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Purpose: The aim of this study was to analyze the early and late results of pediatric liver transplantation, with particular reference to complications that required surgical or radiologic intervention. Methods: The records and code sheets of children who underwent liver transplantation in the authors' institution between September 1993 and December 2001 were reviewed. Results: Twenty-nine children (16 boys and 13 girls) underwent 31 liver transplantations (23 living donor, 8 cadaveric donor) during the study period. The ages of the children ranged from 4 months to 132 months (median, 16 months). Eighteen children had complications that required surgical or radiologic interventional procedures. Complications included, among others, hepatic vein thrombosis (n = 1, 3%), hepatic vein stenosis (n = 2, 7%), portal vein thrombosis (n = 2, 7%), biliary stricture (n = 3, 10%), bile leakage (n = 2, 7%), hepatic artery pseudoaneurysm (n = 1, 3%), jejuno-jejunostomy leakage (n = 1, 3%), graft hepatitis (n = 1, 3%), and posttransplant lymphoproliferative disorder (n = 2, 7%). In addition, 6 children (21%) suffered from intraabdominal bleeding from a variety of causes. After appropriate interventions, at a median follow-up of 38 months (range, 1 to 96 months), patient and graft survival rates were 79% and 74%, respectively. The retransplantation rate was only 7%. There was no incidence of hepatic artery thrombosis. All living donors remain alive and well. Conclusions: Complications are inevitable in pediatric liver transplantation. However, with timely recognition and active intervention, a good outcome can be achieved. J Pediatr Surg 37:1673-1677. Copyright 2002, Elsevier Science (USA). All rights reserved.

The mode of Helicobacter pylori spread is not well defined. Urea breath test (UBT) is an accurate and noninvasive method for H pylori detection. This study evaluates the role of intrafamilial spread of H pylori using UBT.The family members of 16 Hpylori-positive and 16 negative (control) children confirmed by histology and rapid urease test were investigated with UBT. A 58% change was considered positive.A total of 139 persons (72 in the positive group; 67 in the control group) were studied. Fifty-eight (81%, 58 of 72) and 13 (19%, 13 of 67) were found to be positive in the H pylori-positive and control groups, respectively (P.01). Among children from 19 positive mothers, the positive rate was 60% (25 of 42), whereas among children of negative mothers, the positive rate was 16% (4 of 25; P.01). The positive rate among children of positive fathers was 66% (23 of 35), whereas that among children of negative fathers was 30% (7 of 23; P.01). When both parents were H pylori-positive, the children's positive rate was 83% (19 of 23); when both parents were negative, the children's positive rate was 0% (0 of 9; P.01).There is strong evidence of intrafamilial spread of H pylori. The positivity of parents with H pylori has an important bearing on their children's H pylori status.

A 12-year-old girl who suffered from cholangitis was treated successfully with appropriate antibiotics. She had undergone an operation in mainland China, the exact nature of which was unknown. After an ultrasound study, she underwent a helical computed tomography (CT) cholangiogram using intravenous meglumine iodoxamine. The volume data were transferred to a workstation and virtual endoscopy rendering reconstruction of bile ducts was performed. Findings of this study showed that she had cyst excision with hepaticojejunostomy (HJ), and her intrahepatic ducts were packed with stones. Virtual endoscopy gave the impression that the examiner was flying inside the lumen and showed the stricture at the HJ anastomosis, the inner surface of the bile ducts, areas of dilated intrahepatic ducts, and the intrahepatic stones. The study overcame the need for an invasive study such as a percutaneous transhepatic cholangiography (PTC) and also facilitated appropriate surgical treatment in a timely fashion. It is believed that virtual intraluminal endoscopy (VIE) is helpful in the evaluation and management of selected cases of choledochal cyst.

