Pancreaticobiliary maljunction: retrospective and nationwide survey in Japan

Pancreaticobiliary maljunction (PBM) is a congenital anomaly defined as a union of the pancreatic and biliary duct that is located outside the duodenal wall. The Japanese Study Group on Pancreaticobiliary Maljunction and the Committee for Registration enrolled and analyzed 1627 patients with PBM who had been diagnosed and treated from January 1, 1990 to December 31, 1999 at 141 hospitals throughout the country. There were 1239 patients with dilatation of the bile duct (group A) and 388 patients without dilatation (group B). The average age was 24 years in group A and 47 years in group B; the age was significantly higher in group B. The type of confluence between the terminal choledochus and the pancreatic duct has been classified into three types (type a, right-angle type; type b, acute-angle type; and type c, complex type). In group A, type a accounted for 57.9% and was significantly more frequent compared with the other types (type b, 32.4%; type c, 5.6%). In group B, type b accounted for 60.8%, being significantly more frequent compared with the other types (type a, 29.4%; type c, 7.2%). Subjective symptoms, preoperative complications (e.g., liver dysfunction and acute pancreatitis), pancreatic stone, and pancreatic duct morphological abnormality were significantly more frequent in group A. However, the amylase levels in the bile and gallbladder were significantly higher in group B, and the presence of gallstone and morphological abnormality of the gallbladder was significantly more frequent in group B. The occurrence rate of cancer in the biliary tract was 10.6% in group A and 37.9% in group B, being significantly higher in group B. In group A, cancer of the extrahepatic bile duct was seen in 33.6% and cancer of the gallbladder was seen in 64.9%, but gallbladder cancer was present significantly more frequently in the patients with diffuse or cylindrical dilatation, and bile duct cancer was present significantly more frequently in the patients with cystic dilatation. In group B, 93.2% of the patients had gallbladder cancer, and bile duct cancer was found in as few as 6.8%. Against this background Japanese surgeons regard cholecystectomy, resection of the extrahepatic bile duct, and hepaticojejunostomy as standard operations for PBM with dilatation of the bile duct. However, opinion on whether or not the bile duct should be removed in the treatment of PBM without dilatation of the bile duct has been divided among Japanese surgeons. A randomized controlled trial is necessary.

Smallest Todani's type II choledochal cyst

A choledochal cyst is defined as an isolated or combined congenital dilation of the extra hepatic or intrahepatic biliary tree. Todani and colleagues proposed the five types of congenital choledochal cysts which have gained widespread acceptance. Type II choledochal cyst, a diverticulum of common bile duct, is rarest, and most reported cases of Type II were as large as several centimeters in size. We herein report the case of a small Type II choledochal cyst which was resected at pancreatoduodenectomy for carcinoma of the papilla of Vater. A 58-year-old Japanese male was referred to our hospital for the evaluation of jaundice. Preoperative cholangiogram via the percutaneous transhepatic biliary drainage tube revealed a complete obstruction at the narrow terminal segment. Furthermore, a small diverticular protrusion was demonstrated on the lower part of the common bile duct. The resected specimen showed a 2.2 x 1.7 x 1.2 cm carcinoma of the major papilla, and a deep, 2 mm in diameter and 5 mm in depth, depression on the posterior wall of the common bile duct. The anomalous pancreatobiliary duct was not seen. The deep depression was confirmed microscopically to penetrate the fibromuscular layer of the common bile duct and diagnosed as a Todani's Type II choledochal cyst. To our knowledge, the current case is the smallest Type II choledochal cyst which was completely resected.

Bile duct cancer developed after cyst excision for choledochal cyst

Oncogenesis after cyst excision for choledochal cyst and suitable surgical procedures for this operation are discussed. The clinical data of 23 patients with cancer of the biliary tree after excision of choledochal cyst reported in the English-language and Japanese literature were reviewed, and data for 1353 Japanese patients with choledochal cyst and/or pancreaticobiliary malunion were analyzed. In the 23 patients reported in the literature, age at cyst excision ranged from 1 to 55 years (average, 23.0 +/- 13.7 years), and cancers were detected at age 18-60 years (average, 32.1 +/- 12.2 years), with intervals between cyst excision and cancer detection of 1-19 years (average, 9.0 +/- 5.5 years). Sites of cancer development were: intrahepatic, six; anastomotic, eight; hepatic side residual cyst, three; and the intrapancreatic duct, six. In the Japanese patients with choledochal cyst and/or pancreaticobiliary malunion, the incidence of cancer associated with primary choledochal cyst and/or pancreaticobiliary malunion was 16.2% (219/1353). The incidence of cancer development after cyst excision in this population, of whom 1291/1353 underwent surgery, was assumed to be 0. 7%. Nearly half of the 23 patients in the literature had undergone inadequate cyst excision. Oncogenesis of cancers after cyst excision is possibly different from that of choledochal cysts.

Germ-cell degeneration in experimental unilateral cryptorchidism: role of apoptosis

We investigated the possible involvement of apoptosis in the increased germ-cell degeneration in undescended testes (UDT). Experimental unilateral cryptorchidism was induced in 21-day-old rats, and both testes were removed for in-situ TUNEL staining of apoptotic cells at 1, 3, 7, 10, and 14 days postoperation. A gradual increase in the incidence of apoptosis was seen at 21-28 days of age in the control testes, followed by a decrease thereafter. After 10 days postoperation, the weight of the UDT was significantly lower than that of the contralateral descended testis (CDT) and the controls. However, the weight of scrotal testes in each group was similar. UDTs demonstrated a markedly increased incidence of apoptosis. By 7 days postoperation, the percentage of seminiferous tubules containing apoptotic germ cells significantly increased in UDTs compared with that in CDTs and controls (P < 0.001). Moreover, there was a significant difference in the percentage of seminiferous tubules containing apoptotic germ cells between CDTs and controls (P < 0.01). In addition, an increased incidence of seminiferous tubules containing 8-10 and >10 apoptotic germ cells from 7, 10, and 14 days postoperation in UDTs was detected. In-situ TUNEL analysis demonstrated spermatocytes to be the main type of germ cells affected in all groups. These findings suggest that spermatogenesis decreases not only in the UDT, but also in the CDT, and that the germ-cell degeneration in cryptorchidism took the form of apoptosis.

