A Case of Congenital Duodenal Web Causing Duodenal Stenosis in a Down Syndrome Child: Endoscopic Resection with an Insulated-Tip Knife

A 35-month-old girl visited our hospital with repetitive vomiting and abdominal distention; this was especially aggravated after the introduction of solid and semisolid foods. At 5 months of age, the patient, who had Down's syndrome, had undergone surgery for ventricular septal defect, atrial septal defect, and patent ductus arteriosus, and had subsequently been frequently hospitalized for respiratory infections and other viral infectious diseases. After her admission, the abdominal distension improved with fasting and intravenous fl uid therapy. Radiograph from a small-bowel series revealed a thin fi lling defect with a dilated duodenal bulb in the distal region of the second portion of the duodenum, suggesting a duodenal web, and endoscopy revealed duodenal stenosis. We therefore performed endoscopic resection with an insulated-tip knife because of the history of prior operations, fasting problems after operations, and respiratory infections. Seven days later, scar formation was noted on the second portion of the duodenum, the scope passed well at the excision site, and no retained food material was noted on the follow-up endoscopy. After the procedure, the patient's abdominal distention and repetitive vomiting subsided, and she was discharged with the ability to eat eat an age-appropriate normal diet. There were no specifi c symptoms or other complications for 1 year after the procedure.

Successful Opening of Ductus Arteriosus with Milrinone in a Newborn with Tetralogy of Fallot and Pulmonary Atresia

Tetralogy of Fallot (TOF) assumes its' most severe form when accompanied by pulmonary atresia (PA). Preserving the patent ductus arteriosus to maintain pulmonary blood flow is life-saving for patients with this congenital heart disease. Milrinone, a selective phosphodiesterase III inhibitor, is a potent vasodilator. Here, we report the successful use of milrinone for a newborn infant with TOF and PA for keeping the ductus arteriosus open and thereby maintaining pulmonary circulation. Milrinone is a useful drug because of its inotropic, lusitropic, and pulmonary vasodilating effects, in addition to its ability to keep the ductus arteriosus open and its relatively mild side-effects. Case series and comparative studies will be needed in the future to verify the effectiveness of this drug.

Iatrogenic Esophageal Perforation: An Occurrence from Feeding Tube Placement in a Premature Infant with a Pneumothorax

Spontaneous neonatal esophageal perforation (EP) is a rare condition. However, iatrogenic EP due to a feeding tube is not uncommon, particularly in premature infants. Iatrogenic EP can result in serious complications, such as a pneumothorax, and can be fatal. Usually a pneumothorax develops as a result of EP. However, we experienced an EP in a patient with a pneumothorax. The EP occurred after inserting a feeding tube while the patient was suffering from a pneumothorax. Thus care is needed when inserting the feeding tube in a patient with a pneumothorax.

Intracystic Bleomycin Injection for Craniopharyngioma: Case Report

As craniopharyngioma is histologically benign, recent trend of managing this tumor has been complete surgical removal without adding any adjuvant therapy. But because of its close relation with surrounding vital structures, total removal sometimes results in unacceptable neurologic sequelae. To avoid these serious complications various management options have been suggested. Among these, bleomycin injections into the cystic cavity have been sporadically reported with satisfactory results. The authors report a 50-year-old woman presented with visual symptoms, who was found to have a largely cystic craniopharyngioma. Because the boarder between the tumor and hypothalamus was ill defined, intracystic bleomycin injection followed by delayed surgery was scheduled. A total of 80mg bleomycin was given over the 8 days. After the treatment high fever, skin rash and mental change developed but these symptoms were gradually subsided and the cysts were shrunken with surrounding infarction. During the follow-up period, visual symptoms became rapidly worse for which surgery was undertaken. Optic nerve was severely compressed by the underlying solid tumor and overlying A1 portion of the anterior cerebral artery. The tumor was near totally removed without any vascular insult. After the operation, the patient remained drowsy and lapsed into coma 6 days later and died. CT scan just before her death showed an infarct in the right ACA and MCA territories suggesting ICA occlusion. The cause of ICA occlusion remained to be unsolved.

