Stomal Complications in Children

This is a 20 year analysis of the problems associated with enterostomy formation, and closure. Forty-three stomas were established in 43 patients: 23 for anorectal malformations, 11 for Hirschsprung's diseases, 4 for necrotizing enterocolitis, 3 for multiple ileal atresias, 1 for volvulus neonatorum with perforation, and 1 for diaphragmatic hernia with colon perforation. Thirty boys and 13 girls were included (mean age 4.8 months). Stoma complications were encountered in 13 patients (30.2 %): stomal prolapse, stenosis, obstruction, paracolic hernia, retraction, dysfunction, and skin excoriation. Four patients (9.3 %) required stomal revision. Occurrence of complications was not related to age and primary disease, but sigmoid colostomy showed lower complication rate than transverse colostomy (20.0 % vs 42.9 %, p<0.05). There were five deaths but, only one (2.3 %) was directly related to the enterostomy complication. Twenty-one stomas were closed in our hospital and complications occurred in seven patients (33.3 %). The most common complication was wound sepsis in 5 children. In conclusion, because the significant morbidity of stomal formation still exists, refinements of the surgical technique seem to be required. Sigmoid loop colostomy is preferred whenever possible.

Two Cases of Stercoral Perforation of Colon

While colon perforation as a complication of diseases such as carcinoma, colitis, diverticular disease, or abdominal trauma is not uncommon, spontaneous perforation of the colon is rare. Although spontaneous perforation is classified as either stercoral or idiopathic on the basis of its etiological background, the pathological mechanisms of the lesions have yet to be determined in detail. Stercoral perforation is a very rare cause of acute abdomen, with fewer than 70 cases documented in the literature; and idiopathic perforation is also infrequently reported. Both disease entities have often been grouped together as idiopathic or spontaneous perforation, resulting in confusion. We report herein two cases of stercoral perforation of the sigmoid colon. The clinical features, diagnosis, and treatment of the disease are reviewed. Surgeons should be aware of the possibility of this fatal disease, despite its rare incidence. Furthermore, it is important to recognize the condition at an early stage of the disease because it has significantly high mortality if surgery is delayed.

A Case of Colon Cancer in Peutz-Jeghers Syndrome

Peutz-Jeghers syndrome is an autosomal dominant disease characterized by hamartomatous polyps in the gastrointestinal tract and by mucocutaneous melanin pigmentations. The relationship between gastrointestinal polyps and the syndrome has been discussed for many years, and many reports have recently suggested an association between the development of gastrointestinal carcinomas and the presence of the syndrome. The reasons for such an association are unknown; some possible reasons are 1) the transformations of some hamartomas into adenomatous polyps and cancer, 2) malignant transformation of adenomatous polyps, or 3) de novo occurrence of malignant tumors. We here present our clinical experience with a 53-year-old male patient who had Peutz-Jeghers syndrome and an adenocarcinoma at the hepatic flexure of the colon.

Composite Carcinoma-Carcinoid Tumor of the Common Bile Duct: A case report

The occurrence of a carcinoid admixed with an adenocarcinoma of the gastrointestinal tract is an unusual phenomenon which has been reported in the esophagus, stomach, gallbladder, colon, and appendix. Herein, we describe an extremely rare case of a composite tumor of the common bile duct. A 50-year-old woman who suffered from right upper abdominal pain and jaundice was found on radiographical investigations and operation to have a tumor in the common bile duct. Histopathologically, the resected tumor was composed mainly of solid nests of atypical round cells and partially of a well-differentiated adenocarcinoma showing a mutual transition in the mucosal layer. Both immunohistochemical and ultrastructural analyses confirmed a composite tumor: a neuroendocrine cell carcinoma and a tubular adenocarcinoma.

Is Early Postoperative Oral Intake Safe after Elective Colorectal Surgery?

PURPOSE: The routine use of postoperative nasogastric decompression after abdominal surgery has been challenged. Furthermore, investigators have recently shown that early postoperative oral feeding is safe and generally well tolerated. This study was aimed to determine whether or not early postoperative feeding is safe after elective colorectal surgery. METHODS: All patients who underwent elective colorectal surgeries between June 1998 and March 1999 were permitted to take oral intake one day after the operations. The patients were compared with other patients, who had underwent elective colorectal surgeries between September 1997 and June 1998 and permitted to have a meal after resolving postoperative ileus. The nasogastric tube was removed from all patients immediately after surgery. The patients were monitored for the time of ileus resolution, nausea/vomiting, abdominal distension, nasogastric tube reinsertion and complications. RESULTS: Fifty-one patients were studied, 24 patients in early feeding group and 27 patients in traditional feeding group. Eighteen patients (75.0%) in the early feeding group tolerated the early oral intake. There were no significant differences between two groups in the time for resolution of ileus (3.46 1.38 days vs 3.56 1.80 days), nausea/vomiting (33.3% vs 29.6%), abdominal distension (16.6% vs 14.8%) and nasogastric tube reinsertion (12.5% vs 7.4%). No significant difference was noted in complications such as wound infection, pulmonary problems, intestinal obstruction and anastomotic leak. CONCLUSIONS: Early oral intake after elective colorectal surgery was safe and most of the patients tolerated it. And it may become a kind of managements after elective colorectal surgery.