Esophageal hiatal hernia after omphalocele repair

Esophageal hiatal hernias (EHH) are probably caused by congenital, traumatic, or iatrogenic factors, although the etiology remains unknown. EHHs may develop after abdominal wall closure for omphalocele or gastroschisis due to the increased intra-abdominal pressure, however, there have been few reports in the literature. We present a case of EHH developing after abdominal wall closure.

Co-existing biliary anomalies and anatomical variants in choledochal cyst

BACKGROUND

Excision is the treatment of choice for choledochal cyst, and free bile drainage is essential to avoid ascending cholangitis. However, anastomosis between the relatively narrow common hepatic duct and bowel (conventional anastomosis) in case of type IV-A cyst, co-existing biliary anomalies and anatomical variations may cause ascending cholangitis resulting from insufficient biliary decompression.

METHODS

One hundred and four patients with choledochal cyst were treated by cyst excision. Conventional anastomosis was performed in 22 patients and hilar anastomosis in 82.

RESULTS

An anastomotic stricture developed in nine of the 22 conventional anastomosis cases and all required reoperation. Of the 82 hilar anastomosis cases, only one required reoperation for a primary stricture. Co-existing biliary anomalies and anatomical variants were seen in 26 patients: (1) primary stricture in 18; (2) aberrant posterior duct in two; (3) low confluence of the hepatic ducts in two; (4) aberrant hepatic artery in two; and (5) very small bile duct in two. All 26 patients underwent widening of the ductal lumen (ductoplasty) or additional procedures.

CONCLUSION

Complete removal of the extrahepatic bile duct and a wide hilar anastomosis is essential to prevent ascending cholangitis. Ductoplasty or additional procedure can be performed only at the hilum.

The effects of adenosine on the energy metabolism of the reperfused intestine in rats

The effects of adenosine on energy metabolism in the intestine during reperfusion after intestinal ischemia were examined in rats subjected to intestinal ischemia for 60 min by clamping the superior mesenteric artery, followed by 20 min reperfusion with tested agents. The rats were divided into a control group, a 200 micrograms adenosine group, a 500 micrograms adenosine group, and a 500 micrograms adenine group. Jejunal tissues were taken preischemia, 30 and 60 min post-ischemia, and 20 min after starting reperfusion. Adenosine triphosphate, -diphosphate, -monophosphate, and thiobarbituric acid reactive substances (TARS) of lipid peroxidation were measured by high-performance liquid chromatography or spectrophotometry. The ATP levels in the jejunal tissues decreased extensively 30 min after ischemia, but no further decrease was observed 60 min after ischemia. These levels recovered slowly 20 min after starting reperfusion in the control group, but they recovered significantly in the 500 micrograms adenosine group and moderately in the adenine group, with no significant difference between the 200 micrograms adenosine and control groups. Thus, the effect of adenosine on energy metabolism appears to be dose-dependent. The TARS levels increased significantly during ischemia and reperfusion, but no significant difference was observed between the control and 500 micrograms adenosine groups. In conclusion, adenosine promotes the rapid resumption of ATP levels during reperfusion, but adenine is less effective. Adenosine does not affect lipid peroxidation mediated by free radicals.

Conservative management of fistula in ano in infants

We analyzed the natural course of fistula in ano (FIA) and/or perianal abscess (PAA) in 97 children (male: 90, female: 7) and recommend conservative management in infants. Nearly one-half of these children had no recurrent episodes, and 80% of the infants recovered spontaneously within their 1st year of life. A radical operation was required in only 6 children after 2 years of age. Two-thirds of the children with a PAA did not develop fistula. Of the children who developed FIA, 42% had no recurrence. Although the duration of FIA was relatively longer than that of PAA, 55% of the children were cured within 1 year. PAA and/or FIA in infants is likely to be a period-limited disorder that occurs mainly in infancy and spontaneously resolves within 1 year of life. Fistulotomy or fistulectomy should be avoided in infants.

Standard splenic volume in children and young adults measured from CT images

The number of children and adolescents with hypersplenism is increasing as the number of long-term survivors undergoing successful Kasai operation for biliary atresia increases. The aim of this study was to determine the standard splenic volume in normal children and adolescents. We measured the splenic volumes with computed tomography (CT) images obtained from 49 Japanese children, adolescents, and young adults, ranging from 9 days to 25 years of age, and from 3.0 kg to 89.0 kg of body weight. The best correlation was observed between splenic volume (SV: cm3) and body weight (BW: kg) with a power curve regression; SV = 6.516 BW0.797, r = 0.924. The splenic volume and age (AG: years) also correlated well on a power curve; SV = 41.879 AG0.411, r = 0.897. The ratio of the splenic volume to the body weight (SV/BW: cm3/kg) decreased with age; from 4.5 cm3/kg at 1 month to 2.4 cm3/kg at 25 years of age, according to an exponential curve; SV/BW = 4.473e-0.026AG, r = 0.593. The above formulas are thus considered to be clinically useful, especially in the assessment of splenic size in children with hypersplenism both before and after partial splenic embolization.

Carcinoma of the colon in childhood; report of 2 cases expressing p53 without K-ras mutation

We report on 2 children with colonic carcinoma and also review 62 cases of Japanese children with colonic carcinoma including ours. Although the dismal prognosis in colonic cancer in children is possibly due to the predominance of poorly differentiated carcinoma, there is no significant difference in the 5-year survival rates among well, moderately and poorly differentiated carcinomas in children. Positive staining with p53 in tumor cells was observed in each, but K-ras mutations were not detected in any. Therefore, these carcinomas possibly developed from de-novo carcinoma. The development pathway of colonic carcinoma may relate to the prognosis in children, and be different from that in adults.