Temporal Lobectomy and Hematoma Removal for Large Hemorrhage of the Basal Ganglia

Severe hemorrhage of the basal ganglia is usually associated with massive surrounding edema, and even after removal of the hematoma, edema persists for as long as several weeks and exerts an additional deleterious effect on the recovery from the ictus. To determine whether the provision of intracranial space will improve the outcome, we performed temporal lobectomy in addition to hematoma removal and compared the result with hematoma removal only. Over a three-year period from January 1993 to March 1996, we encountered 476 cases of spontaneous intracerebral hemorrhage and of these, 52 with severe hemorrhage of the basal ganglia were selected for this study. On admission, the neurological status of these 52 patients was very poor or progressively deteriorating, and all underwent surgical intervention. They were divided into two groups according to the surgical procedure : hematoma removal with temporal lobectomy(Group I) and hematoma removal only(Group II). GCS score at discharge, GOS score, Barthel index and mortality were compared between the two groups. In overall comparison of GCS score at discharge, GOS score, rate of persistent vegetative state, and death rate between the two groups, there was no significant difference, but among patients with a GCS score 6 and below, this score was higher and the rate of persistent vegetative state and death were lower in Group I than in Group II(p<0.05). Among those with a GCS score of above 6, there was no difference between the two groups. We conclude that for patients whose neurological status is poor(GCS score 6 and below), the benefit of temporal lobectomy in addition to hematoma removal is greater than that of hematoma removal alone.

Geometric Analysis of Dural Compression in Non-traumatic Spinal Instability

We studied the extent of dural sac compression and the contributory factors involved during lumbar flexionextension motion in non-traumatic spinal instability patients. In a total of 79 patients, spinal instability at L4-L5 or L5-S1 had been clinically and radiologically diagnosed. Their lateral flexion-extension lumbar myelograms were reviewed and we selected 48 cases which had adequate lumbar mobility, and clear and unequivocal measuring points. Those patients were divived into four groups of 12, as follows: Group I: transient low back pain without radiologic abnormalities(Control); Group II: spinal instability without displacement(SIWD) had been clinically and radiologically diagnosed; Group III: symptomatic degenerative spondylolisthesis(DSL); Group IV: symptomatic isthmic spondylolisthesis(ISL). Using the OPTIMAS 5.2 image analyzing program, we measured dural AP distance(DD) at intervertebral disc level and dural area(DA) at each functional motion segment, as seen on flexion-extension lumbar myelograms. The results were as follows: (1) In the control group and SIWD group, the degree of dural sac compression was not significantly different. (2) In the DSL group, DD and DA at the L4-L5 level were markedly lower than in the control group(p<0.05). In the ISL group, DD was significantly higher(p<0.05), but DA was slightly lower than in the control group. In addition, DD and DA in the ISL group were significantly higher than in the DSL group. (3) At the L5-S1 level, these changes were variable and there were no significant trends. In conclusion, we discovered that in determining the extent of dural sac compression in spondylolisthesis, measuring both dural distance and dural area is more valuable than measuring either of these alone. This is because in this condition, anterior displacement of the vertebral body or posterior displacement of the mobile lamina plays an important role. We also found that the different mechanisms of dural sac compression seen in the DSL and ISL group, as well as the variable changes seen at the L5-S1 level, are due to anatomical characteristics.

Experimentally induced Chiari-like malformation with myeloschisis in chick embryos

Though several pathogenetic theories concerning the frequent association of Chiari malformation and hydrocephalus with myeloschisis have been suggested, none of them explains all the aspects of the disorder. To investigate whether myeloschisis is the direct cause of Chiari malformation and hydrocephalus or these conditions are the results of another basic event, we observed the morphological changes of the posterior cranial fossa and its components in the chick embryos with surgically induced myeloschisis. To make myeloschistic lesions, we opened the neural tube for a length of 9-11 somites in Hamburger and Hamilton stage 16-19 chick embryos. They were divided into cervicothoracic (C-T) and lumbosacral(L-S) groups according to the area of incision. The embryos were re-incubated until postoperative day 11. In the control group, embryos were incubated with the eggshell window open as their experimental counterparts. The survival rates of each group were as follows; 11% (9 survivors/85 operated embryos), 8% (7/83), and 17% (10/60) in the C-T, L-S and control groups, respectively. Myeloschisis positive rates were 100% in the operated groups and 0% in the control group. The heads of embryos were sectioned along the sagittal plane to observe the morphological changes in the posterior cranial fossa and its components. Of the survivors, five in the C-T group, two in the L-S group and six in the control group were available for light microscopic inspection. In the majority of embryos with myeloschisis, without difference between the C-T and L-S groups, the fourth ventricles were smaller than those of the control group and the subarachnoid spaces in the posterior cranial fossa were also narrower. In embryos with severe changes, the cerebellum displaced downward comparing with that of the control embryos. No evidence of hydrocephalus was present Though not always typical, morphological changes similar to Chiari malformation were observed in chick embryos with surgically induced myeloschisis. It suggests a strong direct causal relationship between the two conditions and supports the theories of derangements in cerebrospinal fluid dynamics rather than those of primary mesenchymal or neural origin as a pathogenetic mechanism of Chiari malformation.

