Clinical Analysis of Choledochal Cysts in Children

PURPOSE: The object of this study is to evaluate the clinical findings and the outcome of choledochal cysts (CC) in children. METHODS: All cases of CC that underwent operation between 1983 and 2006 were studied retrospectively. We evaluated the symptoms and signs, types, anomalous pancreaticobiliary union (APBDU) and complications of CC. RESULTS: Forty-five children were included. The common age range was from 1 year to 5 years. The male to female ratio was 1 to 3. The most common symptom was abdominal pain (71.1%). The main methods of diagnosis were US and CT. According to Todani's classification, type I (60%) and type IV (35.6%) were most common types. APBDU was confirmed in 21 cases. B-P type (13 cases) was more common than P-B type (8 cases). Three among four patients with pancreatitis had a stone or protein plug in the common channel. Cyst excision with hepaticojejunostomy was performed in most cases. The overall morbidity and mortality were 8% and 0%, respectively. There were no problems, such as cholangitis, biliary stone and biliary cancer during the follow up. Intrahepatic duct dilatations of type IVa disappeared in the postoperative follow up study, except one. CONCLUSION: The outcome of cyst excision with hepaticojejunostomy was excellent. As for CC accompanied with the pancreatitis, the presence of stone or protein plug in the common channel needs to be examined. It is hard to precisely interpret that intrahepatic duct dilatation in type IVa normalize during the postoperative follow up until more evidence is accumulated.

A Case of Successful Management of Sarcoidosis with Chylothorax Using Octreotide / 결핵및호흡기질환

Sarcoidosis is a multi-system granulomatous disorder of an unknown etiology and affects individuals worldwide. It is characterized pathologically by the presence of non-caseating granulomas in more than one involved organ. However, pleural involvement of sarcoidosis is rare and there are no reported cases in Korea. Traditionally, sarcoidosis has often been treated with systemic corticosteroids or cytotoxic agents. In particular, chylothorax with sarcoidosis is usually treated with corticosteroid for approximately 3~6 months, followed by repeated therapeutic thoracentesis, talc pleurodesis, dietary treatment, or thoracic duct ligation where needed. We encountered a 46 years old female patient presenting with cough, dyspnea and both hilar lymphadenopathy (stage I) on chest radiograph. The patient was diagnosed with a non-caseating granuloma, sarcoidosis by a mediastinoscopic biopsy. For one month, she had suffered from dyspnea due to right side pleural effusion, which was clearly identified as a chylothorax on thoracentesis. Corticosteroid therapy with dietary adjustment was ineffective. She was treated successfully with a subcutaneous injection of octreotide for 3 weeks and oral corticosteroid. We report a case of successful and rapid treatment of chylothorax associated with sarcoidosis using octreotide and oral corticosteroid.

The Difference of Lung Cancer Prevalence According to Smoking Habits / 결핵

BACKGROUND: The purpose of this study was to analyze the smoking habits in patients with lung cancer and identify any difference of prevalence according to histologic types of lung cancer. METHODS: The data were calculated by total amounts of tar and nicotine inhaled during the whole lifetime according to variation of smoking habits. This study was to investigated any difference of prevalence in lung cancer according to smoking habits. The subjects comprised 150 lung cancer cases and 300 hospital control cases that were matched by age and sex. Smoking habits during the whole lifetime were surveyed by standardized questionnaire. Odds ratios were estimated by unconditional logistic regression analysis. RESULTS: There were 104 male and 34 female lung cancer cases. By histologic type, there were 53 cases of squamous cell carcinoma, 67 of adenocarcinoma and 30 of small cell lung carcinoma. The differences between lung cancer cases and controls according to smoking habits were total duration of smoking, total pack years of smoking and number of cigarettes smoked per day during the previous two years. The odds ratios were higher in Kreyberg I, but not in Kreyberg II, for the longer duration of smoking, the greater total pack years of cigarettes consumed, the more cigarettes smoked per day during the previous two years, the longer duration of non-filter smoking, the earlier life cases who began to smoke, and the higher amounts of calculated total tar and nicotine inhaled over the whole lifetime. When we added grade of inhalation to calculation of amounts of tar and nicotine inhaled over the lifetime, the odds ratios of total inhalation amounts of tar and nicotine were as high as those the without them. CONCLUSIONS: This study reconfirmed that smoking habits were strongly associated with lung cancer and that there were different associations between smoking habits and histologic types of lung cancer. In particular, calculations of total tar and nicotine amounts inhaled over the whole lifetime were calculated for the first time in trials from lung cancer epidemiologic studies.

