A Case of Digital Intraosseous Epidermoid Inclusion Cyst of the Distal Phalanx

Intraosseous epidermoid inclusion cyst is a very rare cystic lesion of the bone, that has been reported primarily in middle-aged men. A congenital etiology has been proposed, although post-traumatic or iatrogenic events remain the most prevalent hypotheses. A 61-year-old woman visited Soonchunhyang University Gumi Hospital complaining of painful swelling of her right middle finger. Radiologic findings of the lesion showed a well-defined, lytic, expansile lesion originating at the tip of the distal phalanx. Preoperative imaging suggested benign cartilage tumors such as enchondroma or acute osteomyelitis. Intralesional curettage, culture, and biopsy were performed. Histopathological analysis demonstrated stratified squamous epithelium with keratinized cellular debris, consistent with a diagnosis of digital intraosseous epidermoid inclusion cyst. We present a case of an epidermoid inclusion cyst originating at the tip of the distal phalanx of the right middle finger.

A Case of Pneumatosis Cystoides Intestinalis in a Patient with Chronic Diarrhea and Abdominal Pain / 계명의대학술지

Pneumatosis cystoides intestinalis is a rare gastrointestinal complication with multiple gas-filled cysts in the submucosa or subserosa of the bowel wall. It can occur as primary or secondary disease with other etiology. Although this disease is usually asymptomatic and found incidentally during radiologic or endoscopic examination, it can be a cause of severe problem such as obstruction or pneumoperitoneum. We report a case of pneumatosis cystoides intestinalis in a 45-year-old male with chronic diarrhea and abdominal discomfort.

A Case of Small Bowel Obstruction Caused by Intestinal Endometriosis / 계명의대학술지

Endometriosis is a common disease affecting females of reproductive age. Intestinal involvement has been estimated to occur in 15% to 37% of females with endometriosis. Unlike endometriosis of large intestine, it is very rare for the condition to manifest as small bowel obstruction caused by intestinal endometriosis. Preoperative diagnosis of intestinal endometriosis is very difficult. This disorder should be considered in the differential diagnosis of females of child-bearing age with symptoms of bowel obstruction. We report a 44-year-old woman who presented with symptoms and signs of acute small bowel obstruction. A segmental resection of the small bowel was performed with end to end anastomosis. Pathologic examination demonstrated acute small bowel obstruction secondary to intestinal endometriosis. The patient died on the second day after the surgery because her condition worsened. Intestinal endometriosis also should be included in the differential diagnosis of bowel obstruction for the prompt treatment.

A Case of Digital Intraosseous Epidermoid Inclusion Cyst of the Distal Phalanx

Intraosseous epidermoid inclusion cyst is a very rare cystic lesion of the bone, that has been reported primarily in middle-aged men. A congenital etiology has been proposed, although post-traumatic or iatrogenic events remain the most prevalent hypotheses. A 61-year-old woman visited Soonchunhyang University Gumi Hospital complaining of painful swelling of her right middle finger. Radiologic findings of the lesion showed a well-defined, lytic, expansile lesion originating at the tip of the distal phalanx. Preoperative imaging suggested benign cartilage tumors such as enchondroma or acute osteomyelitis. Intralesional curettage, culture, and biopsy were performed. Histopathological analysis demonstrated stratified squamous epithelium with keratinized cellular debris, consistent with a diagnosis of digital intraosseous epidermoid inclusion cyst. We present a case of an epidermoid inclusion cyst originating at the tip of the distal phalanx of the right middle finger.

A Case of Pneumatosis Cystoides Intestinalis in a Patient with Chronic Diarrhea and Abdominal Pain / 계명의대학술지

Pneumatosis cystoides intestinalis is a rare gastrointestinal complication with multiple gas-filled cysts in the submucosa or subserosa of the bowel wall. It can occur as primary or secondary disease with other etiology. Although this disease is usually asymptomatic and found incidentally during radiologic or endoscopic examination, it can be a cause of severe problem such as obstruction or pneumoperitoneum. We report a case of pneumatosis cystoides intestinalis in a 45-year-old male with chronic diarrhea and abdominal discomfort.