Purpose: This study investigates the usefulness of Gadolinium (Gd)-infusion magnetic resonance angiogram (MRA) in the detection of impalpable undescended testes. Methods: Magnetic resonance (MRI) examination was performed in 14 patients with 17 impalpable undescended testes (unilateral, n=11; bilateral, n=3). MRA was then performed as follows: Gadolinium-DTPA-BMA (Omniscan) at 0.3 mmol/kg body weight was injected intravenously, and dynamic coronal examination using fast spoiled gradient recalled sequences was obtained with images taken at early arterial and delay venous phases. The testis was located by detection of the enhanced pampiniform venous plexus. Results: Of the 17 undescended testes, 11 canalicular hypoplastic testes and 3 intraabdominal testes were detected in both routine MRI and MRA. Three atrophic testes were found in the scrotum by MRA but not detected by routine MRI. The detection rates of impalpable testes by MRI and MRA were 82.4% and 100%, respectively. All imaging findings were confirmed by surgical exploration. There was no morbidity associated with MRA. Conclusion: Gd-infusion MRA is an accurate and sensitive method of preoperative localization of impalpable testes and is superior to conventional MRI in the detection of atrophic testes.

A cutaneous stoma in the Roux limb of hepaticojejunostomy (hepaticocutaneous jejunostomy) was used for stone extraction in two children who had hepatolithiasis (14.5 and 15.5 years, respectively) after operation for choledochal cysts. In constructing the hepaticocutaneous jejunostomy, a short, straight proximal limb from the skin to the bilioenteric anastomosis is mandatory. It provides a pathway, superior to the T-tube tract, for repeated stone extraction, which can be performed under sedation, thus obviating repeat laparotomies. The stoma allows flexible choledochoscopy, balloon dilatation of intrahepatic duct strictures, and extraction of intrahepatic stones using grasping forceps, baskets, and balloons. The electrohydraulic lithotriptor may be applied to fragment larger stones.

Purpose: Immature gut immunity can be a predisposing factor for necrotizing enterocolitis (NEC). The gut active immunity and innate defense to the Escherichia coli endotoxin lipopolysaccharide (LPS) in immature and mature rats were studied. Methods: LPS, started at a dose of 10 mg/kg, was instilled into the stomachs of fetal, newborn, 1-month and 3-month-old rats. Boost doses and normal saline control instillations were given on day 14. Rats that died after instillation had detailed postmortem examinations. For survivors, a group of 6 immunized and 6 controls were killed on day 7 for the collection of serum, spleens, mesenteric lymph nodes, and small intestines. Lymphocytes (10 6 ) prepared from each tissue sample of individual group were cultured for 5 days. Serum and supernatant were analyzed for IgA and anti– E coli IgA levels. Results: All control rats survived. The doses of LPS given were 10, 5, 2.5, and 1.25 mg/kg. All fetal rats died after LPS instillation. Half-lethal dose for newborns was 2.5 mg/kg. One-month and 3-month-old rats survived all doses of LPS. The cause of death was endotoxemia. The serum IgA and total supernatant anti– E coli IgA levels of rats of all ages studied showed no significant difference. Conclusion: The poor innate gut defense, not so much the active immunity, may provide an explanation for the susceptibility of the premature babies and newborn infants to the development of NEC. J Pediatr Surg 37:1435-1440. Copyright 2002, Elsevier Science (USA). All rights reserved.

Background/Purpose: Liver transplantation is the only therapeutic option for biliary atresia (BA) patients with failed Kasai portoenterostomy (PE). The indication for and timing of liver transplantation in these patients are important management issues. The aims of this study are to evaluate the relationship between portal venous velocity (PVV) and clinical and biochemical indicators of liver function in BA, and to examine the role of PVV in the postoperative surveillance of these patients. Methods: Twenty-nine children (mean age, 8 years 4 months) who had PE for BA underwent Doppler ultrasonography to evaluate PVV. Using regression analysis, these findings were correlated with biochemical indicators of liver function. The Mann-Whitney test was used to detect any significant differences in PVV between the Child-Pugh A group and combined Child-Pugh B and C group patients. Results: The mean ± SD PVV for the Child-Pugh A group and the combined Child-Pugh B and C group was 17.1 cm/s ± 8.9 cm/s and 10.2 cm/s ± 3.3 cm/s, respectively, and this difference was statistically significant ( P =.037). Conclusions: Doppler ultrasonography measurement of PVV provides adjunctive information to the clinical and biochemical assessment of the liver function status in BA. Its use in the postoperative surveillance of these patients is helpful in identifying the need for and in timing of liver transplantation. J Pediatr Surg 37:873-876. Copyright 2002, Elsevier Science (USA). All rights reserved.

