Ileovesical Fistula Caused by Ingested Foreign Material

Ileovesical fistula is a rare condition in children. A case of 13 year-old female with ileovesical fistula caused by an ingested foreign material is presented. She had dysuria and lower abdominal pain for one month. There was no history of medico-surgical illness such as Crohn's disease or diverticulitis. Preoperative imaging study showed a movable calcified object in the pelvic cavity and air bubbles in the bladder. At laparotomy a bezoar-like mass was found at the antimesenteric border of the terminal ileum adherent to the dome of bladder. Segmental resection of the ileum and partial cystectomy were performed.

Comparison of Emergence Agitation from Sevoflurane Anesthesia after Thiopental Sodium, Propofol or Ketamine Induction in Pediatric Inguinal Herniorrhaphy / 대한마취과학회지

BACKGROUND: This study compared the incidence of emergence agitation and the recovery profile from sevoflurane anesthesia after thiopental sodium, propofol or ketamine induction in pediatric inguinal herniorrhaphy. METHODS: Forty eight children aged 1-7 years undergoing high ligation due to an inguinal hernia were examined. All patients received a 0.004 mg/kg glycopyrrolate injection for premedication prior to induction and were randomly assigned to receive thiopental sodium 5 mg/kg (Group T, n = 16), propofol 2 mg/kg (Group P, n = 16) or ketamine 1 mg/kg (Group K, n = 16) for induction. The side effects during the induction time were checked. All patients received sevoflurane (2-2.5 vol%)-N2O (2 L/min)-O2 (2 L/min) for the maintenance of anesthesia. Ventilation was given to assist spontaneous ventilation using a facial mask. The agitation score, pain score, discharge score, incidence of emergence agitation and postoperative side effects in the three groups were assessed at the recovery room and compared. RESULTS: The emergence time in Group T (7.5 +/- 1.8 min) was significantly rapid. The agitation and pain scores were significantly low in Group P. The discharge score was more rapid in Groups P and K than in Group T. The incidence of emergence agitation was similar in all three groups. CONCLUSIONS: Although recovery was faster and emergence agitation was low in the propofol group, propofol induction was not smooth compared with thiopental or ketamine induction. The incidence of emergence agitation after sevoflurane anesthesia in pediatric inguinal herniorrhaphy was similar in the thiopental sodium, propofol or ketamine induction groups.

Acute Left-sided Appendicitis with Intestinal Malrotation in a Child

Appendicitis is a common disease in children. But left lower abdominal pain in acute appendicitis is a rare clinical feature. A 6 year-old-girl complained of left sided abdominal pain for 2 days. Past medical history was not contributory. Abdominal tenderness and guarding in left lower quadrant were noticed. Abdominal sonography and abdominal computed tomography scan demonstrated reversed position between superior mesenteric artery and vein, and a mass in the left lower quadrant abdomen suggesting appendicitis. Acute appendicitis in left lower quadrant, associated with intestinal malrotation, was found at laparatomy.

Usefulness of Ad Lib Feeding for Hypertrophic Pyloric Stenosis

Infantile hypertrophic pyloric stenosis (HPS) is a relatively common entity. A number of studies for the postoperative feeding schedule has been studied to allow for earlier hospital discharge and improve cost-effectiveness in the treatment of HPS. The purpose of this study was to compare 3 feeding-methods and to evaluate the usefulness of ad lib feeding for HPS. The authors retrospectively reviewed the records of 116 patients who underwent pyloromyotomy for HPS from 1995 to 2004. Three cases were excluded because of the duodenal perforation during pyloromyotomy. Three feeding-methods were defined as: Conventional feeding (>10 hours nothing by mouth and incremental feeding every 2 hours, C), Early feeding(for 4 to 8 hours nothing by mouth and incremental feeding every 2 hours, E), and Ad lib feeding (for 4 hours nothing by mouth and ad lib feeding, A). Time to normal feeing in C, E and A were 51+/-24, 34+/-12 and 24+/-6 hours, respectively. Hospital-stay in C, E and A were 72+/-17, 55+/-13 and 43+/-12 hours, respectively. There were statistically significant differences according to the method of feeding. Frequency of postoperative emesis in C, E and A were 38%, 47% and 53%, but was not significant statistically. Ad lib feeding decreased time to normal feeding and hospital stay, and did not increase postoperative emesis. We conclude that ad lib feeding is recommended for patient with pyloromyotomy in HPS.