Spiral computed tomography with 3-dimensional reconstruction for the diagnosis of tracheobronchial stenosis

We report on the usefulness of spiral computed tomography (CT) with 3-dimensional (3D) reconstruction in the diagnosis of tracheobronchial abnormalities based on three cases of children with congenital tracheobronchial strictures. Images were reconstructed using a curved planar reformat and shaded surface display. The images obtained from our three cases of tracheal stenosis, subglottic stenosis and tracheobronchial strictures were extremely clear. Spiral CT with 3D reconstruction provides excellent anatomic delineation of the tracheobronchial airway, and is safe and less invasive than tracheobronchography.

Anti-asthma effect of an antiviral drug, acyclovir: a clinical case and experimental study

BACKGROUND

Although acyclovir (9-(2-hydroxyethoxymethyl) guanine) is an antiviral drug that inhibits DNA polymerase of herpes virus, we have had the experience of an asthmatic patient's peak flow rate being improved by oral administration of acyclovir.

OBJECTIVE

The aim of this experiment is whether acyclovir has anti-asthma effects using an asthma model in guinea-pigs.

METHODS

The airway response was induced by a single inhalation of calcium ionophore A23187 (2 mg/mL). The airway obstruction was estimated by the ratio of expiration to inspiration time (E/I). The peribronchial eosinophil infiltration and eosinophil influx into bronchoalveolar lavage (BAL) fluid 7 h after the inhalation were also examined. To assess the effects of acyclovir (1, 10, and 100 mg/kg), aminophylline (20 mg/kg) and pemirolast potassium (TBX, 20 mg/kg) on A23187-induced asthmatic response, the drugs were intraperitoneally administered before the inhalation.

RESULTS

The immediate airway obstruction was significantly suppressed by acyclovir (10 mg/kg) and aminophylline, whereas different doses of acyclovir (1 and 100 mg/kg) and TBX showed only a small inhibitory effect on the airway obstruction. On the other hand, the peribronchial eosinophilia was most successfully inhibited by TBX. Acyclovir (10 mg/kg) and aminophylline also suppressed the eosinophilia significantly. Furthermore, acyclovir significantly suppressed eosinophil influx into BAL fluid, whereas aminophylline and TBX weakly suppressed the influx.

CONCLUSION

These results suggest that acyclovir exhibits not only antiviral but also antiasthma activity.

Liver volume in children measured by computed tomography

Liver volume was measured by computed tomography in 54 children and young adults with no history of liver disease. Their ages ranged from 10 days to 22 years. The volume was calculated as follows: (1) the edges of the liver were traced on each scan image and the area was calculated by computer; (2) the areas were summed and multiplied by the scan interval in centimeters. The mean liver volume (+/-SD) was 178.2 +/- 81.9 cm3 in infants (less than 12 months old) and 1114.3 +/- 192.9 cm3 in adolescents (more than 16 years old). The mean liver volume in relation to body weight (+/-SD) was 34.1 +/- 5.5 cm3/kg in infants and 20.2 +/- 3.1 cm3/kg in adolescents. In general, liver volume increases rapidly in infants, gradually in schoolchildren, and not at all in adolescents. Volumetry might be clinically useful for evaluating the liver function in children and determining the graft size in liver transplantation.

Bone mineral analysis in patients with biliary atresia after successful Kasai procedure

Metabolism is probably disturbed in patients with abnormal liver function who have undergone a successful Kasai procedure. We examined bone mineral metabolism in patients who have successfully undergone Kasai procedure. Bone mineral metabolism was examined in 8 patients with biliary atresia after a successful Kasai procedure. Five patients were female and 3 were male. The ages at Kasai procedure ranged from 50 to 80 days, and the follow-up periods ranged from 3 to 27 years after the operation. All patients eat a normal oral diet. We examined plasma levels of 25-OH-D3, 1, 25-(OH)2-D3, Ca and phosphorus (P). Bone mineral content of the lumbar spine (L2-L4) was assessed by dual energy x-ray absorptiometry (DEXA), and the data were expressed as a bone mineral density (BMD). Two patients showed abnormal levels on hepatic function tests. Plasma levels of 1, 25-(OH)2-D3, Ca, and P were normal in all patients. The level of 25-OH-D3 was normal in 7 patients. BMD levels were normal in 6 patients, but low in 2 who had undergone partial splenic embolization and splenectomy, respectively, due to hypersplenism. In long-term survivors of Kasai procedure, measurement of BMD may detect bone mineral deficiency earlier than measurements of serum levels of 25-OH-D, 1, 25-(OH)2-D, Ca and P.

Ductoplasty for an aberrant hepatic duct in a choledochal cyst

The confluence of the right and left hepatic ducts at the hepatic hilum frequently shows normal anatomic variations. Choledochal cysts (CC) are also accompanied by similar variations, and devices for free drainage of bile are occasionally required in biliary reconstruction. We present a CC that had an aberrant posterior branch of the right hepatic duct draining into the distal common hepatic duct. A capacious hepaticoduodenostomy at the hilum was performed after joining the hilar and aberrant ducts.

Changes of hepatic volume after successful Kasai operation

The number of long term survivors who have undergone Kasai operation for biliary atresia is increasing, but some have a hepatic dysfunction likely to require liver transplantation in the near future. Hepatic volume possibly reflects whole liver function, and our objective was to assess the changes of hepatic volume after Kasai operation. Ten patients were studied. Ages ranged from 3 to 27 years. They underwent Kasai operation at ages ranging from 50 to 80 days. Liver areas (cm2) on CT images were measured with an image processing and analysis program (NIH Image 1.57). Hepatic volume (cm3) was calculated by summing up the areas of each image and multiplying by slice thickness (cm). After Kasai operation, the size of the liver increased to 1.7-1.9 times the standard volume, and then reduced to normal size around 5 years of age. In the teens, hepatic volume decreased below the standard volume. Segmental hypertrophy accompanying atrophy of other hepatic segments was observed in 9 out of 10 patients; right lobe hypertrophy: 6, medial segment: 2, and lateral segment: 1. Therefore, progressive hepatic atrophy begins in the teens, but is compensated for by segmental hypertrophy.