The pathogenesis of necrotizing enterocolitis (NEC) is unknown. Ischemia and reperfusion (I/R) injury has been considered a major contributing factor. Nitric oxide (NO) and superoxide dismutases (SODs) have been shown to protect bowel from I/R injury. This study aims to assess (1) the ability of premature intestine to resist I/R injury compared with mature intestine and (2) the possible role of NO and SODs in modulating such response.Intestines from 5 groups of rats (n = 6 for each study group) were studied: (1) premature, gestational age 20 days; (2) premature, gestational age 22 days; (3) full-term, newborn; (4) infant, day 15; (5) infant, day 30.(1) The degrees of I/R injury after 0, 30, 60, 90 and 120 minutes, respectively, of ischemia and 25 minutes of I/R were assessed histologically by a pathologist who was unaware of the operative details. (2) Tissue NO and copper levels were measured by electroparamagnetic resonance (EPR) study; and nitric oxide synthases, copper zinc (CuZn) SODs and manganese (Mn) SODs were examined immunohistochemically. (3) and (4) I/R injury was assessed in rats that had received intraperitoneal injections of L-arginine (NO donor) and L-NAME (NO antagonist), respectively.For premature (1,2), newborn (3) and mature (4,5) intestines, grades of injury at maximum I/R period studied (120 minutes of ischemia, 25 minutes of reperfusion) were 0, 0, and 3, respectively (P.05); NO levels were 1 u +/- 1.5, 3 +/- 2.5, and 22 u +/- 3.5, respectively (P.05); Cu levels were 150 u +/- 15, 200 u +/- 41 and 12 u +/- 2, respectively (P.05); NOS in intestines were +, +, +++ and CuZnSODs were ++, +++, +, respectively; and MnSODs were +++, ++, -, respectively. No change in NO levels was detected in groups (1), (2), or (3) after L-arginine and L-NAME injections.Premature rat intestine is highly resistant to I/R injury, which may indicate that I/R alone, in the absence of other predisposing factors (eg, bacterial colonization) may not be sufficient in causing NEC. Nitric oxide does not have a protective role for immature and newborn intestines in I/R as in mature intestine. The high level of SODs of the immature and newborn intestine may play an important role in its high resistance to I/R injury.

Purpose: The aim of this study was to evaluate the results of laparoscopic treatment of varicocele and findings of testicular volume and blood supply using color Doppler ultrasound scan on follow-up. Methods: Fourteen patients aged 7 to 15 years old (median, 12.3 years) with left varicocele (grade II, n=4; grade III, n=10) underwent laparoscopic clipping of internal testicular vein and artery. At follow-up, both testes were scanned by ultrasonography in axial and longitudinal planes, and at least 3 measurements—length, width, and thickness—were taken to calculate testicular volumes. Arterial perfusion of the testes also was assessed. Results: Operating time ranged from 25 to 80 minutes (mean, 60 minutes). There was no perioperative complication. At a mean follow-up of 14 months (range, 2 to 39 months) all children were asymptomatic with disappearance of varicocele. The volumes of bilateral testes were equal (difference in volumes less than 10%) in 9 children. Ipsilateral testicular hypertrophy was found in 3 children. There was no difference in arterial perfusion between the testes in each patient. Small transient ipsilateral hydrocele was observed in 2 patients. Conclusion: Laparoscopic clipping of testicular vein and artery was simple and effective for varicocele treatment and did not compromise testicular blood supply. J Pediatr Surg 36:1704-1707. Copyright © 2001 by W.B. Saunders Company.