A Case of Lung Abscess Caused by Pulmonary Actinomycosis

Actinomycosis is a slowly progressive and indolent infectious disease characterized by acute suppurative inflammation, necrosis, and fibrosis. It usually occurs in cervicofacial, abdominopelvic, and pulmonary areas. Pulmonary actinomycosis accounts for 15%–20% of total cases and is often accompanied by empyema, necrosis, and pleural effusion. Its clinical manifestations and radiologic features are nonspecific unfortunately. We report a case of lung abscess caused by pulmonary actinomycosis in a 53-year-old man, presented with fever, chilling, myalgia, and hemoptysis for 15 days. The plain chest radiograph showed a mass-like lesion in the left upper lung field. The computed tomography scan revealed mass-like infiltration with a huge cavity and central necrosis. Microscopic examination of the lung specimen showed Gram-positive sulfur granules and was consistent with pulmonary actinomycosis.

A Case of Adult Intussusception Secondary to Lymphangioma of the Cecum

Lymphangioma is benign vascular malformation, commonly found in children. It is found more often in the head, neck, and axillary area, and rarely occurs in the gastrointestinal tract such as the colon. It resembles hemangioma but consists of cystic spaces of variable sizes containing clear lymphatic fluid. Adult intussusception accounts for 5%–15% of all intussusceptions. Clinical manifestations of intussusception may include nonspecific symptoms such as abdominal pain, nausea, vomiting, melena, and anemia. Colonic lymphangioma may be a rare cause of adult intussusceptions. We report a case of adult intussusception due to cecal lymphangiomawith a literature review.

F-18 Fluorodeoxyglucose PET/CT and Post Hoc PET/MRI in a Case of Primary Meningeal Melanomatosis

Primary meningeal melanomatosis is a rare, aggressive variant of primary malignant melanoma of the central nervous system, which arises from melanocytes within the leptomeninges and carries a poor prognosis. We report a case of primary meningeal melanomatosis in a 17-year-old man, which was diagnosed with 18F-fluorodeoxyglucose (F-18 FDG) PET/CT, and post hoc F-18 FDG PET/MRI fusion images. Whole-body F-18 FDG PET/CT was helpful in ruling out the extracranial origin of melanoma lesions, and in assessing the therapeutic response. Post hoc PET/MRI fusion images facilitated the correlation between PET and MRI images and demonstrated the hypermetabolic lesions more accurately than the unenhanced PET/CT images. Whole body F-18 FDG PET/CT and post hoc PET/MRI images might help clinicians determine the best therapeutic strategy for patients with primary meningeal melanomatosis.

Congenital Pulmonary Lymphangiectasia, Associated with Total Anomalous Pulmonary Venous Return

Congenital pulmonary lymphangiectasia (CPL) is very rare. It shows diffuse pulmonary lymphatic dilatation without lymphatic proliferation. CPL can occur as a primary disorder or arise secondarily from other diseases such as the obstruction of pulmonary veins or lymphatics. The prognosis of CPL is very poor. Approximately 50% of infants are stillborn and most others usually die within the first day of life. The present case showed diffuse lymphangiectasia in the subpleural, interlobular, and peribronchovascular areas. The flat lining cells were immunohistochemically positive for D2-40 and CD31. CPL is usually diagnosed by clinicoradiological or postmortem examinations. However, our case was diagnosed by an antemortem lung biopsy. We report a case of CPL with total anomalous pulmonary venous return.

Clinical Experience of Spontaneous Hemopneumothorax / 대한흉부외과학회지

BACKGROUND: Spontaneous hemopneumothorax is characterized by the accumulation of air and more than 400 mL of blood in pleural cavity without any apparent cause. It is a rare disease and can cause life-threatening situation. We analyzed clinical reviews of two medical centers to aid in optimal management. MATERIAL AND METHOD: Retrospective review between March 2003 and August 2010 with 18 spontaneous hemopneumothorax patients was made. RESULT: These 18 patients were comprised of 15 male and 3 female with average 24.6 years (range 15~46 years). Almost patients (16) underwent a closed thoracostomy initially and 15 patients received video-assisted thoracic surgery (VATS). Mean postoperative chest tube removal was 2.9 days and one complication was post-removal pneumothorax. During the follow-up periods there were no other complications and recurrence. CONCLUSION: Proper initial diagnosis and management of spontaneous hemopneumothorax prevent significant hypovolemic shock. Video-assisted thoracic surgery should be considered an early surgical management in spontaneous hemopneumothorax. However conservative manage without bleb excision may be effective in selected patients.

