Suguru Fukahori

自施設では小児外科疾患患児の広い臨床症状を対象に漢方指導医の下，様々な漢方薬が処方されてきた。現在は漢方指導医不在の中で漢方処方を継続している。小児外科診療で漢方診療を継続し，より充実させることを目的として14名の医師にアンケート調査を実施した。全員が漢方の有効性の実感と漢方治療の学習意欲を有していた。漢方の情報取得方法は，文献からが全員と最も多く，処方決定法は病名，症状からが全員であった。漢方指導医の不在により，多剤を併用することが少なくなったという意見がみられた。今回の調査では当科である程度漢方薬の処方がされており，漢方薬の有効性を実感している医師が多数であった。今回のアンケート調査を契機に当科医師3名が漢方専門外来施設で研修を開始した。指導医が不在になってもこれまでの漢方診療を持続可能にすることが重要であり，アンケートの実施により各医師が漢方診療の必要性を再認識した。

Purpose A nationwide survey was conducted to investigate the current status of pediatric gastroesophageal reflux disease (GERD) in Japan, with special reference to the characteristics of intractable GERD. Methods Data were collected using a questionnaire from facilities specializing in the treatment of pediatric GERD in Japan. Intractable GERD was defined as follows: I, no symptomatic improvement after 8 weeks of optimal medical treatment (OMT) plus fundoplication; II, no symptomatic improvement after 8 weeks of OMT and with no indications for fundoplication; and III, no symptomatic improvement after surgery without OMT. Results We collected data from 3,463 pediatric patients with GERD from 91 institutions, and 81 satisfied the definition of intractable GERD. Additional clinical information was obtained from 56 patients, and 41 represented cases of definite intractable GERD. The main underlying disorders included neurological impairment (NI), esophageal atresia (EA), and congenital heart disease (CHD), which altogether accounted for 85% of patients. Of the 41 patients, 33 received fundoplication, and the remaining 8 received medical treatment alone because surgery was considered unsuitable. Conclusions The nationwide survey revealed that pediatric intractable GERD is rare in Japan. Three main underlying disorders—NI, EA, and CHD—were implicated in the majority of cases of intractable GERD.

Background: A questionnaire survey was conducted to clarify whether surgical treatments performed by a pediatric surgeon improve the quality of life (QOL) of caregivers (medical doctors, nurses, physical therapists, and nursery teachers) supporting neurologically impaired (NI) patients who work at specialized institutions. Methods: The questionnaire survey was conducted with caregivers who cared for NI patients who underwent an operation at the Department of Pediatric Surgery, Kurume University Hospital. Quality‐of‐life related responses concerning the change of care after surgical procedures in NI patients were collected in addition to the background data related to caregivers and the surgical procedures performed for them. Degrees of difficulty in caring for NI patients and of the caregivers’ own QOL postoperatively were also compared. Results: There were 192 valid responses. The majority of responses were from females and nurses aged in their 40s and 50s. The surgical procedure performed most often in the NI patients was gastrostomy. Of the respondents, 77% answered that the postoperative care became easier. The degrees of difficulty in caring for NI patients and the caregivers’ own QOL were significantly higher and lower, respectively, among physical therapists compared with caregivers in other occupations. Moreover, the QOL in respondents with factors related to a longstanding relationship with NI patients was significantly higher compared with the respondents without them. Conclusion: This survey indicated that surgical procedures for NI patients might contribute to improved QOL for the caregiver by reducing the difficulty of caring for NI patients.

Background Development of gastroesophageal reflux disease (GERD) after gastrostomy remains debatable. Therefore, this study aimed to evaluate whether laparoscopy-aided gastrostomy (LAG) influence on the occurrence of GERD in neurologically impaired (NI) patients. Furthermore, we investigated whether preoperatively excluding NI patients with GERD can reduce the number of patients requiring subsequent anti-reflux surgery (ARS) after LAG. Methods This retrospective study included 35 NI patients (median age: 11.0; interquartile range 5.0–23.5 years) who underwent LAG according to our criterion from October 2012 to June 2020 and MII-pH before and after LAG. MII-pH parameters were compared in all patients and among three age groups between before and after LAG. Results There were no significant differences in MII-pH parameters before and 1 year after LAG in all patients, and no patient underwent subsequent ARS. Only one paediatric patient with 64 number of reflux episodes before LAG required subsequent ARS 3 years after LAG. Conclusions Generally, LAG did not influence the postoperative GERD at 1 year after LAG, and our criteria could reduce the number of patients requiring subsequent ARS. However, paediatric NI patients with higher number of reflux episodes in preoperative MII-pH study may need careful long-term follow-up after LAG.

Daisuke Masui, Suguru Fukahori, Naoki Hashizume, Shinji Ishii, Naruki Higashidate, Saki Sakamoto, Shiori Tsuruhisa, Hirotomo Nakahara, Nobuyuki Saikusa, Yoshiaki Tanaka, and Minoru Yagi. J Neurogastroenterol Motil 2021;27:198-204. https://doi.org/10.5056/jnm20125

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

The authors would like to add the following sentence in Acknowledgements in the original publication of this paper.

Multichannel intraluminal impedance-pH measurements (MII-pH) are useful for evaluating acid and non-acid gastroesophageal reflux (GER). However, the use of MIH-pH is not yet established in Japan. The Japanese Pediatric Impedance Working Group (Japanese-PIG) convened to devise a standard protocol for MII-pH in Japanese children. The expert members of the Japanese-PIG collected data on pediatric MII-pH from the relevant literature in English, including the standard protocol of MII-pH presented by the European PIG, and the insights of international experts. The resultant consensus was included in the contents of the standard protocol of MII-pH. The standard protocol included standardization of the indication, methodology, and interpretation of MII-pH in Japanese children. The criteria for abnormal GER by MII-pH were defined using the Reflux Index and number of total reflux episodes independently in children aged < 1 year and those aged ≥ 1 year. Moreover, a significant relationship between GER and symptoms was identified using the symptom index and symptom association probability approach. We conclude that the current version of the protocol for MII-pH is tentative because it is not based on data from Japanese children. Further studies are needed to render this protocol clinically beneficial and expand its use in Japan.