A Case of Thymolipoma in a Child

Thymolipoma is a rare benign mediastinal tumor, composed of mature fatty and thymic tissues. A 9-year-old boy was referred with a one-month history of neck swelling. Preoperative computed tomography scan and fine needle aspiration biopsy suggested thymolipoma. Despite it being rare, thymolipoma should be considered in the differential diagnosis of mediastinal tumors. Characteristics of its clinical feature and radiological findings that can differentiated it from other mediastinal tumors are discussed with a review of the literatures.

A Case of Retroperitoneal Mass in Infancy, Fetus in Fetus / 대한산부인과학회잡지

"Fetus in fetus" is a rare pathologic feature consisting of a parasitic twin included within the body of the other twin, which most likely arises from inclusion of a monozygotic, diamniotic twin pregnancy. The exact embryogenesis of fetus in fetus is controversial. Some investigators propose that it is a highly organized teratoma. Since the condition was first described by Meckel in the late 18th centry, approximately 100 cases have been reported in the literature. Most cases present as an abdominal mass during the first year of life, with a few cases being detected prenatally by ultrasound examination. So we report one case of fetus in fetus detected by ultrasound examination prenatally.

Expression of Neural Cell Adhesion Molecule (NCAM) and Glial Cell Line-Derived Neurotrophic Factor (GDNF) in Aganglionic Bowel of Hirschsprung's Disease

The pathophysiology of Hirschsprung's disease (HD) is not fully understood, but recent studies have disclosed that neural cell adhesion molecule (NCAM) and glial cell line-derived neurotrophic factor (GDNF) play important roles in the formation of aganglionic bowel of Hirschsprung's disease. To evaluate the roles of NCAM and GDNF in HD, immunohistochemical analysis was performed using formalin-fixed and paraffin-embedded tissue sections. On the basis of the results, we tried to evaluate them as diagnostic markers. The specimens were obtained from 7 patients with HD who underwent modified Duhamel operation. The diagnosis was based on the clinical findings and the absence of ganglion cells in the nerve plexuses by routine microscopy. NCAM immunoreactivity was found in the nerve plexuses and scattered nerve fibers in the smooth muscle layers of ganglionic segments. In aganglionic segments, the number of NCAM positive nerve fibers in the smooth muscle layers was significantly reduced compared with ganglionic segments. In two cases the nerve plexuses in aganglionic segments, NCAM was negligible. The smooth muscle cells showed diffuse immunoreactivity for GDNF and the staining intensity was not different in the aganglionic and ganglionic segments. However, higher expression of GDNF in the nerve plexus of the ganglionic segments was noted comparing to aganglionic segments. These data suggest that both NCAM and GDNF may play important roles in pathogenesis of Hirschsprung's disease and immunohistochemical staining for NCAM can be used as an ancillary diagnostic tool for HD.