Anti-calcification Effects in Decellularized and Variously Fixed Bovine Pericardium / 대한흉부외과학회지

BACKGROUND: Our goal was to evaluate anti-calcification effects of decellularization and diverse fixing methods including preincubation of the bovine pericardium with ethanol. We also assessed changes in mechanical properties. MATERIAL AND METHOD: Harvested bovine pericardium was decellularized with 0.25% sodim dodecysulfate and then treated with 5 methods of fixation: (1) 0.5% glutaraldehyde (GA) for 14 days, (2) 0.5% GA for 5 days, 2% GA for 2 days and 0.25% GA for 7 days, (3) 0.5% GA for 5 days, 2% GA for 2 days, 0.25% GA for 7 days, and then 70% ethanol for 2 days, (4) 0.5% GA for 5 days, a mixture of 2% GA and 70% ethanol for 2 days, and 0.25% GA for 7 days, (5) 0.5% GA for 5 days, a mixture of 2% GA, 65% ethanol, and 5% octanediol for 2 days and then 0.25% GA for 7 days. All treated bovine pericardia were tested for histological variables, lipid content, and mechanical properties including tensile strength and thermal stability. A total 10 kinds of differently treated bovine pericardia were implanted into rat subdermis and harvested 8 weeks later. Harvested pericardia were evaluated for calcium content. RESULT: No protein denaturation was observed microscopically after decellularization. There was a 32% mean decrease in tensile strength index after decellularization in the bovine pericardium group fixed. Octanediol preincubation attenuated the decrease in tensile strength and maintained thermal stability. TG and cholesterol were not affected by decellularization but were decreased by organic solvent. Calcium content was decreased after decellularization, and organic solvent preincubation decreased calcification in the non-decellularized bovine pericardium group. CONCLUSION: Decellularization and organic solvent preincubation have anti-calcification effects but decellularization may cause mechanical instability. A method of decellularization and fixation that does not cause damage to matrices will be needed for evaluation of the next step in using tissue-engineering for replacement of cardiac valves.

A Trend for Atrioventricular Valve Regurgitation after a Modified Fontan Operation / 대한흉부외과학회지

BACKGROUND: Anatomic and functional abnormalities of the systemic atrioventricular (AV) valve are common in single ventricle pathologies and continue to be associated with poor early and late outcomes in surgically palliated single ventricle patients. We aggressively performed valvuloplasty for atrioventricular valve regurgitation (AVVR) during the course toward a Fontan operation. MATERIAL AND METHOD: Between January 1995 and December 2004, 209 patients underwent a Fontan operation in our institution. We retrospectively evaluated the prevalence of AVVR and the influence of AV valve repair on outcome, and we analyzed the progression of AVVR after the Fontan operation for 168 patients where echocardiographic follow up results for more than 6 months after the Fontan operation were available. During the course toward a Fontan operation, 25 patients underwent 30 procedures for AVVR. These procedures were carried out during placement of a bidirectional cavopulmonary shunt (BCPS) for nine patients, between the time of placement of a BCPS and the Fontan operation for four patients, and during the Fontan operation for 17 patients. Five patients underwent procedures for AVVR twice. RESULT: The late mortality rate after the Fontan operation was 4.2% (n=7), with a median follow-up duration of 52 months (range, 6~123 months). Seven patients (4%) had unfavorable outcomes such as significant (moderate or severe) AVVR in six patients, and significant AV valve stenosis in one patient was determined at the last follow up after the Fontan operation. Among the seven patients, four patients underwent AV valve repair after the Fontan operation, and one patient underwent subsequent AV valve replacement. Progression to AVVR of equal to or greater than grade 2 was noted in 30 patients (18%) at the last follow up after the Fontan operation, including 12 patients that underwent previous AV valve procedures. Initial grading of AVVR, a previous AV valve operation, and specific AV valve morphology such as a common AV valve or mitral atresia were significant risk factors for the progression of AVVR after the Fontan operation. CONCLUSION: In our surgical series, a small percentage of patients showed unfavorable outcomes related to AVVR during the course toward a Fontan operation. However, a closer follow-up is required to evaluate the progression of the AVVR after a Fontan operation, especially for patients showing poor AV valve function at the first presentation and specific AV valve morphology.