Congenital right diaphragmatic hernias through posterolateral and anterolateral defects associated with extralobar pulmonary sequestration: a case report

Multiple diaphragmatic hernias in the unilateral diaphragm are extremely rare. The authors report a neonate with diaphragmatic hernias through two defects in the right diaphragm: a posterolateral defect without a hernia sac and an anterolateral defect with one. After excision of the anterolateral hernia sac, each defect was closed. Histology studies showed extralobar pulmonary sequestration in the removed hernia sac. The presence of sequestrated pulmonary tissue indicates the possibility of interference with the closure of the pleuroperitoneal canal and muscularization in the diaphragm, which may result in multiple defects.

Modified Kasai's procedure for a choledochal cyst with a very narrow hilar duct

Excision has been widely recognized as the treatment of choice for choledochal cysts. For biliary reconstruction after cyst excision, we have strongly recommended hepaticoenterostomy at the hepatic hilum with a wide anastomotic stoma to prevent postoperative cholangitis. However, we recently treated two infants in whom a wide anastomotic stoma could not be made due to a narrow hilar duct. Therefore, a hepatic portojejunostomy with Roux-en-Y anastomosis (Kasai's procedure) was performed after cyst excision in both case to permit free drainage of bile. The mucosa of the hilar duct was everted and fixed to the liver parenchyma to prevent stricture formation. Both babies have done well since the surgery.

[Cancer arising in choledochal cyst and management]

Biliary cancer develops in 20-30% of the patients with choledochal cyst and pancreatobiliary malunion. Some bile acid fractions and refluxed pancreatic enxymes into the bile duct is probably responsible for carcinogenesis. Cancer often develops in the extrahepatic bile duct and gallbladder, and rarely in the intrahepatic duct. In cystic dilatation, cancer often occurs in the common bile duct, while in diffuse or non-dilated type it occurs in the gallbladder. Cancer usually occurs in younger patients than does biliary cancer in general population, and the average age is in the 40s. The risk of malignancy in cysts with internal drainage is higher than that in primary cysts, and early removal of the retained cyst should be performed as quickly as possible. Although the prognosis of biliary cancer is usually dismal, aggressive procedures are recently gaining better results than that by conventional methods. The prevention of cancer is the procedure of choice by early excision. Removal of the whole extrahepatic bile duct is necessary, even in case of malunion with no biliary dilatation. Cancer rarely arises in the intrahepatic duct after excisional surgery, due to long standing biliary stricture. Wide anastomosis with ductoplasty should be essential. Cancer also occurs in the remnant duct. Excision of the distal duct in the pancreas is also necessary.

Changes in splenic volume after partial splenic embolization in children

AIM

The authors studied changes in splenic volume after partial splenic embolization (PSE) in children who had thrombocytopenia caused by splenomegaly.

MATERIALS AND METHODS

Five children with hypersplenism (ages of 1, 6, 7, 10, and 14 years) underwent PSE. The follow-up period ranged from 1 month to 8 years 9 months. Whole and infarcted splenic volumes were measured from computed tomography images obtained before and after PSE.

RESULTS

Within 2 weeks after PSE, the whole splenic volume increased to 110% to 140% of the pre-PSE volume. The infarcted area disappeared 3 to 4 months after PSE, and the whole splenic volume decreased markedly. The decreased volume tended to be stable during the follow-up period. The splenic enlargement before PSE ranged from 7.2 to 14.2 times the standard splenic volume for a corresponding body weight. The splenic volume did not become normal after PSE; it remained between 2 and 7 times larger than standard. Platelet counts stayed above 10 x 10(4) /mm3 when the splenic volume reduced to 2 times the standard volume.

CONCLUSION

The first 4 weeks after PSE is the most dangerous period for the development of splenic capsule. The infarcted parenchyma is absorbed 3 to 4 months after PSE, and the whole splenic volume is reduced. Thereafter, the splenic volume is stable for several years. Reembolization is not likely to be necessary in the majority of patients who have had splenic embolization with an infarction rate of > or = 80%.

Alveolar rhabdomyosarcoma of the lung in a child

The case of a 22-month-old boy with alveolar rhabdomyosarcoma of the lung is presented. Brain metastasis and recurrence of the right pulmonary hilum and parietal pleura developed 6, 11, and 24 months (respectively) after tumor resection. Chemotherapy and radiotherapy were effective. Neuron-specific enolase was very helpful in detecting metastasis and disease recurrence. Primary pulmonary rhabdomyosarcoma can be divided into two groups: tumor in the normal lung, and tumor in cystic lesions of the lung.

Does hyperamylasemia in choledochal cyst indicate true pancreatitis? An experimental study

Patients with choledochal cyst often have repeated attacks of abdominal pain accompanied by hyperamylasemia, and they may be diagnosed as having acute pancreatitis. However, the attacks generally tend to subside in a short period by conservative treatment, and evidence of pancreatitis is rarely observed at the time of surgery. Choledochal cyst is commonly associated with pancreatobiliary maljunction, and high concentrations of pancreatic enzymes in bile are usually observed. When the bile duct pressure increases due to obstructive cholangitis, pancreatic enzymes in bile may regurgitate into the blood stream. Cholangiovenous reflux of amylase might cause hyperamylasemia. In order to investigate the mechanism of hyperamylasemia by cholangiovenous reflux, canine pancreatic juice or bile from a patient with choledochal cyst was injected into the obstructed common bile duct in dogs. The pancreatic enzymes in bile could readily enter into the blood stream at the pressure level of 15 mmHg or more in the bile duct. The peak amylase level in the thoracic lymph was observed to be more than 4 times higher than that in the blood serum, and the lymph flow during 30 minutes increased significantly from 8.1 to 20.4 ml at the bile duct pressure level of 20 mmHg. The reflux of amylase in bile into the blood stream via both the hepatic vein and thoracic duct might result in hyperamylasemia in the patients with choledochal cyst.

