens showed little proliferation of granulation and no dislodgement of the stents. This procedure was attempted in two children who had severe bronchomalacia. One 5-year-old patient underwent implantation with a stent of 5 mm in diameter and 25 mm in length into the left main bronchus. The patient was relieved from apneic attacks. The stent was removed 2 years after implantation after a remarkable improvement of ventilation. The other patient with left bronchomalacia, age 1 year 2 months, underwent implantation with a 5-mm x 20-mm stent. The animal experiment and clinical experience indicated that (1) this stent can be easily inserted and removed bronchoscopically, (2) the stent has good tissue compatibility and little interference of mucociliary function, and (3) the SMA stent is a promising therapeutic adjunct in the management of children with severe tracheobronchomalacia.

Biliary atresia: current management and outcome

Between 1986 and 1994, 42 patients with BA were treated at the Kobe Children's Hospital. These patients underwent a wider excision of the hilar fibrous remnant with Roux-Y reconstruction (with or without intussuscepted valve) without stoma. Corticosteroids were used postoperatively when the stool was acholic or unsteadily cholic. The daily dose was reduced from 20 mg/day by half down. The patients were divided into two groups; in Group I (n = 17, before October 1990), a single course of corticosteroid therapy was employed. In Group II (n = 25, from November 1990 on), this regimen was repeated whenever the stool appeared less cholic. The bile flow improved significantly (excellent in 29% and 60%, and poor in 71% and 32% in Groups I and II, respectively.) Corticosteroids were used in 15 Group I patients with good response in 10 and in 21 Group II patients, 15 of whom had multiple courses. Sixteen of the 21 Group II patients had a good response. The incidence of the cholangitis was not significantly different between the 19 patients with valve and the 23 patients without valve. A 5 year survival significantly improved from 70% in Group I to 96% in Group II. In both groups, the survival rate significantly increased, when compared with the survival rate figured out with an assumption of OLT survivors as dead. On the same assumption, the survival rate of Group II is significantly more than that of the Group II. These suggest a positive contribution of liver transplantation and an aggressive corticosteroid therapy on better survival of Group II.

Successful endoscopic balloon dilatation for hypertrophic pyloric stenosis

The authors successfully applied endoscopic balloon dilatation for the treatment of hypertrophic pyloric stenosis (HPS). The patient was an infant girl who had undergone repair of a giant omphalocele. Endoscopic balloon dilatation was performed using a 9-mm endoscope and an 8-mm polyethylene terephthalate (PET) balloon dilator. Dilatation was performed three times for 10 minutes. Vomiting continued after the dilatation. At the second session, dilatation was performed using a 12-mm PET balloon dilator. The 9-mm endoscope then passed through the pylorus. The patient has had no episodes of vomiting since the second treatment. This procedure is an important therapeutic option for selected patients with HPS.

[Currarino triad : a case report]

The authors report a case of Currarino triad comprising anorectal malformations, sacral bony anomaly and presacral mass. A 1-year-old boy was presented with constipation as his chief complaint. No neurological deficit was found on admission. There was no cutaneous evidence of underlying spinal dysraphism. Lumbar X-ray films showed bony defect caudal to the third sacral vertebra. A barium-enema examination revealed an anterior displacement of the rectum. A myelography showed a presacral cavity filled with contrast medium. MRI demonstrated a thick filum terminale, and a round hypointense mass in the pelvis on T1 weighted images and hyperintense on T2 weighted images. Surgically we released the thick filum terminale, and obliterated the anterior sacral meningocele, because total removal would have been hazardous. Postoperatively transient dysuria was observed for a month, and the difficulty in defecation persisted. Recognition of this rare condition will lead to correct diagnosis and proper treatment.

Posterior plication of the rectum for rectal prolapse in children

Fourteen patients with rectal prolapse (age range, 1 to 12 years) underwent posterior plication of the rectum for rectal prolapse. The procedure consisted of (1) natal cleft incision, (2) midline separation of the levator muscle, (3) dissection of two thirds of the circumference of the rectum, (4) plication of the posterior wall of the rectum using U-shaped mattress sutures, and (5) fixation of the sutures of the rectal wall to the coccyx. There has been no recurrence of prolapse in any of the patients. The authors' experience suggests that an elongated rectum is responsible for prolapse. This simple but definitive technique is recommended.