Colonic Complication of Acute Necrotizing Pancreatitis: a Case Report

We present a case of a colonic involvement associated with necrotizing pancreatitis, with a review of the literature. A 10 year old boy had an appendectomy at the local clinic ten days ago. On admission, he complained nausea, vomiting and severe constipation. His abdomen was distended and he had tenderness on the left abdomen. Laboratory and radiologic studies revealed findings consistent with acute pancreatitis with colonic complication. He was treated conservatively for 30 days but did not improve. On hospital 30th day, abdominal pain developed and his vital sign changed. Abdominal CT suggested ischemic change of the transverse colon. At laparotomy, the left colon showed stenosis. The greatly distended transverse colon was resected and a transverse end colostomy was done. He was discharged at postoperative 45th day with improvement and colostomy closure was performed 8 months later.

A Case of Mediastinal Pancreatic Pseudocyst / 결핵

BACKGROUND: A pancreatic pseudocyst is one of various complications occurring in acute of chronic pancreatitis. It is usually located in the retroperitoneal space near the pancreas. However, other unusual locations are also possible. Jones intially described the mediastinal pseudocyst in 1940. Since then, fewer than 50 cases have been reported. A diagnosis of a mediastinal pseudocyst is accomplished by imaging studies revealing the cystic nature of the mass with evidences of acute or chronic pancreatitis. There is some controversy regarding the appropriate management of mediastinal pseudocyst because of the high mortality and morbidity after surgical management. Here we report a case of a mediastinal pancreatic pseudocyst found in a patient with asymptomatic alcohol-related pancreatitis complicated by the development of a mediastinal peudocyst, which quickly resolved after endoscopic retrograde pancreatic and biliary drainage and subcutaneous injection of a somatostatin analog(octreotide acetate) without any complications.

Laparoscopic Appendectomy is Feasible for All Forms of Appendicitis

PURPOSE: Acute gangrenous and perforated appendicitis are associated with an increased risk for intraoperative conversion, postoperative complications and have been considered a relative contraindication for laparoscopic appendectomy. The objective of this study was to analyze the feasibility of the laparoscopic approach in all forms of appendicitis. METHODS: A retrospective review of 101 patients who underwent laparoscopic appendectomy for uncomplicated and complicated appendicitis (perforated appendicitis and periappendiceal abscess) between June 2000 and May 2001 was performed. RESULTS: There were 84 patients with uncomplicated appendicitis (group A), 11 patients with perforated appendicitis (group B) and 16 patients with periappendiceal abscess (group C). The mean age of the patients was 42 (12~79) years and there were 47 men and 54 women. The mean operation time was 43, 67 and 105 minutes in groups A, B and C, respectively. Oral intake commenced at 1.4, 2.2 and 2.9 days and the hospital stay was 2.5, 2.9 and 5.2 days in groups A, B and C, respectively. There was no conversion to open surgery in groups A and B; however 4 patients in group C were converted. Complications were noted in 3 patients, one for each group. The overall complication rate was 2.9% and conversion rate, 0.9%. CONCLUSION: Although our experience is limited, the laparoscopic appendectomy seems to be a feasible and safe procedure for all forms of apppendicitis, including periappendiceal abscess.

Clear Cell Sarcoma of the Kidney: A case report

Clear Cell Sarcoma of the Kidney (CCSK) is a rare malignant childhood tumor with frequent metastasis to the bone. We report a case of right sided in a 5 month-old girl. A radical nephrectomy was performed. It was clinical stage III with renal capsular invasion and lymph node metastasis by the classification of NWTS-5. Histologic examination revealed the classic pattern of CCSK. Postoperative adjuvant chemotherapy with doxorubicin and radiotheraphy were applied.