Primary Malignant Neoplasms of the Small Intestine: Histopathologic Determinants of Recurrenec and Survival

Primary malignant neoplasms of the small intestine account for only a small percentage of gastro intestinal tumors, but their prognosis is one of the worst. We reviewd the clinical features, diagnostic procedures, and outcome of surgical treatment in 29 patients with primary neoplasms of the small bowel in order to identify aspects of management that might be improved. A retrospective review of cases from 1981 to 1996 identified 29 patients with primary small intestinal tumors. Four histologic groups were identified: adenocarcinoma, 11 patients; lymphoma, 10 patients; malignant stromal tumor, 7 patients; carcinoid, 1 patient. There were 20 men and 9 women. The mean age was 47.5 years(median age: 51 years). The median follow-up was 19.1 months. Survival analysis was done by Kaplan-Meier methods. Preoperative diagnosis of a small intestinal tumor were rarely made because symtoms are vague and nonspecific, so preoperative diagnoses were made in only 11 of the 29 patients (37.9%). The median survival was 20.73 (+/-3.75) months for adenocarcinomas, 21.00 (+/-7.99) months for lymphomas, and 24.50 (+/-5.89) months for stromal tumors. Curative resection was achieved in 17 (58.6%) of the 29 patients, and the mean survival was significantly longer for this gruop (32.27 months vs 7.67 months, p<0.001). Of the 17 curative resections, the disease recurred in 8 patients (47.1%). Wide surgical resection of early lesions is the only potentially curative treatment, but it is possible in only a minority of patients.

A Case of Ganglioneuroma in the Pelvic Cavity / 대한비뇨기과학회지

We present a case of ganglioneuroma arsing from the sympathetic ganglia in the pelvic cavity.

Stomal Complications in Infants and Children

We performed this study to analyse the morbidity and mortality of stoma formation in infants and children over a 17-year period. Thirty-seven stoma formations were performed in 37 patients: 21 for anorectal malformation, 9 for Hirschsprung's disease, 3 for necrotizing enterocolitis, 2 for multiple ileal atresia, 1 for volvulus neonatorum with perforation, and 1 for diaphragmatic hernia with colon perforation. There were 26 boys and 11 girls with a mean age of 0.4 years. Complications after stoma formation were encountered in 12 patients(32.4%) and included stomal prolapse, stenosis, retraction, dysfunction, skin excoriation and parastomal hernia. Four patients(10.8%) required stomal revision. The incidence of complications was neither related to the age nor to the primary indication for the stoma formation, but sigmoid colostomy was associated with a lower complication rate compared to transverse colostomy(22.1% versus 42.1%, P<0.05). Five patients died, but only one(2.7%) was dead, which was directly related to stoma formation. Eighteen of these children subsequently underwent stoma closure which was associated with complications in six patients(33.3%). The most common complication after stoma closure was wound sepsis in 4 children. In conclusion, because the significant morbidity of stoma formation still exists the refinements in surgical technique may help in reducing the incidence of complications and a sigmoid loop colostomy should be used whenever possible.

Anatomical Variations of the Right Colic Artery

A through knowledge of the anatomy of colonic mesenteric arteries is necessary to accomplish successful, uncomplicated abdominal operations, especially laparoscopic colonic resections in which the mesenteric vessels can't be palpated. Such knowledge is also important when performing a colonic resection for cancer using proximal vascular ligation and wide en bloc resection. Most surgical textbooks depict a "normal pattern" of arterial supply to the right colon as consisting of three arterial branches (the ileocolic, the right colic, and the middle colic arteries) arising independently from the superior mesenteric artery (SMA). Based on the literature, there are only two colonic arteries arising independently from the SMA in many cases. We examined the anatomy of these arteries in 50 patients who had had SMA angiographies for various diseases from January 1995 to May 1997. In all of our cases, the ileocolic artery and the middle colicartery emanated directly from the SMA, but the right colic artery originated directly from the SMA in only 54% of the cases. The right colic artery was absent in 8% of the cases. It also arose as a single trunk with the middle colic artery (22% of the cases) and from the ileocolic artery (16% of the cases). Our data, together with published anatomic studies, lead us to conclude that in many cases there are only two independent branches arising from the SMA that supply the large intestine, the ileocolic artery and the middle colic artery. This knowledge may be helpful in laparoscopic colon surgery, radical colon resections for cancer, and colon replacements after operations on the esophagus or the urinary bladder.