Purpose: In the eradication of Helicobacter pylori infection, a 1-week therapy improves patient compliance, but drug resistance may limit its efficacy. The effectiveness of the 1-week nonbismouth quadruple therapy was studied prospectively in children with proven H pylori infection in a population with a high rate of metronidazole resistance. Methods: All pediatric patients who presented to our institutions with acute and chronic upper gastrointestinal conditions requiring endoscopy from June 1997 to February 2000 were investigated prospectively for H pylori infection. Gastric biopsy specimens were analyzed with rapid urease test and histopathology, H pylori –positive children were treated with omeprazole, clarithromycin, amoxicillin, and metronidazole for 7 days. The result of treatment was assessed 1 month after treatment with endoscopy and biopsy. The same treatment was repeated for 2 weeks if H pylori was still present. In patients who needed a third endoscopy, their biopsy specimens were cultured to determine antibiotic sensitivity. Results were correlated with patients' symptoms and endoscopic findings. Results: Thirty-three children with acute (severe epigastric pain, n=14; gastrointestinal bleeding, n=9) and chronic (recurrent abdominal pain, n=7; anemia, n=3) conditions were treated for H pylori . Thirty-one (94%) were confirmed to have H pylori eradicated by a 1-week therapy, whereas 1 patient had eradication after a further 2-we`ek therapy (3.3%). The only unresponsive patient had H pylori resistant to both clarithromycin and metronidazole. All ulcers and erosions healed after the eradication of H pylori . Three patients had persistent recurrent abdominal pain despite H pylori eradication. Conclusions: The 1-week therapy with omeprazole, clarithromycin, amoxicillin, and metronidazole is an effective treatment of H pylori in children in a population with a high incidence of metronidazole resistant strain of H pylori . Peptic ulcers and erosions healed with the eradication of the bacteria. J Pediatr Surg 36:1008-1011. Copyright © 2001 by W.B. Saunders Company.

Purpose: In view of the earlier reports that children below 1 year of age constitute a high-risk group for liver transplantation, the authors reviewed their experience in performing orthotopic liver transplantation in this age group. Methods: The records of 9 children aged less than 1 year who underwent 6 living-related liver transplants and 3 reduced-size liver transplants between December 1993 and June 1997 were reviewed. Results: Five reexplorations were required for 3 children who had 1 or more of the following early complications: bleeding from hepatic vein to inferior vena cava anastomosis (n = 1), right hepatic vein stump bleeding (n = 1), intraabdominal hematoma (n = 2), jejuno-jejunostomy leakage (n = 1), and colonic perforation (n = 1). Late complications include stricture at the biliary-enteric anastomosis requiring percutaneous balloon dilation (n = 3) and hepatitis of undetermined etiology requiring retransplantation (n = 1). There was no hepatic artery thrombosis despite the small arteries available for anastomosis. Follow-up ranged from 19 to 61 months (mean, 40 months). Patient survival rate was 100%, and graft survival with good liver function was 89%. All living donors, 2 fathers and 4 mothers, are well. Conclusions: Liver transplantation in infants less than 1 year of age is technically demanding but feasible and still can be performed with a good outcome. Age alone (under 1 year) should not be considered as a contraindication for liver transplantation.

Purpose: Small bowel transplantation (SBT) is the ultimate treatment for intestinal failure. It remains unclear as to which intestinal segment is more suitable for use in segmental SBT. The current study aims to assess the susceptibility of various parts of small intestine to ischemia and reperfusion injury and their capacity for regeneration. Methods: Thirty-two segments of pig jejunum and ileum were isolated with intact vascular pedicles that were clamped for periods varying from 12 to 8 hours. Biopsy specimens were taken immediately before clamp release and 20 minutes afterwards. All segments were anastomosed together before abdominal closure. Laparotomy was performed 24 hours later, and biopsy specimens were taken at all segments. All specimens were examined histologically by a pathologist. Results: Evidence of injury was detected after 1.5 hours of ischemia at jejunum, but only after 5 hours at ileum. More severe injury was noted at the initial period on reperfusion, but there was no further deterioration at the later period. Complete reepithelialization occurred after 24 hours even where there had been total villous sloughing at reperfusion, but regeneration was impossible when the crypts had been damaged completely. Conclusions: Ileum, because it is more resistant to ischemia and reperfusion injury, may be preferred for segmental SBT. Regeneraiton of the bowel epithelium is fast, provided that the crypts are not damaged completely.

This is the first report of the successful use of percutaneous transcatheter arterial embolization (TAE) in controlling hemorrhage from ruptured hepatoblastoma, allowing early major hepatic resection to be performed safely in a young infant. A 6-month-old girl presented with a huge abdominal mass and was found to have a hepatoblastoma that measured 15 x 10 x 12 cm and arose from the right lobe of her liver on computed tomography (CT) scan examination. The tumor spontaneously ruptured, and she went into shock. TAE with gelfoam cube particles successfully arrested the tumor bleeding and allowed stabilization of her blood pressure with blood transfusion. Right trisegmentectomy was performed 12 hours later. The postoperative course was uneventful. With three courses of cisplatin, vincristine, and 5-fluorouracil after the hepatectomy, the serum alpha-fetoprotein level returned to normal, and the patient has remained well 4 months postoperation.