Intravenous Remifentanil Infusion during EVLT for Varicose Vein / 대한흉부외과학회지

BACKGROUND: We compared the analgesic effects of an intravenous infusion of remifentanil with local lidocaine injection during endovenous laser treatments (EVLT) for varicose veins. MATERIAL AND METHOD: In order to compare the efficacy of analgesia between the lidocaine group (n=15) and the remifentanil group (n=15), we measure the pain intensity of the patients, with using the visual analogue scale, during EVLT and at the first week, the second week, the third week and the fourth week after EVLT. RESULT: The remifentanil group showed significantly less pain intensity during EVLT (p0.3). CONCLUSION: The result showed that the intravenous infusion of remifentanil during EVLT can be a good option to reduce pain during EVLT for treating varicose veins.

The Clinical Application and Results of Palliative Damus-Kaye-Stansel Procedure / 대한흉부외과학회지

BACKGROUND: The Damus-Kaye-Stansel (DKS) procedure is a proximal MPA-ascending aorta anastomosis used to relieve systemic ventricular outflow tract obstructions (SVOTO) and pulmonary hypertension. The purpose of this study was to review the indications and outcomes of the DKS procedure, including the DKS pathway and semilunar valve function. MATERIAL AND METHOD: A retrospective review of 28 patients who underwent a DKS procedure between May 1994 and April 2006 was performed. The median age at operation was 5.3 months (13 days~38.1 months) and body weight was 5.0 kg (2.9~13.5 kg). Preoperative pressure gradients were 25.3+/-15.7 mmHg (10~60 mmHg). Eighteen patients underwent a preliminary pulmonary artery banding as an initial palliation. Preoperative main diagnoses were double outlet right ventricle in 9 patients, double inlet left ventricle with ventriculoarterial discordance in 6, another functional univentricular heart in 5, Criss-cross heart in 4, complete atrioventricular septal defect in 3, and hypoplastic left heart variant in 1. DKS techniques included end-to-side anastomosis with patch augmentation in 14 patients, classical end-to-side anastomosis in 6, Lamberti method (double-barrel) in 3, and others in 5. The bidirectional cavopulmonary shunt and Fontan procedure were concomitantly performed in 6 and 2 patients, respectively. RESULT: There were 4 hospital deaths (14.3%), and 3 late deaths (12.5%) with a follow-up duration of 62.7+/-38.9 months (3.3~128.1 months). Kaplan-Meier estimated actuarial survival was 71.9%+/-9.3% at 10 years. Multivariate analysis showed right ventricle type single ventricle (hazard ratio=13.960, p=0.004) and the DKS procedure as initial operation (hazard ratio=6.767, p=0.042) as significant mortality risk factors. Four patients underwent staged biventricular repair and 13 received Fontan completion. No SVOTO was detected after the procedure by either cardiac catheterization or echocardiography except in one patient. There was no semiulnar valve regurgitation (>Gr II) or semilunar valve-related reoperation, but one patient (3.6%) who underwent classical end-to-side anastomosis needed reoperation for pulmonary artery stenosis caused by compression of the enlarged DKS pathway. The freedom from reoperation for the DKS pathway and semilunar valve was 87.5% at 10 years after operation. CONCLUSION: The DKS procedure can improve the management of SVOTO, and facilitate the selected patients who are high risk for biventricular repair just after birth to undergo successful staged biventricular repair. Preliminary pulmonary artery banding is a safe and effective procedure that improves the likelihood of successful DKS by decreasing pulmonary vascular resistance. The long-term outcome of the DKS procedure for semilunar valve function, DKS pathway, and relief of SVOTO is satisfactory.