Results of Treatments for Pyogenic Liver Abscesses

Pyogenic liver abscess has been a life-threatening disease with a uniformly fatal outcome if left untreated. Changes in the etiology, clinical manifestations, methods of diagnosis, treatment and prognosis of pyogenic liver abscess have occurred slowly, but continuously, over the past century. Modern imaging techniques, improved drainage procedures, and appropriate antibiotic therapy have substantially reduced the mortality and the morbidity. A review of 103 patients with pyogenic liver abscess who were treated at Masan Samsung Hospital over a 5-year period from January 1992 to December 1996 was undertaken to characterize recent trends in diagnosis and management. There were 60 males and 43 females whose ages ranged from 11 to 85 years (mean 62.3 years). The peak age was in the 6th decade. Pyogenic liver abscess more often involved the right lobe (65.1%) than the left lobe (26.2%), and a single abscess was encountered more often than multiple abscesses in a 2.2:1 ratio. Upper abdominal pain, fever, and chills were the most common symptoms, and upper abdominal tenderness was the most common physical finding. An elevated serum alkaline phosphatase was seen in 73.8% of all patients and was the most common biochemical abnormality. Biliary tract disease was the most frequent underlying disorder. In the bacteriological study, we obtained positive cultures in 89.3% of the cases:65.0% were Gram-negative organism, 17.5% were Gram-positive organism, and 6.8% were anaerobes. E. coli was the most frequently cultured organism (31.5%). Ultrasonography and/or CT scanning was employed in the diagnosis and the follow up of all patients. Surgical open drainage was performed in 52 cases (50.5%) and percutaneous closed drainage in 51 cases (49.5%). The outcome of surgical open drainage was similar to that of percutaneous closed drainage, except for the mortality rate. Post-treatment complications occurred in 26 cases (25.2%), and the most frequent complication was a pulmonary problem (8.7%). The mortality rate due to pyogenic liver abscess was 7.8%, and the most common cause of death was sepsis.

The Diagnostic Value of Serum C-Reactive Protein in Patients Suspected to Have Acute Appendicitis

C-reactive protein(CRP), a normal constituent of the serum in healthy individuals, increases in response to various bacterial infections and cellular necrosis. To find out if the C-reactive protein concentration is of any value in the diagnosis of acute appendicitis, ninety consecutive patients suspected to have acute appendicitis were studied prospectively. Of these, 54 patients(group A) had acute appendicitis and 6 patients(group B) underwent surgery with a diagnosis of acute appendicitis; however, histopathology disclosed a normal appendix. Seventeen patients(group C) had no identifiable cause for their illness and 13 patients(group D) had an identifiable cause for their illness, though not appendicitis. The mean serum CRP value was 49.00mg/L in group A, 18.92mg/L in group B, 20.31mg/L in group C, and 63.22mg/L in group D. Within group A, the mean CRP value in the 36 patients with the inflammed appendix was 33.56mg/L. The mean value in the 7 patients with the gangrenous appendix was 73.16mg/L, and 97.61mg/L in 11 patients with the perforative appendix. Serum CRP levels were normal in two patients with acute appendicitis. Besides these 2 patients, all patients with normal CRP had a normal appendix found at the time of operation or their symptoms resolved spontaneously. It is concluded that an increase in CRP levels to more than 5 mg/L is not a definitive indicator of acute appendicitis. However, when there is doubt about the diagnosis of acute appendicitis, a normal serum CRP level should be used as a basis for the decision to defer surgery.

A Clinical Study of Periappendiceal Abscess

This is a clinical analysis and review of one-hundred ninety-four patients with periappendiceal abscesses who were treated at the Departmeat of Surgery, Masan Samsung Hospital over a ten year period from January 1985 to December 1994. The following results were obtained. The incidence of periappendiceal abscesses was 7.24% of the total cases of appendicitis operated on during the same period, and most of the patients(43.8%) were over fifty years old. The male to female ratio was 1:1.02. 41.2% of the patients had operations within four days after their symptoms occurred. On admission, the most common physical finding was tenderness on the right lower quadrant of the abdomen (92.9%) and leukocytosis(> OR = 10,000/mm3) was noted on CBC in 82% of the patients. Abdominal sonograms revealed periappendiceal abscesses in 88% of the patients, 83% were revealed with barium enema and 88% with abdominal CT scan. Many patients(75.5%) visited the local clinic and were treated under the diagnosis of gastritis or enteritis instead of appendicitis. One-hundred eighty-three patients(94.3%) had appendectomies with drainages(94.3%), two patients had drainages of abscesses without appendectomy, six patients had ileocecal resections and three patients had right hemicolectomies. Microbiologically, E. coli was the most frequently cultured species(63%) from abscess, and Klebsiella, Enterococcus and Proteus were isolated in some cases. Postoperative complication occurred in seventy-five patients(38.6%) and the most frequent complication was wound infection(28.8%). There was no mortality and the mean hospital stay was fifteen days.