Time Dependent Changes of Nitric Oxide Synthesis Following Anoxia and Reoxygenation of Endothelial Cells of Umbilical Vein

High systemic complication rates and severe tissue injuries are associated with more successful revascularization and reperfusion of ischemia rather than ischemia itself. It is regarded as a "ischemia- reperfusion (I/R) injury". It is well recognized that the microvasculature is highly sensitive to I/R and that the initial damage of endothelial cells contributes to I/R-induced tissue injury. The endothelial cells serve as an important modulator of vascular homeostases by secreting vasoactive materials. One of the important product of endothelial cells, nitric oxide helps to maintain hemostasis through its involvement in coagulation, platelet activation, vascular tone regulation. But The exact role of nitric oxide and time dependent change of its synthesis during the reperfusion injury are not clear. In this study, endothelial cells were isolated from human fetal umbilical vein and cultured in M-199 medium. We observed morphological change of the endothelial cells and time dependent change of nitric oxide synthesis following anoxia and reperfusion injuries. The results were as follows: 1) More significantly, the endothelial cells of anoxia group were flattened and detached than contol group. More severe detachment of endothelial cells was founded in R-O group than anoxia group. There is no significant differences in morphological changes between allopurinol group and anoxia group. 2) The concentration of NO in the anoxia group (2511.62 428.60nM/1 105 cells/ml) was lower than that of the control group (3505.14 192.95nM/1 105 cells/ml) (P<0.005). The NO concentration of the reoxygenation group reached its highest level of 2953.14 90.98 nM/1 105 cells/ml at 180 minutes (P<0.05) and decreased thereafter. There was no significant differences in NO concentration between allopurinol group and anoxia group. In conclusion, morphologic damage of endothelial cells in reoxygenation group was significantly increased compared with anoxia group. Nitric oxide syntheses in reoxygenation group and anoxia group were decreased compared with control group. More advanced study will be needed to elucidate the detailed mechanism of time-dependent change of nitric oxide synthesis during the reperfusion injury.

Morphologic and Time Dependent Changes of Nitric Oxide Synthesis Following Anoxia and Reoxygenation of the Endothelial Cells of the Umbilical Vein

PURPOSE: In order to clarify the exact role of nitric oxide for a ischemia-reperfusion (I/R) injury, we observed morphologic change of endothelial cells and a time dependent change of nitric oxide synthesis following anoxia and reperfusion injuries. METHODS: The experimental groups were divided into 4 sub-groups: a control group without any treatment, an anoxia group treated with anoxic air (93% N2, 5% CO2, 2% H2) for 50 minutes, a reoxygenation group treated with 100% O2 for 480 minutes, and an allopurinol group treated with allopurinol immediately prior to reoxygenation. Endothelial cells were isolated from a human fetal umbilical vein and cultured in M-199 medium. We observed a morphological change of the endothelial cells with inverted light microscopy and we studied the time dependent change of nitric oxide synthesis with microelectrode following anoxia and reperfusion injuries. RESULTS: Most significantly, the endothelial cells of the anoxia group were more flattened and detached than those of the control group. A more severe detachment of endothelial cells was found in the reoxygenation group than in the anoxia group. There was no significant difference in the morphological change between the allopurinol group and the anoxia group. Additionally, the concentration of NO in the anoxia group (2511.62 428.60 nM/1 105 cells/ml) was lower than that of the control group (3505.14 192.95 nM/1 105 cells/ml) (P<0.005). The NO concentration of thereoxygenation group reached its highest level of 2953.14 90.98 nM/1 105 cells/ml at 180 minutes (P<0.05) and decreased thereafter. There was no significant difference in the NO concentration between the allopurinol and anoxia groups. CONCLUSION: The morphologic damage of endothelial cells in the reoxygenation group was significantly increased as compared with the anoxia group. Nitric oxide syntheses in the reoxygenation and anoxia groups was decreased as compared with the control group.