Experimentally induced Chiari-like malformation with myeloschisis in chick embryos

Though several pathogenetic theories concerning the frequent association of Chiari malformation and hydrocephalus with myeloschisis have been suggested, none of them explains all the aspects of the disorder. To investigate whether myeloschisis is the direct cause of Chiari malformation and hydrocephalus or these conditions are the results of another basic event, we observed the morphological changes of the posterior cranial fossa and its components in the chick embryos with surgically induced myeloschisis. To make myeloschistic lesions, we opened the neural tube for a length of 9-11 somites in Hamburger and Hamilton stage 16-19 chick embryos. They were divided into cervicothoracic (C-T) and lumbosacral(L-S) groups according to the area of incision. The embryos were re-incubated until postoperative day 11. In the control group, embryos were incubated with the eggshell window open as their experimental counterparts. The survival rates of each group were as follows; 11% (9 survivors/85 operated embryos), 8% (7/83), and 17% (10/60) in the C-T, L-S and control groups, respectively. Myeloschisis positive rates were 100% in the operated groups and 0% in the control group. The heads of embryos were sectioned along the sagittal plane to observe the morphological changes in the posterior cranial fossa and its components. Of the survivors, five in the C-T group, two in the L-S group and six in the control group were available for light microscopic inspection. In the majority of embryos with myeloschisis, without difference between the C-T and L-S groups, the fourth ventricles were smaller than those of the control group and the subarachnoid spaces in the posterior cranial fossa were also narrower. In embryos with severe changes, the cerebellum displaced downward comparing with that of the control embryos. No evidence of hydrocephalus was present Though not always typical, morphological changes similar to Chiari malformation were observed in chick embryos with surgically induced myeloschisis. It suggests a strong direct causal relationship between the two conditions and supports the theories of derangements in cerebrospinal fluid dynamics rather than those of primary mesenchymal or neural origin as a pathogenetic mechanism of Chiari malformation.

Intracerebral Aspergillus Abscess Combined with Large Frontal Mucopyocele

Intracranial aspergillosis is rare and often fatal, and the brain is the third most frequent origine involved, precede by the lung and the gastrointestinal tract. Two routes of infection are considered important for infection of the central nervous system with aspergillus ; direct spread of infection, mostly within the paranasal sinuses, or hematogenous spread, usually originated from the lung. Paranasal sinus mucocele is a chronic expanding lesion lined by sinus mucosa and containing thickened mucus. Complication arise as a result of infection or expansion of mucoceles. Mucoceles that invade adjacent area, such as the orbits or anterior cranial fossa, can cause complication by a mass effect. The authors report their surgical experience of intracranial aspergillus abscess combined with large frontal mucopycele.

Experiences of Reoperation on Failed Lumbar Disc Surgery

Nine patients, who had once low back operation due to herniated lumbar disc, underwent repeated low back surgery at the same level because of persistent or recurred symptoms. All patients were proved to have no psychological or compensative problems. Seven of them had satisfactory results but two, one who had no definite symptom free interval and had surgically proven epidural fibrosis only and another who underwent reoperation as early as 45 days after the first operation had persistent previous symptoms. After review of these cases we obtained several favorable factors which influence the post-operative results. When a patient had a definite symptoms free interval longer than 2 years or the main offending lesion was proved to be a disc herniation or spinal stenosis, satisfactory results could be anticipated.

Postoperative Discitis

Twelve cases of postoperative discitis, experienced during the past 9 years, are presented and discussed along with review of literatures. The etiology of these postoperative complications is not fully known, but most likely, the cause seems to be of a low-grade infection and chemical and mechanical injuries are given as the causes in literature. It is presumed that the high incidence (3.9%) of postoperative discitis may have some relation with the use of steroids for a long period prior to operation in our series. The characteristic of this disease are recurrence of severe lowback & gluteal pain, spasm of lumbar paravertebral muscle and elevated E.S.R. following the asymptomatic postoperative period, a roentgenogram showed an early destructive change in the adjacent vertebrae, the narrowing of the intervertebral disc space, sclerotic changes in the vertebral bone and occasional fusion of the spine, and relatively good prognosis. The most important treatment was found to be an adequate immobilization of the vertebral column by means of a plaster of paris cast or absolute bed rest. The authors stress the importance of a regular check of E.S.R and an X-ray examination of the spine after surgery for an early diagnosis of postoperative discitis.