Tracheal agenesis with multiple congenital anomalies: a case report.
Wang CM. Chen SJ. Lu JH. Hwang BT.
Department of Pediatrics, Veterans General Hospital-Taipei, Taiwan, ROC.
Tracheal agenesis (TA) is a rare congenital anomaly that is incompatible with prolonged life. It may occur alone or with other associated anomalies. A term infant presented with cyanosis, hypotonia, absence of crying and respiratory distress at birth. Intubation was difficult. Esophageal intubation was performed under laryngoscopy. As TA was suspected, a bronchoscopy was performed and the infant was found to have a normal epiglottis and vocal cords; however, there was no trachea. Cardiorespiratory deterioration developed and the patient died on the night of the second day at the postnatal age of 41 hours. Tracheal agenesis was confirmed at autopsy. Associated anomalies included bronchoesophageal fistula, double outlet of the right ventricle with ventricular septal defect, bicuspid pulmonary valve, single lobe of the right lung, imperforate anus and a rectourethral fistula. According to development theory, tracheal agenesis and VACTERL (vertebral defects, anal atresia, cardiovascular defects, tracheoesophageal fistula, radial dysplasia or renal defects and limb defects association may result from a mesodermal deficiency caused by abnormal blastogenesis.
Severe colonic complications in acute pancreatitis.
Yang WG. Wang SS. Lee FY. Chao Y. Chen CC. Chang FY. Chiang JH. Tsay SH. Su CH. Yang YH. Lee SD.
Department of Medicine, Veterans General Hospital-Taipei, Taiwan, ROC.
BACKGROUND: Colonic complications in patients with acute pancreatitis may be very severe and have rarely been analyzed in Chinese patients. METHODS: We retrospectively evaluated 1,637 patients with acute pancreatitis who were admitted to the Veterans General Hospital-Taipei from January 1986 to December 1995 in order to identify those with severe colonic complications. The clinical, radiologic and pathologic features and surgical findings in these patients are reviewed. RESULTS: Eight of 1,637 patients with acute pancreatitis had severe colonic complications. Six of them were diagnosed between two and eight weeks after the onset of clinical pancreatitis. All had a Ranson's score of at least 3. Four patients, including one with hematochezia, had a strong positive reaction for occult blood in stool specimens. Computed tomography (CT) revealed necrotizing pancreatitis and colonic wall swelling in all eight patients. Colonic involvement was discovered by CT in two patients prior to surgery, one with colocutancous fistula and the other with colonic perforation. The other six patients were found to have colonic involvement incidentally at the time of laparotomy. All of the colonic involvements were located near the splenic flexure. In addition to necrosectomy, three patients underwent segmental hemicolectomy and the remaining five patients had simple closure of the perforation. Diverting loop ileostomy or colostomy was also carried out in all patients. Three patients (34%) died of overwhelming sepsis superimposed on the subsequent multiple organ failure between 44 and 122 days after the onset of pancreatitis. CONCLUSIONS: Severe colonic complications of acute pancreatitis are rare. Although preoperative diagnosis is difficult, CT may be helpful to make an early diagnosis. These complications should be suspected in patients with severe acute pancreatitis when acute lower gastrointestinal hemorrhage or positive stool occult blood is found two to eight weeks after the onset of pancreatitis or when CT reveals necrotizing pancreatitis and colonic wall swelling; this will allow early surgical intervention.
Lymph node metastasis in squamous cell carcinoma of the intrathoracic esophagus.
Liu CC. Fahn HJ. Li WY. Wu YC. Huang MH. Wang LS.
Department of Surgery, Veterans General Hospital-Taipei, Taiwan, ROC.
BACKGROUND: In esophageal carcinoma lymph node metastasis is one of the most important factors of prognosis. This prospective study evaluated the incidence and extent of lymph node metastasis, and assessed the relationship between the depth of tumor invasion and lymph node metastasis in esophageal carcinoma. METHODS: Between 1985 and 1996, tissue samples from 112 patients undergoing radical esophagectomy and gastric substitution for squamous cell carcinoma of the intrathoracic esophagus were collected. Patients with distant organ metastasis were excluded. All specimens were evaluated and sent for histopathologic examination. RESULTS: In 108 men and four women with a mean age of 63.1 years, the average number of dissected lymph nodes in one surgical procedure, was 30 per person. The most commonly involved nodes were the periesophageal (42.9%) and the perigastric (42.9%) nodes, followed by the recurrent laryngeal nerve (23.8%) and thoracic paratracheal (22.2%) nodes. For tumors in the upper third of the esophagus, the most frequently involved nodal groups were the periesophageal (28.6%) and the paratracheal (28.6%) nodes, followed by the recurrent laryngeal nerve (21.4%) the deep cervical (21.4%), and the perigastric (21.4%) nodes. For tumors in the middle third of the esophagus, the periesophageal nodes (27.3%) were most commonly involved, followed by the perigastric (18.2%) and the subcarina (10.6%) nodes. For tumors in the lower third of the esophagus, the perigastric lymph nodes (37.5%) were the most common nodal metastatic site, followed by the celiac (18.8%) and the recurrent laryngeal nerve (18.2%) nodes. Depth of tumor invasion was also found to correlate significantly with lymph node metastasis (p = 0.0015). CONCLUSIONS: Wide lymph node metastasis between the neck and the upper abdomen occurs frequently in squamous cell carcinoma of the esophagus. For potentially curable esophageal carcinomas, en-bloc esophagectomy with complete locoregional lymph node dissection may provide favorable local control of the lesion and more accurate tumor staging.