Morphologic and Time Dependent Changes of Nitric Oxide Synthesis Following Anoxia and Reoxygenation of the Endothelial Cells of the Umbilical Vein

PURPOSE: In order to clarify the exact role of nitric oxide for a ischemia-reperfusion (I/R) injury, we observed morphologic change of endothelial cells and a time dependent change of nitric oxide synthesis following anoxia and reperfusion injuries. METHODS: The experimental groups were divided into 4 sub-groups: a control group without any treatment, an anoxia group treated with anoxic air (93% N2, 5% CO2, 2% H2) for 50 minutes, a reoxygenation group treated with 100% O2 for 480 minutes, and an allopurinol group treated with allopurinol immediately prior to reoxygenation. Endothelial cells were isolated from a human fetal umbilical vein and cultured in M-199 medium. We observed a morphological change of the endothelial cells with inverted light microscopy and we studied the time dependent change of nitric oxide synthesis with microelectrode following anoxia and reperfusion injuries. RESULTS: Most significantly, the endothelial cells of the anoxia group were more flattened and detached than those of the control group. A more severe detachment of endothelial cells was found in the reoxygenation group than in the anoxia group. There was no significant difference in the morphological change between the allopurinol group and the anoxia group. Additionally, the concentration of NO in the anoxia group (2511.62 428.60 nM/1 105 cells/ml) was lower than that of the control group (3505.14 192.95 nM/1 105 cells/ml) (P<0.005). The NO concentration of thereoxygenation group reached its highest level of 2953.14 90.98 nM/1 105 cells/ml at 180 minutes (P<0.05) and decreased thereafter. There was no significant difference in the NO concentration between the allopurinol and anoxia groups. CONCLUSION: The morphologic damage of endothelial cells in the reoxygenation group was significantly increased as compared with the anoxia group. Nitric oxide syntheses in the reoxygenation and anoxia groups was decreased as compared with the control group.

Spnontaneous Regrssion of liver metastasis in Stage IV-S neuroblastoma after adrenalectomy: One Case Report

Prenatally diagnosed neuroblastomas have been reported in increasing numbers over the past several years. The vast majority are in favorable stages of the disease (stage I, II, IV-S). The authors experienced one case of stage IV-S neuroblastoma of the adrenal gland with liver metastasis, which regressed spontaneously after removal by adrenalectomy. This patient was noticed to have an abdominal mass at prenatal ultrasonography performed at 36weeks of gestation. This tumor was a neuroblastoma of the left adrenal gland with multiple liver metastases. Left adrenalectomy and liver biopsy were performed at 3 months of age. Thirty-eight months after surgery, an MRI demonstrated that the hepatic metastatic lesions had completely regressed without chemotherapy or radiation.

Beckwith-Wiedemann sydrome with left adrenal cortical neoplasm

Beckwith-Wiedemann sydrome is a multisystemic pattern of congenital anomalies with overgrowth. This syndrome is first described independently by Beckwith in 1963 and by Wiedemann in 1964. There is wide spectrum of clinical manifestations, including prenatal or postnatal overgrowth, neonatal hypoglycemia, macroglossia, visceromegaly, omphalocele, hemihypertrophy and a predisposition for embryonal tumors, most frequently Wilms' tumor. We experienced a case of Beckwith-Wiedemann syndrome who developed left adrenal cortical neoplasm of indeterminate malignant potential.

A Case Report of Primary Hyperparathyroidism Caused by Parathyroid Carcinoma

A parathyroid carcinoma is a rare cause of primary hyperparathyroidism. Even though the clinical presentation in a parathyroid carcinoma is usually symptomatic and different from that in benign parathyroid disease, a definite diagnosis can be made only by using a histologic examination of local invasion to surrounding tissue or metastases to regional lymph nodes or distant sites. It is important to confirm the malignancy at the initial operation because a radical resection offers the only possibility for cure. We experienced a 62-year-old woman with primary hyperparathyroidism caused by a parathyroid carcinoma, who had revealed the clinical manifestations of acute pancreatitis. A carcinoma in the right lower parathyroid was confirmed by histopathologic findings of invasion to the thyroid capsule. The patient was cured by using a radical resection of the parathyroidal mass, including the right lobe of the thyroid, the surrounding soft tissues, and the regional lymph nodes.