Comparative Review of Perianal Sinus & Fistula in Ano

PURPOSE: A fistula in ano is a granulating track between the anorectum and the perianal region or perineum. A typical fistula may consist of the track, the primary (internal) opening and secondary (external) opening. Its hallmark is frequent discharge through external opening. Sometimes this track become occluded and a sinus remains. Therefore abscence of an external opening should not be taken as evidence that there is no fistula, and then this study is aimed to make clear perianal sinus as another form of fistula in ano. METHODS: This study is a clinical analysis of 17 patients with perianal sinus, who were treated at the Department of General Surgery of Pundang-CHA hospital from June, 1995 to December, 1998. As comparative group, 91 patients of typical fistula in ano were also taken in same period. RESULTS: The ratio of male to female was 4.6:1 in sinus group, 4.1:1 in fistula group. The prevalent ages were in the third decade in both group. The main symptoms of sinus group were a palpable mass (94.1%), pain & discomfort (35.3%) but that of fistula group were purulent discharge (87.9%) and pain (28.6%). The most frequent duration of illness was 6 months~1 year (52.9%) in sinus group, within 6 months (40.7%) in fistula group. The distributions of sinus size were 7 cases (41.2%) in 2 cm. The most common type was intersphincteric in both group. The operative procedures included excision with fistulectomy in 4 cases (23.5%), lay open of sinus with fistulotomy in 11 cases (64.7%), seton procedure in 2 cases (11.8%). The mean hospital stay was 5.0 day in sinus group, 4.9 day in fistula group. CONCLUSIONS: There was no distinct difference in the clinical features or characteristics between the both groups, therefore perianal sinuscould be taken as fistula in ano and treated similar procedures.

Sacral ratio in normal children and patients with anorectal malformations

Evaluation of the sacrum in anorectal malformations (ARMs) is important because of the frequent association with ARMs and functional outcome after correction of ARMs. Sacral defects are not easily detected because of immaturity of sacrum in children and overlooking of pediatric surgeons. The authors utilized the sacral ratio in normal children and patients with ARMs. In normal children, the mean true sacral ratio and mean sacrococcygeal ratio were 0.60+/-0.08 and 0.72+/-0.13 respectively. Sacral ratio was not correlated with age and did not changed with age in same patient. However, true sacral ratio and sacrococcygeal ratio were significantly lower in patients with high type ARMs than those of normal children (p<0.001). There was no difference between patients with low type ARMs and normal children. These results suggest that abnormal sacrums are more frequently encountered in patients with high type ARMs than in normal children, and that true sacral ratio and sacrococcygeal ratio can be used in the evaluation of the abnormal sacrum.

Bile Carcinoembryonic Antigen in Colorectal Cancer

PURPOSE: Serum level of carcinoembryonic antigen (CEA) is clinically one of the prognostic factors in the follow-up evaluation of the colorectal cancer (CRC) patient. It has been recently suggested that the bile CEA level is also useful in early detection of the liver metastasis of colrectal cancer. If the bile CEA is also correlated with the cancer progression or prognosis like as serum CEA, it will be another useful clinical parameter in the evaluation and treatment of CRC patients. Therefore this study is aimed to reveal the correlation of the bile CEA with the progression of tumor and to estimate the possibility of bile CEA as a useful clinical parameter. METHODS: Preoperative serum levels of CEA were measured in 58 patients of CRC who were operated in Pundang CHA hospital. The levels of bile CEA were also checked with the aspiration of bile in gall bladder at laparotomy. The positive value of CEA was settled as more than 5ng/ml. RESULTS: The 58 patients were classified into 29 cases of Dukes'AB group, 23 cases of Dukes'C group & 6 cases of Dukes'D group. The positive rates of serum CEA were 24.1% in AB group, 30.4% in C group & 66.7% in D group, and those of bile CEA were 44.8%, 56.5% & 83.3% individually. When group C was also divided into N1(13 cases) & N2 (10 cases) groups according to the number of the metastatic lymph nodes, serum & bile CEA positive rates were 15.4% & 46.1% in N1 group, and 50% & 70% in N2 group. Both of serum & bile CEA levels were all positive and markedly elevated in 4 hepatic metastasis cases of group D. CONCLUSIONS: Positive rate of bile CEA was increased according to the progression of tumor stage. Marked elevation of bile CEA was especially noted in liver metastatic cases. Therefore bile CEA can be considered as a clinical parameter in evaluation of cancer progression & prognosis like as serum CEA, and also as a useful indicator of hepatic metastasis.