Characteristics of choledochal cysts in neonates and early infants

Thirty-six infants with choledochal cyst consisting of 28 babies less than 12 months of age and 8 between 13 and 24 months of age, were analyzed. Characteristics of cases were as follows: (1) they were usually of the cystic type, (2) a huge abdominal mass and jaundice with alcoholic stool were typically found, (3) no symptom suggesting acute pancreatitis was observed, (4) amylase levels in bile were usually low, despite the presence of pancreatobiliary malunion, while other pancreatic enzymes in bile commonly showed a high concentration, and (5) primary cyst excision and biliary reconstruction was the treatment of choice, and could be safely performed with favorable outcomes even in babies less than 1 year of age.

Peritoneal lavage versus drainage for perforated appendicitis in children

A total of 231 children with acute appendicitis were treated at our hospitals during the 10 years between 1984 and 1993, 53 of whom had a perforated appendix. These 53 patients were randomly assigned to two groups at the time of surgery according to the different procedures performed. Thus, 29 children were managed by appendectomy followed by peritoneal lavage using a large amount of saline, and intravenous antibiotic therapy consisting of aminoglycoside and cephem (lavage group), while the other 24 children were treated by appendectomy with silicon tube drainage and the same systemic antibiotic therapy (drainage group). The mean length of hospitalization, and the mean durations of fever and the need for fasting after laparotomy in the lavage group were significantly less than those in the drainage group: 10.1 versus 18.8 days, 2.8 versus 7.7 days, and 1.8 versus 3.5 days, respectively. The operation wounds healed well in the lavage group due to the fact that there was no drain. Wound infections occurred in two children from the lavage group and six from the drainage group. Intra-abdominal abscesses occurred in two children from the drainage group. Accordingly, peritoneal lavage appears to be superior to intraperitoneal tube drainage for the management of perforated appendicitis in children.

Biliary complications after excisional procedure for choledochal cyst

During the last 25 years, from 1969 to 1994, the authors treated 97 choledochal cysts by surgical excision. Biliary reconstruction consisted of 67 hepaticoduodenostomies and 30 hepaticojejunostomies. The common hepatic duct was the site of anastomosis in 9 of the duodenostomies and 13 of the jejunostomies and of the bifurcation of the hepatic ducts in 58 duodenostomies and 17 jejunostomies. Reoperation was required in 10 cases because of recurrent cholangitis with intrahepatic gallstones. Biliary strictures were responsible for the cholangitis in 9 children with anastomoses at the level of the common hepatic duct and in 1 with an anastomosis at the level of the bifurcation. These results suggest that biliary complications develop because of anastomotic stricture or primary ductal stricture, and may be minimised by the creation of a wide anastomosis, which is best accomplished at the hepatic hilum.

The effects of feeding and secretin administration on the pancreaticoduodenal papilla of conscious dogs

The aim of this study was to define the functional role of the pancreaticoduodenal papilla (PDP) in the regulation of pancreatic outflow into the duodenum in response to feeding and secretin administration in conscious dogs. The canine model we developed allowed for measurement of the pancreatic ductal pressure and pancreatic outflow simultaneously in a physiological state without interfering with the flow of pancreatic juice via the intact sphincter of the duodenal papilla. Feeding increased the pancreatic outflow from 2.8 +/- 0.2 to 13.4 +/- 1.3 ml/15 min with a slight increase in the pancreatic ductal pressure from 8.5 +/- 0.6 to 13.7 +/- 1.4 cmH2O. The administration of secretin increased the pancreatic outflow from 2.8 +/- 0.2 to 12.7 +/- 1.0 ml/15 min without increasing the pancreatic ductal pressure. The viscosity of the pancreatic juice increased during exposure to food, but decreased following food intake and secretin administration, after which the PDP seemed to dilate by about 40% of the fasting value. The results suggest that PDP changes its opening to maintain the pancreatic ductal pressure below a certain level, even if pancreatic secretion into the pancreatic duct increases due to food intake and secretin administration.

Ischemic jejunal stricture developing after diabetic coma in a girl: a case report

A 15-year-old girl with ischemic stricture of the jejunum, probably due to microangiopathy caused by diabetes mellitus is presented. Laparotomy revealed two circular strictures in the proximal jejunum, and histology showed ischemic enteritis with ulceration, granulation with microvascular proliferation, inflammatory cell infiltration, marked fibrosis, and hemosiderin deposition. Uncontrolled diabetes mellitus often causes ketoacidosis, increased blood viscosity and platelet aggregation, dehydration in addition to hyperglycemia, and occasionally results in occlusive or non-occlusive vascular disease of the intestine. Ischemic stricture of the bowel in the diabetic state is probably related to moderate ischemia resulting in ulceration and scar formation in the intestine.

Successful left hepatectomy for hepatocellular carcinoma in a child after transcatheter arterial chemoembolization: report of a survival

A 12-year-old boy with large hepatocellular carcinoma is presented. The tumor was successfully resected after reducing the tumor size by transcatheter arterial embolization with Lipiodor containing an antitumor drug. The patient has achieved a 2-year-10-month disease-free survival.

Effects of pectin and cellulose on fat absorption after massive small-bowel resection in weanling rats

The effects of pectin and cellulose on fat absorption after massive small-bowel resection were studied in rats. Weanling Wistar rats underwent 80% resection of the small intestine with gastrostomy, and fat emulsion labeled with 14C-linoleate was given via a gastrostomy tube for the fat absorption test on the 10th postoperative day. They were classified into three groups by diet as follows: E group, a fiber-free, chemically defined diet (CDD); EP group, CDD with 2% pectin; and EC group, CDD with 2% cellulose. The cumulative and hourly output of 14C in the expired air, the absorption rate of 14C in the intestine, and the metabolic utilization rate of 14C were calculated. The cumulative 14CO2 output was significantly lower in the EC group than in the E and EP groups. However, there was no significant difference in the 14CO2 output between the E and EP groups. The highest hourly 14CO2 output in the E and EP groups was observed during the first 2 hours. However, in the EC group, this fluctuated at low levels. No significant difference in the 1-14C-linoleate absorption rate was observed between the E and EP groups, whereas it was significantly lower in the EC group than in the E and EP groups. The metabolic utilization rate of 1-14C-linoleate showed no significant difference among the three groups. These data suggest that an addition of pectin to CDD does not impair small intestinal absorption of 1-14C-linoleate after massive small-bowel resection, and an addition of cellulose decreases absorption of 1-14C-linoleate.