Clinical Analysis of Fournier's Gangrene

PURPOSE: Fournier's gangrene is a rapidly progressive (and aggressive), necrotizing fasciitis of the genitalia and perineum. Despite the use of broad spectrum antibiotics and surgical debridement, morbidity and mortality remain significant. The purpose of this study is to investigate and evaluate the clinical and laboratory characteristics of this disease. METHODS: We reviewed 17 cases of Fournier's gangrene during 10 years from January, 1990 to December, 1999. We retrospectively analyzed these patients and considered several factors, which were age, sex, combined and etiologic factors, symptom and location of infection, duration of admission, operation and its complication, result of bacterial culture and sensitivity of antibiotics, morbidity and mortality. RESULTS: the mean age was 47.4 years with an age range of 3 to 77. The etiologies included unknown (65.7%), anorectal infection (23.5%) and hemorrhoidectomy (11.8%). The combined diseases (predisposing factors) included diabetes mellitus (52.9%), alcohol abuse, steroids or chemotherapy, liver cirrhosis and malignancy. Aggressive surgical debridement with broad spectrum antibiotics therapy was done on 16 patients, 1 patient refused operation. There were 3 colostomy cases, one orchiectomy, one suprapubic cystostomy case. The most common cultured organism was E.coli, 8 cases (53.3%). The mean hospital stay was 32.9 days. 3 patients (17.6%) were died due to sepsis and multiorgan failure. CONCLUSIONS: Our results showed that the early recognition, aggressive debridement of devitalized tissue, antibiotic therapy, search for primary source are considered as the treatment of choice for Fournier's gangrene.

Repair of cloacal anomaly using "Total urogenital mobilization method of Pena"

Persistent cloaca in a female newborn is one of the most complex and challenging developmental malformations. The incidence is about 10% of all anorectal anomalies. Treatment of cloacal malformations has evolved during the past 40 years; however, it still remains one of the most difficult operations. In 1997, Pe a reported that a new technical variant called "Total urogenital mobilization" We also repaired cloacal anomaly using "Total urogenital mobilization" in 3 patients. The operations were performed between age 15- and 28-month. The length of the common channels was 2.5-3.0 cm. Two cases had double vaginas and one of them also had double uterus. The operation time was 4-5 hours and no major complications occurred. A satisfactory functional and cosmetic results were obtained.

Bile Peritonitis Due To Choledochal Cyst Perforation In Infants

Choledochal cyst is rare in the Western countries, but common in the Oriental countries. The reported complicatioins of choledochal cyst are ascending cholangitis, recurrent pancreatities, progressive biliary cirrhosis, portal hypertension, stone in the cyst, and malignant in the biliary tract. Bile peritonitis secondary to rupture is one of the rarest complications of choledochal cyst, and its reported incidence was 1.8% (Yamaguci, 1980) to 18% (Karnak et al, 1997). The exact cause of perforation of choledochal cyst is unknown, but an anomalous arrangement of the pancreatobiliary ductal system with a long common channel may contribute to the formation of choledochal cyst and even perforation of cyst.Authors reviewed 4 cases (14.2%) of bile peritonitis among 28 cases of choledochal cyst in infants from Jan. 1983 to Jan. 1998. Their ages ranged from 6 months to 3 years and three of them were female. Abdominal distension, pain, and vomiting were common symptoms, and clinical jandice and palpable mass were present in one case. Pre-operative laboratory investigations showed elevated serum bilirubin, serum AST and serum ALT in 3 cases, and elevated serum amylase in one case. The perforation sites were located on the common bile duct at its junction with the cystic duct in 2 cases, distal cyst wall in 1 case and left hepatic duct at its junction with cyst in 1 case. The types of choledochal cysts according to Todani's classification (1977) were as follows;Type IVa was in 3 cases, type I was in 1 case. The results of operative cholangiogram according to new Komi's classification (1992) were as follows;Type Ia was 2 cases, type IIb 1 case, and type III 1 case. One stage primary cyst excision and hepaticojejunostomy(Roux-en Y type) was done in 3 cases, and two staged operation in 1 case. All patients have recovered unevenfully after surgery and discharged at post -operative 9.8th day averagely. Authors concluded that the primary choledochal cyst excision with biliary recontinuity was a safe surgical procedure in ruptured choledochal cyst in infants.