Angioleiomyosarcoma Arising from the Deep Femoral Vein: A report of one case / 대한흉부외과학회지

A 69-year-old man was admitted to our hospital for deep vein thrombosis, and he had experienced two episodes of left leg swelling: one happened after an 11 hour-air trip from Europe in June 2007, and the other developed 3 days after an operation for a herniated lumbar disc in July 2007. We treated him for a deep vein thrombosis of the deep femoral vein after admission. However, we arrived at the final diagnosis of angioleiomyosarcoma after the operation for the tentative diagnosis of deep vein thrombosis. We removed the firmly engorged deep femoral vein on the second operation. We report here on a case of angioleiomyosarcoma that arose from the deep femoral vein.

Clinical Experiences of Congenital Aortic Stenosis / 대한흉부외과학회지

BACKGROUND: The aim of this study is to assess the clinical results of various procedures in congenital aortic stenosis. MATERIAL AND METHOD: From August 1987 to June 2004, 53 patients of congenital aortic stenosis underwent procedures such as percutaneous balloon valvuloplasty, aortic valvuloplasty, Ross procedure, and aortic valve replacement. The mean age of initial procedures was 8.2+/-6.0 years. Percutaneous balloon valvuloplasty was performed in sixteen patients, aortic valvuloplasty in thirty two patients, Ross procedure in nineteen patients, and aortic valve replacement in fourteen patients. The mean follow duration was 80.6+/-60 (0~207) months. RESULT: There was 15.1% (8/53) of early mortality and no late mortality. The six patients with critical aortic stenosis were died of left ventricular dysfunction in early series (before 1 year; 4 cases) and two patients died after the Ross procedure and aortic valve replacement respectively. After percutaneous balloon valvuloplasty, most patients needed reoperations (14/16). Thirteen patients needed reoperation, after aortic valvuloplasty. After Ross procedure, two patients needed reoperation due to aortic regurgitation caused by progressive aortic root dilatation. The actuarial survival rate after Ross procedure at 7 years was 90.5%. CONCLUSION: In young children before the age of one, percutaneous balloon valvuloplasty was considered as the safe initial palliative procedure. But children over one year-old, aortic valvuloplasty were the effective procedure. Ross procedure can be preformed safely with good results.

Risk Factor Analysis for Operative Death and Brain Injury after Surgery of Stanford Type A Aortic Dissection / 대한흉부외과학회지

BACKGROUND: Surgery for Stanford type A aortic dissection shows a high operative mortality rate and frequent postoperative brain injury. This study was designed to find out the risk factors leading to operative mortality and brain injury after surgical repair in patients with type A aortic dissection. MATERIAL AND METHOD: One hundred and eleven patients with type A aortic dissection who underwent surgical repair between February, 1995 and January, 2005 were reviewed retrospectively. There were 99 acute dissections and 12 chronic dissections. Univariate and multivariate analysis were performed to identify risk factors of operative mortality and brain injury. RESULT: Hospital mortality occurred in 6 patients (5.4%). Permanent neurologic deficit occurred in 8 patients (7.2%) and transient neurologic deficit in 4 (3.6%). Overall 1, 5, 7 year survival rate was 94.4, 86.3, and 81.5%, respectively. Univariate analysis revealed 4 risk factors to be statistically significant as predictors of mortality: previous chronic type III dissection, emergency operation, intimal tear in aortic arch, and deep hypothemic circulatory arrest (DHCA) for more than 45 minutes. Multivariate analysis revealed previous chronic type III aortic dissection (odds ratio (OR) 52.2), and DHCA for more than 45 minutes (OR 12.6) as risk factors of operative mortality. Pathological obesity (OR 12.9) and total arch replacement (OR 8.5) were statistically significant risk factors of brain injury in multivariate analysis. CONCLUSION: The result of surgical repair for Stanford type A aortic dissection was good when we took into account the mortality rate, the incidence of neurologic injury, and the long-term survival rate. Surgery of type A aortic dissection in patients with a history of chronic type III dissection may increase the risk of operative mortality. Special care should be taken and efforts to reduce the hypothermic circulatory arrest time should always be kept in mind. Surgeons who are planning to operate on patients with pathological obesity, or total arch replacement should be seriously consider for there is a higher risk of brain injury.