Effects of enteral fat emulsion on fat absorption in obstructive jaundiced rats

The effects of fat emulsion given enterally on fat absorption were studied with obstructive jaundiced rats (J group) as compared with jaundice-free rats (C group). The J and C groups were subdivided into JE and CE groups using emulsified fat for the fat absorption test, and JU and CU groups using unemulsified fat. Rats in all groups were fed for 7 days with regular rat chow. After fasting for 12 hours, 14C-labeled fat emulsion was infused to the JE and CE, and 14C-labeled unemulsified fat to the JU and CU groups through a gastrostomy for the absorption test. The hourly and cumulative output of 14CO2 by respiration, absorption rate of 14C-labeled fat in the intestine, and metabolic oxidation rate of the absorbed fat were determined during an 8-hour period after the gastroenteral administration of emulsified or unemulsified fat. The peak of hourly output was seen after the first 2 hours in the CE, JE, and CU groups, following which a remarkable decline was seen in the CE and CU groups. However, a more gentle descent in the JE, and fluctuation at a low level in the JU group were observed. The cumulative output in the JE was 61% of that in the CE, while the output in the JU was 16% of that in the CU group. The absorption rate in the JE was 81% of that in the CE group, while the rate in the JU was 22% of that in the Cu group.(ABSTRACT TRUNCATED AT 250 WORDS)

Air reduction for intussusception in infancy and childhood: ultrasonographic diagnosis and management without X-ray exposure

For the treatment of uncomplicated intussusception in infants and children, we attempted air reduction without x-ray study to avoid the genetic and carcinogenic effects of radiation. Intussusception could generally be diagnosed by ultrasonography in addition to the history and typical clinical signs without using a barium enema. The success of reduction could also be safely evaluated from the disappearance of both the characteristic sonographic target sign and the abdominal palpable mass, and improvement in the general condition 2 or 3 hours after completing this procedure. This simple, cheap and clean reduction method was applied to 127 patients under strict indications and sedation with diazepam. The successful reduction rate was high (90.6%) and equal to that by hydrostatic reduction. Accordingly, this procedure appears to be safely applicable to the management of uncomplicated intussusception in infancy and childhood.

Endodermal sinus tumour of the posteroinferior mediastinum resembling dumbbell neuroblastoma in a child

A male infant presenting with paraplegia due to intraspinal extension of an endodermal sinus tumour in the posteroinferior mediastinum is reported. Dumbbell tumours are usually observed in mediastinal neuroblastomas, and rarely in rhabdomyosarcomas of the chest wall. The present case demonstrates the clinical similarity of endodermal sinus tumours to neuroblastomas with extradural extension. Therefore, endodermal sinus tumours should be considered in the differential diagnosis of posterior mediastinal masses, because of the distinctly different treatment from that for other tumours.

Pseudopancreatitis in choledochal cyst in children: intraoperative study of amylase levels in the serum

A case of acute necrotizing pancreatitis in association with choledochal cyst is presented. Pancreatitis associated with choledochal cyst is probably caused by a biliary reflux into the pancreatic duct via a pancreatobiliary malunion, as the intraductal pressure of the cyst exceeds that of the pancreatic duct. Ampullar stenosis due to gallstones or inflammatory changes may increase the intraductal pressure. Bile with activated pancreatic enzymes refluxes into the pancreatic duct, and possibly results in acute pancreatitis. However, patients with choledochal cyst presenting with recurrent bouts of abdominal pain, vomiting, and fever have often been diagnosed as having acute pancreatitis because of hyperamylasemia, despite no evidence of pancreatitis at the time of surgery. At the time of bouts, they also show a slight elevation of serum bilirubin, and an increase in the degree of the choledochal dilatation that are possibly caused by biliary obstruction, not ampullar obstruction, due to suppurative cholangitis. The term "fictitious pancreatitis" or "pseudopancreatitis" in choledochal cyst appears to be appropriate. This clinical study shows that amylase in the biliary tract has ready access to the blood stream, probably through a sinusoidal pathway by cholangiovenous reflux, and a lymphatic pathway, via the Disse's space and denuded cyst wall, provided the biliary ductal pressure is increased.

Retroperitoneal immature teratoma producing alpha-fetoprotein

An alpha-fetoprotein producing retroperitoneal immature teratoma is demonstrated and the aetiology of AFP arising probably from small island of hepatoid cells or various tubular epithelial cells in the immature teratoma is discussed.

Reoperation for congenital choledochal cyst

A reoperation after excisional procedure was carried out in seven cases due to early or late postoperative complications. Of the 12 patients with early complications, four underwent relaparotomy due to anastomotic leakage and bleeding. Late complications were seen in nine patients with recurrent cholangitis caused by an anastomotic stricture, and three patients with intrahepatic involvement required a reoperation several years after the initial surgery. Recurrent cholangitis after biliary reconstruction mainly occurs due to an anastomotic stricture of the hepaticoenterostomy. There was no significant difference in the results between hepaticoduodenostomy and hepaticojejunostomy over a long follow-up period. A wide anastomotic stoma that permits free drainage of bile into the intestine is imperative to the prevention of cholangitis, and can be created by an incision extending along the lateral wall of both the hepatic ducts with a hepaticoenterostomy at the hilum. This procedure is obviously necessary in all patients with or without intrahepatic involvement. Carcinoma of the intrahepatic ducts and the retained distal choledochus have rarely developed in patients undergoing cyst excision followed by biliary reconstruction. Complete excision of the whole extrahepatic bile duct could prevent carcinoma arising in the distal choledochus, although it could not prevent carcinoma arising from the intrahepatic ducts. However, patients with carcinoma of the intrahepatic duct were reported to have had symptoms of biliary stricture for a long time since the cyst excision. Bile stagnation in the intrahepatic ducts is possibly responsible for the development of carcinoma. A wide anastomosis resulting in free drainage of bile appears to be essential to the prevention of carcinoma arising in the intrahepatic ducts after cyst excision.