Left main bronchus compression after aortic reconstruction for interruption of aortic arch

A case of the left main bronchus obstruction after an aortic reconstruction for interruption of the aortic arch is reported. Clinical features and successful management are described, and a mechanism for this complication is speculated on.

[Experimental study of an intratracheal stent made of shape memory alloy]

To develop a new prosthesis for treating tracheal stenosis and tracheobronchomalacia, we examined the usefulness of an intratracheal stent made of shape memory alloy (SMA), a titanium-nickel alloy composed of 50% of each metal. At its recovery temperature (37 degrees C), the SMA stent was designed to recall the memorized shape of a coil with a diameter of 5 or 6 mm and a length of 10 mm. For the present experiment, it was transformed to a smaller coil 3 mm in diameter at a low temperature (-50 degrees C) and then loaded into the prosthesis introducer tube. An experimental model of potentially fatal tracheomalacia was made surgically by cutting and fracturing the tracheal cartilages of rabbits and tracheal collapse was confirmed by rigid bronchoscope. The introducer tube with the SMA stent was inserted and then the prosthesis was advanced into the collapsed segment of the trachea using the stent pusher. The SMA stent warmed bo body temperature and recovered its memorized shape after 1-2 min. In 3 out of 8 rabbits, follow-up bronchoscopy performed at 6, 8, and 10 months after implantation revealed satisfactory patency of the SMA stent and the trachea. After follow-up, 3 animals were sacrificed for histological observation, which showed little proliferation of granulation tissue and no dislocation of the SMA stent from the malacic portion. The remaining 5 rabbits have been followed for 18-24 months and are doing well. We conclude that the SMA stent maintains good tracheal patency, causes little reaction in the tracheal wall, and is easy to handle. Thus, it shows the potential for clinical application.

The use of omental pedicle flap for tracheobronchial reconstruction in infants and children

For the surgical repair of long-segment tracheal stenosis, costal cartilage graft or extensive resection with end-to-end anastomosis has often been used. Both procedures have a risk of developing anastomotic leakage, which is potentially a lethal complication, or stenosis resulting from compromised blood supply to the tissue at the anastomosis. We have used omental pedicle flap (OPF) to seal the anastomotic line and to restore the vascularity of the graft and the trachea in an attempt to avoid fatal complications. During the period between 1986 and 1990, OPF technique was used in tracheobronchial reconstruction in six patients aged 4 months to 3 years; cartilage graft for extensive tracheal stenosis (4), tracheal resection and anastomosis (1), and bronchial resection and anastomosis (1). The omentum was separated from the colon to form an OPF with the right gastroepiploic vessels preserved. The OPF was brought to the upper trachea in the mediastinum through the retrosternal space. There was no immediate postoperative death due to anastomotic leak. Endotrachial tubes were removed in all patients. Four of the six are totally free of airway problems. One patient showed persistent stridor because of remaining stenosis at the cervical trachea. The remaining one patient who underwent bronchial resection developed anastomotic stenosis probably due to the compression of the floppy left main bronchus by adjacent aorta. The OPF seems to be an important surgical adjunct in order to eliminate fatal complications in tracheobronchial reconstruction.

Surgical treatment of airway obstruction associated with congenital heart disease in infants and small children

In the last 12 years, 21 patients age 1 month to 5 years (median, 7 months) underwent surgical treatment for severe airway obstruction associated with congenital heart disease. Plico-suspension of the pulmonary artery was carried out in 14 patients with documented severe left bronchial compression by a distended pulmonary artery together with repair of ventricular septal defects (11 patients), repair of large coronary artery fistula (1), division of ductus (1) and pulmonary artery banding (1), with subsequent significant relief of compression. Aortopexy was used in 2 patients with documented severe tracheal compression by a right aortic arch. Five patients had congenital tracheal stenoses (3 extensive, 2 localized). Two of 3 patients with associated complex intracardiac anomalies underwent concomitant repair of both lesions with the use of cardiopulmonary bypass and 1 had a tracheoplasty and pulmonary artery banding. Tracheal reconstruction with a cartilaginous graft together with repair of pulmonary artery sling was carried out in 2 infants. Nineteen patients are alive and well, at a mean follow-up of 87 months. In conclusion, we advocate early aggressive surgical intervention to both lesions to obtain a better result in the management of infants and small children with this difficult and often fatal combination.