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BACKGROUND: Sonographic demonstration of extramural and intrapancreatic junction of the pancreatic and bile ducts, pathognomonic for pancreatico-biliary maljunction (PBM), is not easy in pediatric patients. We measured sonographic thickness of the gallbladder (GB) and retrospectively examined correlation of it with PBM. METHODS: Twenty-seven children with PBM were examined with conventional ultrasonography (US). All patients underwent hepaticojejunostomy, and resected GB were studied in histological examination. Preoperative extracorporeal US measured gallbladder wall thickness, and abnormal GB wall was defined 3 mm or more in thickness. RESULTS: They consisted of 8 males and 19 females, ranging in age from 2 months to 11 years. The thickness of the GB wall was more than 3 mm in 18: 10 with smooth thickness and 8 with non-uniform thickness. The thickness of GB wall was found in 16 (84.2%) of the 19 patients more than 1 year of age. The difference between sonographic and macroscopic measurements of the wall thickness was less than 1 mm in 24 (89%) of the 27 patients. CONCLUSION: US measurement of gallbladder wall thickness can be a screening test more than 1 year of age for PBM.

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We report a case of torsion of an accessory lobe of the liver (ALL) in a 14-year-old girl. The patient was admitted for acute abdominal pain and laparotomy revealed an ALL, the pedicle of which was elongated with 180 degrees torsion. The diagnosis was not made preoperatively because of the rarity of this condition. However, a close relationship between omphalocele repair and the development of ALL has been reported; thus, a history of omphalocele repair should alert the doctor to the possibility of this condition, which could be suggested by imaging findings preoperatively. Torsion of an ALL should be included in the differential diagnosis of a patient with a history of omphalocele, who presents with acute abdominal symptoms.

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BACKGROUND/AIMS: Although advanced liver fibrosis is a critical complication in influencing the outcome of biliary atresia (BA), the mechanism is poorly understood. In adult hepatic disorders, the relationships between sinusoidal liver cells (SLC) such as hepatic stellate cells (HSCs), some growth factors and enzymes concerned with extracellular matrix (ECM) metabolism have been clarified, but are unknown in BA. This study aimed to investigate such relationships in BA. METHODOLOGY: Seventeen liver samples from 14 patients with BA were immunohistochemically examined using primary antibodies such as alpha smooth muscle actin (alphaSMA), transforming growth factor beta (TGFbeta), platelet-derived growth factor (PDGF), matrix metalloproteinase (MMP)-1, MMP-2, tissue inhibitors of metalloproteinase (TIMP)-1 and TIMP-2. The degree of liver fibrosis and these immunohistochemical findings were compared and examined semiquantitatively. Ultrathin sections from two samples were also examined with electron microscopy. RESULTS: The immunoreactivity of alphaSMA and MMPs increased with the degree of liver fibrosis, whereas that of TGFbeta, PDGF, and TIMPs showed no difference in expression in groups with any degrees of fibrosis. The immunoreactivity of MMPs statistically significantly increased in fibrotic livers. Electronmicroscopically, HSCs had many filaments in their cytoplasm, showing myofibroblastic morphology. CONCLUSIONS: The present study gave a different result than other reports on adult liver fibrosis. Livers with BA may be in a predominant state of fibrolysis, indicating the presence of the similar process to recovery from liver fibrosis in adults.

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AIM: To analyze the efficacy of routine intraoperative ultrasound (IOUS) as a guide for understanding biliary tract anatomy, to avoid bile duct injury (BDI) after laparoscopic cholecystectomy (LC), as well as any burden during the learning period. METHODS: A retrospective analysis was performed using 644 consecutive patients who underwent LC from 1991 to 2006. An educational program with the use of IOUS as an operative guide has been used in 276 cases since 1998. RESULTS: IOUS was highly feasible even in patients with high-grade cholecystitis. No BDI was observed after the introduction of the educational program, despite 72% of operations being performed by inexperienced surgeons. Incidences of other morbidity, mortality, and late complications were comparable before and after the introduction of routine IOUS. However, the operation time was significantly extended after the educational program began (P < 0.001), and the grade of laparoscopic cholecystitis (P = 0.002), use of IOUS (P = 0.01), and the experience of the surgeons (P = 0.05) were significant factors for extending the length of operation. CONCLUSION: IOUS during LC was found to be a highly feasible modality, which provided accurate, real-time information about the biliary structures. The educational program using IOUS is expected to minimize the incidence of BDI following LC, especially when performed by less-skilled surgeons.