Frantz's tumor: a papillary and cystic tumor of the pancreas in girls

Four girls with Frantz's tumor, a papillary and cystic tumor of the pancreas, are studied and discussed in comparison with 112 cases in the literature, including 58 Japanese cases. The neoplasms occur predominantly in girls and young women. Up to recently, the tumors have possibly been misclassified as nonfunctioning islet cell tumor or carcinoma, acinar cell carcinoma, papillary cystadenocarcinoma, or pancreatoblastoma according to microscopic findings and frequently have been managed with aggressive surgery such as pancreatoduodenectomy. The tumors are well encapsulated and the cut surfaces show characteristically solid and hemorrhagic-necrotic patterns. Ultrasonography and CT scan are the most useful tools for the diagnosis. The neoplasms usually behave like a very low-grade malignancy, so that complete removal is the treatment of choice for the tumor arising anywhere in the pancreas. Immunochemical and electron microscopic studies can differentiate Frantz's tumor from other neoplasms and also suggest that the tumors originate from primordial cells or multipotential stem cells capable of differentiating into both exocrine and endocrine lines.

Carcinoma related to choledochal cysts with internal drainage operations

Carcinoma arising in a choledochal cyst retained after enteric drainage is discussed in comparison with primary carcinoma. In our series, carcinoma developed in eight of 82 patients with choledochal cyst and three of the eight had secondary carcinoma occurring several years after enteric drainage. Forty-two similar instances and 235 instances of primary carcinoma have been reported in Japan. The mean age at detection of carcinoma in enteric drainage was 35 years old, 15 years less than that of primary carcinoma. The mean interval between drainage and detection of carcinoma was ten years. Carcinoma mainly arose from the retained cyst in drainage, while primary carcinoma developed in either the cyst or gallbladder. The prognosis was very poor. Almost all patients undergoing enteric drainage died soon after the detection of carcinoma. This is possibly due to the delay in diagnosis. Pancreatic juice can easily regurgitate into the choledochus through an anomalous junction of the pancreatobiliary ductal system, and enteric drainage causes pancreatic juice in the cyst to become activated due to the influx of intestinal juice. Therefore, inflammatory changes of the cyst are accelerated and probably result in carcinoma. Early excision of the choledocus should be recommended in patients with choledochal cyst retained after enteric drainage.

Cylindrical dilatation of the choledochus: a special type of congenital bile duct dilatation

Cylindrical dilatation of the choledochus develops in 20% of patients with congenital bile duct dilatation and usually has acute-angled unions of the pancreatobiliary ductal system. Symptoms generally develop in patients over 1 year of age. The patients frequently complain of abdominal pain, vomiting, and fever as in those with acute pancreatitis. Ultrasonography and infusion cholangiography are the most useful tools in making a correct diagnosis. A high amylase level in the bile caused by the refluxing of pancreatic juice through anomalous ductal unions is commonly observed. This is responsible for biliary perforation in infancy and possibly carcinoma arising in the bile duct. The amylase concentration in the serum at the time of epigastric pain often is high, which leads to the diagnosis of acute pancreatitis. However, evidence of pancreatic inflammation is seldom noted. Accordingly, amylase in the bile may enter the circulating blood through the denuded epithelium or sinusoids of the liver. Excision of the whole extrahepatic duct along with hepaticoenterostomy would be essential for the treatment of cylindrical dilatation of the bile duct, especially when an anomalous ductal union is present.

Wilms' tumor associated with Moyamoya disease: a case report

A high incidence of congenital malformations with Wilms' tumor had been recognized lately. Aniridia, hemihypertrophy, chromosome deletion, urinary tract anomalies, and Wiedemann-Beckwith syndrome have often been observed in patients with Wilms' tumor. However, Wilms' tumor associated with Moyamoya disease, which refers to a stenosis of the distal portion of the carotid artery with an abnormal network in the brain base, has never been reported. In this report, a male child aged 28 mo. with Wilms' tumor associated with Moyamoya disease is presented.

Congenital choledochal cyst with intrahepatic involvement

We reviewed congenital choledochal cyst with intrahepatic involvement in 38 patients aged 52 days to 29 years. Dilatations were classified into the following three forms, based on the shape of the extrahepatic and intrahepatic bile duct: cystic-cystic, cystic-cylindrical, and cylindrical-cylindrical. Stenosis of the hepatic duct near the hilum probably does not cause dilatation of the intrahepatic duct. The anomalous arrangement of the pancreatobiliary union seems to determine only the form of extrahepatic dilatation, and cystic dilatation of the intrahepatic duct may be caused by some other factors. Total excision of the extrahepatic bile duct with the creation of a wide anastomotic stoma apparently is the treatment of choice. Hepatectomy would be recommended for some patients with the cystic-cystic form.

Anomalous arrangement of the pancreatobiliary ductal system in patients with a choledochal cyst

An anomalous arrangement of the pancreatobiliary ductal system is usually observed in patients with a congenital choledochal cyst and is represented by a long common channel distal to the pancreatobiliary junction. According to the angle of the pancreatobiliary junction, anomalous junctions can be classified into four groups: right angle, acute angle, complex union, and normal union (presented here in the order of their incidence). The right-angle type tends to have cystic dilatation of the choledochus, whereas the acute-angle type generally has cylindrical dilatation. However, the grade and length of the stenosis on the distal part of the choledochus tend to determine the type of choledochal cyst. Cystic dilatation is usually observed in patients with high-grade and long stenosis, whereas cylindrical dilatation is seen in those with low-grade and short stenosis. Patients with an acute angle junction seem to only suffer from abdominal pain, and those in the complex union group tend to have jaundice and an abdominal tumor. A high amylase level in the bile within the cyst is observed frequently. In patients with obstructive jaundice, however, the amylase level is usually not elevated, because pancreatic juice cannot enter the choledochus.