A Case of a Choledochal Cyst with a Mucinous Cystadenoma of the Pancreas

A choledochal cyst is a relatively common lesion of the biliary tract in pediatric patients and usually presents abdominal pain, jaundice, and abdominal mass. Its etiology is unknown, but the theory of pancreatobiliary reflux through anomalous pancreatobiliary duct union is widely accepted. A mucinous cystadenoma of the pancreas is very rare in children. To our knowledge, there is no literature reporting a case of a choledochal cyst with a mucinous cystadenoma of the pancreas. We report a case of a choledochal cyst combined with a mucinous cystadenoma of borderline malignancy at the head of the pancreas in a 5-year-old girl and review the literature.

Pseudo-Hirschsprung's Disease Due to Total Intestinal Hypogenesis

Intestinal hypogenesis is a rare cause of functional intestinal obstruction and shows both diminished numbers of ganglion cells and immature ganglion cells. We report a case of intestinal hypogenesis extending from the rectum to the proximal jejunum. A male newborn was noted to have a neonatal intestinal obstruction, and a laparotomy at 4 days of age proved the existence of intestinal hypogenesis. Histologic examination showed immature ganglion cells (cell body, 6.0+/-0.037 micrometer; nucleus, 4.1+/-0.028 micrometer; nucleoli, 0 micrometer in diameter) and hypoganglionosis. At 46 days of age, a reoperation was done, and the intestinal hypogenesis was proved to extend from the proximal jejunum to the rectum. Maturation of the ganglion cells in the small bowel (cell body, 9.3+/-0.28 micrometer; nucleus, 6.3+/-0.61 micrometer; nucleoli, 1.2+/-0.04 micrometer in diameter) was observed compared to initial study. However, the infant had persistent functional intestinal obstruction and was continued on parenteral nutrition with the hope of further maturation of the ganglion cells and improvement of the intestinal motility. Unfortunately, he was discharged against advise at 72 days of age and died. The maturation of the ganglion cells in this case suggests that this entity should not deemed hopeless.

Choledochal Cyst and Anomalous Pancreatobiliary Ductal Union in Children

BACKGROUND: The etiology of choledochal cysts is unknown, but the theory of pancreatobiliary reflux through an anomalous pancreatobiliary ductal union (APBDU) is widely accepted. The aim of this study was to evaluate the correlation between choledochal cysts and APBDUs in children. METHODS: We retrospectively analyzed 33 pediatric patients with choledochal cyst who had undergone excision of the whole extrahepatic bile duct along with hepaticoenterostomy at the Division of Pediatric Surgery, Department of Surgery, Yonsei University College of Medicine, from 1993 to 1998. RESULTS: The mean age of the patients was 51 months, and the ratio of males to females was 1:2.3. Anatomical types were Ia (n=17, 52%), Ic (n=11, 33%), III (n=1, 3%), and IVa (n=4, 12%) in the Todani classification of biliary cysts. We performed endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, or intraoperative cholangiopancreatography in all cases. An APBDU was identified in 24 patients (73%): right angle union (n=11, 33%), acute angle union (n=11, 33%), or a complex union (n=2, 6%) in the Todani classification of APBDUs. Type Ia cystic lesions correlated with right angle unions whereas Type Ic cylindrical lesions correlated with acute angle unions. The mean age of patients with a Type Ic, acute angle union was older than that of patients with a Type Ia, right angle union. In Type Ic, the amylase levels in serum and bile were elevated, but in Type Ia, they were not. CONCLUSIONS: APBDUs correlated highly with the shape of the extrahepatic dilatation, the age at onset, and the reflux of pancreatic juice. We think the excision of the entire extrahepatic duct along with a hepaticoenterostomy and appropriate evaluation of the APBDU are essential for the treatment of choledochal cysts in children.