Acute pancreatitis in pregnancy.
Chang CC. Hsieh YY. Tsai HD. Yang TC. Yeh LS. Hsu TY.
Department of Obstetrics and Gynecology, China Medical College Hospital, Taichung, Taiwan, ROC.
BACKGROUND: Acute pancreatitis in pregnancy is rare. Our purpose in this study was to discuss the etiology, incidence and course of pancreatitis in pregnancy and to evaluate the maternal and perinatal outcomes. METHODS: Pregnant women with pancreatitis admitted to China Medical College Hospital, Taiwan, from 1980 to 1995 were studied retrospectively. A total of 16 patients were enrolled in the study. Two patients had gallstones and hyperlipidemia; four had gallstones alone; seven had hyperlipidemia alone; one had gestational diabetes mellitus; one had hyperparathyroidism and pregnancy-induced hypertension alone; and one had Hashimoto's thyroiditis. Conservative treatment and low-fat diets were administered to the patients. RESULTS: The incidence of gestational pancreatitis in this series was one in 6,790 pregnancies. The fetal outcome included eight preterm deliveries and three fetal losses. There were no maternal mortalities. The etiologies of pancreatitis were primary hyperlipidemia (56.3%) and gallstones (37.5%). All patients responded favorably to supportive therapy, and most of the symptoms subsided after delivery. CONCLUSIONS: Early diagnosis and treatment is of utmost importance in the management of acute pancreatitis in pregnancy. The results of this study showed good maternal outcome following appropriate treatment. Fetal prognosis was less favorable and was most often associated with hyperlipidemia. Fetal monitoring is essential during the management of pancreatitis in pregnancy.
High resistance index of Doppler ultrasound in tuberculous peritonitis presenting as abdominal carcinomatosis: report of two cases.
Wang PH. Yuan CC. Yu KJ. Lee RC. Linn JJ. Hung JH. Chao HT.
Department of Obstetrics and Gynecology, Veterans General Hospital-Taipei, National Yang-Ming University School of Medicine, Taiwan, ROC.
The radiologic features of tuberculous peritonitis (TB peritonitis) are seldom reported, and the use of color Doppler ultrasound in the diagnosis of TB peritonitis is even less common. Herein, we present two patients (a 29-year-old woman and a 56-year-old woman) who were evaluated for months of progressive enlargement of the abdomen, poor appetite and weight loss. In both patients, clinical and laboratory examinations suggested carcinoma, except a very high vascular resistance (resistance index 1.0 and 0.89, respectively) of the tumor feeding vessels detected by color Doppler ultrasound. TB peritonitis was finally diagnosed by exploratory laparotomy. Both patients were treated using a four-drug regimen of isoniazid, rifampicin, ethambutol hydrochloride and pyrazinamide for nine months and were clinically cured. In conclusion, if color Doppler ultrasound reveals normal ovaries, ascites containing thin, delicate incomplete or complete septa, and only a few high-resistance tumor feeding vessels in the abdominal cavity (resistance index > or = 0.80), TB peritonitis should be considered.
Intraoperative non-puncture laparoscopic examination of contralateral internal inguinal rings is feasible in children with unilateral hydrocele.
Liu CS. Chin TW. Wei CF.
Department of Surgery, Veterans General Hospital-Taipei, Taiwan, ROC.
BACKGROUND: Intraoperative non-puncture laparoscopic examination using the hernia sac as the scope entrance has been successfully conducted in children with unilateral inguinal hernia. This technique selects patients for contralateral inguinal exploration. In spite of the thin and narrow processus vaginalis, children with unilateral hydrocele encounter the same problem of subsequent contralateral inguinal hernia or hydrocele. In this study, we discuss the feasibility of this technique in children with unilateral hydrocele. METHODS: From July 1993 to September 1995, 91 children with unilateral hydrocele were examined during surgery at our institution. The results, including success rate, complications, patent rate of contralateral internal ring and contralateral subsequent hernia or hydrocele, at at least one year follow-up, were compared with those of 329 children with unilateral hernia undergoing the same examination during this period. RESULTS: A patent contralateral processus vaginalis was recognized in 31 children and all were confirmed by surgical exploration. The examination failed in three patients, of whom two had a tear in the processus vaginalis and one had retroperitoneal air dissection as a result of false insertion of the laparoscopic sheath. One patient had a postoperative wound infection. No patient with contralateral obliterated processus vaginalis developed inguinal hernia or hydrocele during follow-up of at least one year. The results were similar to those of the 329 children with hernia who underwent the same procedure in the same period. CONCLUSIONS: Intraoperative non-puncture laparoscopic examination is feasible in children with unilateral hydrocele.