Congenital oesophageal stenosis due to fibromuscular thickening

Three patients with fibromuscular oesophageal stenosis are reported. The onset was usually before 6 months of age; earlier than that of stenosis due to tracheobronchial remnants. The localization of the stenotic area varied from the distal to the mid-oesophagus. Extramucosal myotomy seemed to be the treatment of choice for this lesion, particularly in the mid-oesophagus involved diffusely, because of its good effectiveness, less invasiveness, and simplicity.

Inflammatory stenosis of the whole extrahepatic bile duct in a child: a case report

A female child, 5 years and 5 months of age, who had had longstanding obstructive jaundice with hepatic dysfunction from the age of 6 months, underwent Y-hepaticojejunostomy according to Roux after dissection of the entire extrahepatic duct with severe periductal fibrosis. At that time, liver biopsy already showed progress to biliary cirrhosis with prominent ductal proliferation in Glisson's triad. Although good bile drainage to the intestine was obtained early after the operation, 2 years elapsed until disappearance of jaundice and ascites with improvement of liver function. The patient is now 13 years old and doing well with moderately impaired liver function. No oesophageal varices have been seen by endoscopy lately. The clinical course and data are suggestive of an abortive form of biliary atresia.

Glucagon administration for the treatment of postoperative cholangitis after Kasai's operation--a preliminary report

Clinical application of glucagon in postoperative ascending cholangitis after Kasai's operation for biliary atresia is reported. Therapeutic use of glucagon in two patients succeeded in treating ascending cholangitis, but failed to prevent progression to hepatic fibrosis. Prophylactic use in two patients prevented development of ascending cholangitis. Prophylactic glucagon administration appears to improve the prognosis of patients with biliary atresia who have undergone a Kasai's operation.

Rectal carcinoma with a large amount of mucin production in childhood--report of a case

A 10-year-old boy with rectal carcinoma underwent an abdominoperineal resection with postoperative radiotherapy and chemotherapy. The tumor showed a moderately differentiated adenocarcinoma with a large amount of mucin production. Five years later, obstructive hydronephrosis due to postoperative radiotherapy developed and uretero-ileo-cysto-neostomy was performed after transient bilateral nephrostomies. He is now 17 years of age, 7 years after the initial operation, and doing well with nearly normal renal function. Colorectal carcinoma in childhood is very rare and has a poor prognosis, which seems due to the high incidence of mucinous adenocarcinoma and delay in early diagnosis. Besides polyp carcinoma with low grade malignancy, an aggressive abdominoperineal resection with sigmoid colostomy is the treatment of choice as in adults. Postoperative radiotherapy under a total of 3000 rads is also recommended for a better chance of cure. The effectiveness of pre- and postoperative chemotherapy is still doubtful.

Effects of hepatic periarterial neurectomy (HPN) on the treatment of biliary atresia

Thirty one patients with biliary atresia have undergone Kasai's operation in our clinic during the past 10 yr. Three of the patients died from postoperative complications. Of 12 patients who underwent Kasai's operation only five (41.7%) showed good excretion of bile. Two of them, 16.7%, have survived without jaundice for more than 8 yr. Of 16 patients who underwent hepatic periarterial neurectomy (HPN) combined with hepatic portoduodenostomy, 11 (68.8%) showed good bile excretion. Seven of them, 43.8% are alive and well for period between 6 mo and 5 yr 6 mo postoperatively. Although improvement in the technique for boring the porta hepatis may have contributed to these good results, we think that the addition of hepatic periarterial neurectomy to Kasai's operation gives even better results. According to our experimental studies, hepatic periarterial neurectomy resulted in increased bile flow in the early postoperative period and thus seemed to be of value in preventing postoperative ascending cholangitis.

Hepaticoduodenostomy at the hepatic hilum after excision of choledochal cyst

During the past 11 years, 30 patients, aged 27 days to 25 years, underwent excision of choledochal cyst. Reconstruction of the biliary tract was performed by two techniques: hepaticoduodenostomy in 19 patients and Roux-Y hepaticojejunostomy in 11. The technique of hepaticoduodenostomy consisted of transection of the common hepatic duct at the hilum with an incision extending approximately 5 mm along the lateral wall of both the hepatic ducts to permit a wide anastomotic stoma. There was no mortality. Postoperative cholangitis occurred in five patients, four of whom were in the hepaticoduodenostomy group. All episodes except one responded to antibiotics and have resulted in no demonstrable hepatic dysfunction. Intestinal bleeding occurred in one Roux-Y patient and postoperative intestinal obstruction in another. There was no significant difference in the results of these two procedures in the follow-up period (average length 4 years, 3 months). The hepaticoduodenostomy with a wide stoma at the hilum is advocated because (1) it has significant capability of preventing cholangitis, which has been thought to be the primary objection so far, (2) it creates a better physiologic state, and (3) it may be associated with fewer postoperative complications.

Portal hypertension after successful Kasai's operation for biliary atresia--special reference to esophageal varices

Thirty-four patients with biliary atresia have undergone Kasai's operation in our clinic during the past 12 years. Of 21 patients who showed good bile excretion postoperatively, 8 are surviving more than 2 years later. 4 of these survivors and 2 who died of hepatic failure after operation which succeeded in achieving bile excretion, developed portal hypertension with esophageal varices. More than 30 similar patients have been reported in the literature. Esophageal varices after a successful Kasai's operation developed in one fourth of the patients who were expected to be cured. Half of these went on the hemorrhage. Portal hypertension due to biliary hepatic fibrosis could be divided into acute and chronic types. The acute type had a poor prognosis due to concomitant severe postoperative cholangitis, whereas, almost all patients with the chronic type survived, if the esophageal varices were well controlled conservatively or operatively. Transthoracic esophageal transection with paraesophagogastric devascularization seems to be the treatment of choice, and splenectomy may be added through the diaphragm only in patients with hypersplenism. Major or minor shunting procedures should be avoided because they decrease the blood flow to the liver.