Background/Purpose: Reports on the late results of choledochal cyst excision with hepaticojejunostomy in children are relatively few. Methods: Of the 84 patients who had choledochal cyst who came under our care, 79 have had definitive surgery, three are awaiting surgery, one is being observed with Caroli's disease, and the parents of one child have refused surgery. Thirty-eight patients treated decades ago had internal drainage procedures. Since 1972, 41 patients have had cyst excision with hepaticojejunostomy using a 40-cm Roux loop without an antireflux procedure. Early complications in those who underwent cyst excision with hepaticojejunostomy included anastomotic leak in three patients who required reoperation, cholangitis in two, and fluid collection in the gall-bladder bed that required no intervention in one. Results: During a follow-up period ranging from 4 months to 17 years (mean, 8.5 years), anastomotic stricture, cholangitis, and intrahepatic stone formation developed in two children after being well for 8 years and over 11 years. These children required additional surgical procedures to overcome their problems. Asymptomatic intrahepatic stones 2 years after cyst excision with hepaticojejunostomy developed in a third child. There was no mortality in the entire group that underwent cyst excision and they are all enjoying a good quality of life. Conclusions: Careful, long-term follow-up is important in children who have choledochal cyst excision with hepaticoje-junostomy.

Purpose: This study reports the long-term results in children who have duodenal ulcers diagnosed by endoscopy who were treated with H2-receptor antagonist. Methods: The medical records of 32 children admitted into The Queen Mary Hospital with endoscopically proven duodenal ulcers between 1975 and 1988 were reviewed to evaluate the long-term outcome of childhood duodenal ulcers after initial treatment with H2-receptor antagonist (H2RA). Follow-up details were updated and patients who had been lost to follow-up were recalled. The age of the 22 boys and 10 girls at the time of diagnosis of the ulcers ranged from 3 to 16 years (mean, 11.8 yrs). The duration of follow-up ranged from 8.5 to 21 years (mean, 11.6 yrs). Results: Their primary presentations included epigastric pain (n = 9, 28.0%); nonsteroidal antiinflammatory drug (NSAID)-induced gastrointestinal bleeding (GIB, n=6, 18.7%); unprovoked GIB (n = 12, 37.5%); perforation (n = 4, 12.5%); and pyloric obstruction (n = 1, 3.0%). All 13 patients who had NSAID-induced ulcers (pain and bleeding) responded to H2RA therapy and required no further treatment. All 14 patients who had unprovoked ulcers who presented with pain or bleeding did not respond to H2RA treatment. Ulcer healing was achieved only after eradication of Helicobacter pylori with antibiotics (n = 8) or definitive surgery involving either truncal vagotomy and pyloroplasty (VP, n=4) or proximal gastric vagotomy (PGV, n=2). The patient who had gastric outlet obstruction had vagotomy and antrectomy. All four patients who had perforation were initially treated with patch repair, but two had persistent ulceration despite H2RA treatment and required PGV. Complications developed in none of the four patients who had PGV, whereas two of the four patients with VP had problems (diarrhea, n=1; bezoar obstruction, n=1). Conclusions: Unprovoked childhood duodenal ulcer is associated with significant long-term morbidity and requires continued follow-up. The majority of the ulcers are resistant to H2RA treatment alone and ultimately require either eradication of H pylori or surgery. In the absence of obstruction, PGV may be enough to resolve the ulcer diathesis.