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PURPOSE: Biliary atresia (BA) is diagnosed by ultrasound (US) examination of the hepatic artery and gallbladder. This study was designed to assess the usefulness of the hepatic artery resistance index (HRI) measured by Doppler ultrasonography (DUS) for prognostication of liver viability in children with BA. METHODS: Seventeen patients with non-correctable BA were examined by US and DUS before and after hepatoenterostomy to evaluate hepatic artery dynamics. RESULTS: Dilatation of the hepatic artery was demonstrated in all 17 patients. US of the gallbladder showed hypogenesis in seven patients. Preoperatively, all 17 BA patients had an HRI of <1.0. Six of the 17 patients underwent liver transplantation. Four of the six had an HRI of >0.9, and the HRI decreased after the procedure. All patients were alive at the time of writing. CONCLUSIONS: Regular US examinations are helpful for diagnosis of BA and for detecting patients at high risk. A prospective study is required to determine the optimal frequency of assessment.

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Pancreatoblastoma in childhood is a very rare malignant tumor, but is considered to have a relatively good prognosis because of its low metastatic potential. We report 1-day-old female infant who was recently found to have an intraabdominal cyst on prenatal ultrasound examination. The tumor was a unilocular, cystic mass without invasion or metastasis to other organs, allowing total resection. It was diagnosed postnatally with pancreatoblastoma.

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BACKGROUND/AIMS: Inflammatory cytokines, such as interleukin-1 beta and tumor necrosis factor-alpha, which activate neutrophils, contribute to hepatic warm ischemia-reperfusion injury. However, the role of the cytokines in hepatic microcirculation immediately after reperfusion is still unclear. This study was carried out to investigate whether FR167653, a dual inhibitor of interleukin-1 beta and tumor necrosis factor-alpha, attenuates hepatic microcirculatory disturbance at the initial phase of reperfusion following liver ischemia. METHODOLOGY: Adult mongrel dogs were subjected to 90 minutes of liver ischemia by a Pringle's maneuver under portosystemic bypass. The animals were divided into two groups: a control group (n = 10), subjected to hepatic warm ischemia only, and a FR167653 administered group (n = 5), which received 1 mg/kg/h FR167653 for 4 hours since 30 minutes before the ischemia to 2 hours after the reperfusion continuously. Seven days animal survival, hepatic tissue blood flow, liver function test, hepatic venous blood concentration of endothelin-1 and plasminogen activator inhibitor-1, liver tissue biochemistry, and histopathology were analyzed. RESULTS: The treatment with FR167653 attenuated microcirculatory disturbance, lessened liver injury, enhanced adenine nucleotides resynthesis, and improved animal survival after liver ischemia. In addition, FR167653 significantly inhibited release of both endothelin-1 and plasminogen activator inhibitor-1 from the liver cells. CONCLUSIONS: These results suggest that the inflammatory cytokines induce microcirculatory disturbance in the initial phase of reperfusion following liver ischemia.

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We recently treated a 14-year-old girl with a clinically and histologically diagnosed with adenoma of the nipple. Enucleation of a mass preserving the nipple was successfully performed. Adenoma of the nipple is a rare disease which is often mistaken clinically for Paget's disease. About 200 cases of the tumors have been reported worldwide so far. The most common symptom is erosion of the nipple and nipple discharge. Our case had erosion of the nipple but no discharge. Adenoma of the nipple is a benign lesion which can be successfully treated by a simple surgery.

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