Half-turned Truncal Switch Operation for Transposition of Great Arteries, Ventricular Septal Defect and Pulmonic Stenosis / 대한흉부외과학회지

The surgical management of patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis remains a challenge. The Rastelli operation or Lecompte operation is the preferred surgical procedure, but its long-term results are not optimal because of a warped left ventricular outflow tract through a space-occupied intraventricular tunnel and a contrived right ventricular outflow tract. We performed a half-turned truncal switch operation as an alternative surgical procedure in a 3-year-old boy (weighing 9.6 kg) with this anomaly. Postoperative echocardiography showed laminar flow through straight and nonobstructive aortic and pulmonary ventricular outflow tracts.

Early and Mid-term Results for Repair of Ebstein's Anomaly / 대한흉부외과학회지

BACKGROUND: We evaluated the early and mid-term results for repair of Ebstein's anomaly. MATERIAL AND METHOD: Between January 1989 and June 2004, 29 patients underwent repair of Ebstein's anomaly. The median age was 11.4 years (4 days-50 years). Tricuspid insufficiency equal to or greater than grade 3 was present in 21 (72.4%) patients. Surgical techniques included tricuspid valve repair with vertical plication of the atrialized ventricle (n=14), Carpentier's technique (n=7), tricuspid valve replacement (n=4), systemic-to-pulmonary arterial shunt (n=2), tricuspid valve repair (n=1), and Fontan operation (n=1). Bi-directional cavopulmonary shunt (BCPS) was required in 5 patients. Among the 2 neonates, one patient underwent successful biventricular repair, and the other patient underwent systemic-to-pulmonary arterial shunt. Follow-up was possible in 21 patients (75%), and the average follow-up was 37.6 months (3 months~11.3 years). RESULT: There were 1(3.4%) early and 1 late deaths. Reoperation was required in 4 patients. Two patients underwent tricuspid valve re-replacement, and the other 2 tricuspid valve repair. At recent follow-up, only 2 patients showed tricuspid insufficiency equal to or greater than grade 3, and most patients showed clinical improvement. Excluding the patients who underwent tricuspid valve replacement, the actuarial rate of freedom from reoperation at 1 and 5 years were 94.7% and 79.0%, respectively. CONCLUSION: Tricuspid valve repair was possible in most patients with good mid-term outcome. Most patients showed clinical and hemodynamic improvement. Indications for the BCPS should be clarified.

Modified Blalock-Taussig Shunt for the Patients with Complex Congenital Heart Defects in Early Infancy / 대한흉부외과학회지

BACKGROUND: This retrospective review examines the preoperative condition, postoperative course, mortality and cause of death for the patients who underwent modified Blalock-Taussig shunt for complex congenital heart defects in early infancy. MATERIALS AND METHOD: Fifty eight patients underwent modified Blalock-Taussig shunts from January 2000 to November 2003. The mean age at operation was 23.1+/-16.2 days (5~81 days), and the mean body weight was 3.4+/-0.7 kg (2.1~4.3 kg). Indications for surgery were pulmonary atresia with ventricular septal defect in 12 cases, pulmonary atresia with intact ventricular septum in 17, single ventricle (SV) in 18, and hypoplastic left heart syndrome (HLHS) in 11. Total anomalous pulmonary venous return (TAPVR) was associated with SV in 4 cases. RESULT: There were 11 (19.0%) early, and 5 (10.6%) late deaths. Causes of early death included low cardiac output in 9, arrhythmia in 1, and multiorgan failure in 1. Late deaths resulted from pneumonia in 2, hypoxia in 1, and sepsis in 1. Risk factors influencing mortality were preoperative pulmonary hypertension, metabolic acidosis, use of cardiopulmonary bypass, HLHS and TAPVR. Twenty four patients (41.4%) had hemodynamic instability during the 48 postoperative-hours. Six patients underwent shunt revision for occlusion, and 1 shunt division for pulmonary overflow. CONCLUSION: Modified Blalock-Taussig shunt for complex congenital heart defects in early infancy had satisfactory results except in high risk groups. Many patients had early postoperative hemodynamic instability, which means that continuous close observation and management are mandatory in this period. Aggressive management may appear warranted based on understanding of hemodynamic changes for high risk groups.