Seven living-related liver transplants (LRLT) and two reduced-size liver transplants (RSLT) were performed on eight children who suffered from end-stage liver disease, having previously undergone one to three abdominal operations. Their ages at initial transplantation ranged from 8 months to 11 years (mean 35 months, median 12 months). Excluding the two older children aged 7 and 11 years, respectively, the rest of the children weighed 6 to 9.5 kg (mean 7.3 kg) at the time of the initial transplantation. Seven left lateral segments (S2 + 3) and two left lobes (S2 + 3 + 4) were used; of these the smallest graft had a graft-to-recipient body weight ratio of 0.9%. The volunteer living donors were four mothers, two fathers and one sister who were selected after medical and psychiatric evaluations, and their suitability was confirmed by hematological, biochemical, and radiological criteria. During a follow-up period of 3 to 30 months, all eight children are alive and well with normal liver function, one of them having undergone a retransplant LRLT because of hepatitis of undetermined etiology following a RSLT 1.5 years earlier. All seven donors had an uneventful postoperative course and were discharged on day 4 to 7 postoperatively. They have all resumed normal day-to-day activities. There were no complications in the donor group. A variety of complications occurred in the recipients, all of which were overcome. Operating microscope was used to perform all the arterial anastomoses using microvascular techniques. This method has proven to be a major factor in preventing arterial thrombosis even with the smallest of arterial anastomosis where a 1.5-mm diameter recipient artery was anastomosed to a 2.5-mm diameter donor hepatic artery.

A comparison was made of the efficacy of ultrasound guided Hartmann's solution hydrostatic reduction on 23 patients (US group) with the same number of consecutive patients in whom hydrostatic reduction was done by barium enema (BE group) under fluoroscopy for childhood intussusception. The US group was diagnosed by ultrasound scan and reduction was attempted under the guidance of ultrasonography with Hartmann's solution at 100 mm Hg pressure. Excluded were patients older than 12 years, patients in shock, patients with peritonitis, bowel perforation, and gross abdominal distension as well as recurrent intussusception of more than three episodes. There were three patients excluded in this group. The diagnosis of intussusception and complete reduction were confirmed by gastrografin enema. This US group had three recurrences (3 of 26, 11.5%), one lead point (1 of 23, 4.4%), and 19 successful reductions (19 of 26, 73%). Incidentally, there were also three patients excluded in this period of barium enema reduction. There was only one recurrence (1 of 24, 4.2%), one leadpoint (1 of 23, 4.4%), and 12 successful reductions (12 of 24, 50%) in these 23 BE patients. The success rates for the ileo-colic intussusceptions with Hartmann's solution reduction and barium enema reduction were 91% (19 of 21) and 55% (12 of 22), respectively (P = .00865). There was no complication in either group, and the accuracy of diagnosing a complete reduction was 100% in both forms of reduction. Hence, ultrasound-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

A baby boy had had transhiatal gastric transposition for wide gap esophageal atresia in another hospital. Postoperatively, repeated vomiting, chest infection, and frequent attacks of dyspnea developed. After reexploration, the cause was not identified and he was referred to the authors' institution. The diagnosis of iatrogenic organoaxial volvulus with gastric outlet obstruction was made because barium meal studies and nuclear isotope scanning showed persistent obstruction of the gastric outlet but upper endoscopy showed no stenosis and a flexible scope could be passed easily into the duodenum. The diagnosis was confirmed by thoracotomy. After full mobilization of the stomach, the gastroesophageal anastomosis was divided and the thoracotomy was closed. The stomach was reduced into the abdomen via laparotomy, and it was tubularized and rerouted retrosternally for anastomosis to the cervical esophagus. Since the operation the patient has been asymptomatic.

The authors have used the technique of combined retrograde flexible endoscopy and fluoroscopy on two newborn babies with esophageal atresia (EA) without tracheoesophageal fistula (TEF). This technique accurately determined the gap between the two esophageal ends and predicted the feasibility and timing of delayed primary anastomosis. Esophagostomy was not performed, and continuous Replogle tube suction of the upper pouch was maintained during the period of waiting for 10 and 14 weeks, respectively. Gastrostomy feeding allowed satisfactory growth and development during the period of waiting for esophageal growth.

A previously healthy 2-year-old boy was admitted because of shortness of breath, cough, and fever; there was minimal abdominal pain. He had recurrent right, followed by left pleural effusions, which contained markedly elevated amylase levels and high protein content. The pleural fluid amylase levels were disproportionately higher than the serum amylase levels. His abdominal signs were minimal. Surgical exploration showed a disruption of the proximal pancreatic duct. Distal pancreatectomy and Roux-en-Y pancreatico-jejunostomy were performed. After a complicated postoperative course he was discharged well and has remained so for more than 2 years.