Jiin-Haur Chuang

Metabolic effect of parenteral nutrition in dogs with obstructive jaundice

OBJECTIVEnTo assess the effect of total parenteral nutrition (TPN) on macronutrient metabolism in obstructive jaundice.nnnMETHODSnForty adult mongrel dogs were equally divided into four groups: group I (PO-control) received sham ligation of common bile duct (CBDL) and was fed dog chow and water ad libitum; group II (PO-CBDL) underwent CBDL and was fed dog chow; group III (TPN-control) received sham CBDL and TPN; and group IV (TPN-CBDL) underwent CBDL and received TPN. Blood chemistries, plasma amino acids and liver histologies were studied before (Day 1) and at the end (Day 14) of the experiment.nnnRESULTSnA significant elevation of bilirubin and alkaline phosphatase was observed in dogs with CBDL. Blood glucose was not changed significantly in any group. Significant increases in triglyceride and cholesterol were present in CBDL dogs. Significant differences in the concentrations of a few plasma amino acids, including an elevation of phenylalanine, were found in TPN dogs. A significant increase in aromatic amino acids (AAA) and a noticeable depression of the molar ratio of branched-chain amino acids (BCAA) to AAA was present in TPN-CBDL dogs, as was a significant increase in blood ammonia.nnnCONCLUSIONnIn the presence of obstructive jaundice, TPN does not significantly affect carbohydrate or lipid metabolism. However, a derangement in protein metabolism with the standard TPN solution in current use suggests that either a modification of amino acid composition or an increase in total energy to protein energy ratio in TPN solution may be necessary to obviate such a consequence.

Endorphin and cortisol responses to surgical stress in newborns and infants

The beta-endorphin (BE) response to surgical stress in newborns and infants and its relation to pituitary-adrenal dynamics during stress is still unknown. Nine newborns 5 h to 5 days of age, and 5 infants 5 to 10 months old undergoing surgery were studied. All patients were anesthetized with N2O–O2 and halothane. Blood samples for BE and cortisol determinations were taken preoperatively and 30 min, 12 h, and 24 h after operation for radioimmunoassay. Both BE and cortisol levels in newborns were not significantly different from those in infants preoperatively (196±85.2 pg/ml vs. 138±47.8 pg/ml for BE and 23.7±17.5 μg/dl vs. 10.1±5.6 μg/dl for cortisol, P >0.05). At 30 min after operation, no significant increase in BE (220±106 pg/ml) and cortisol (36.1±21.2 μg/dl) was found in newborns, while significant increases (BE 493±281 pg/ml, cortisol 43.9±24.2 μg/dl) were found in infants compared to preoperative levels (both P <0.05). A significant difference between groups was seen in BE but not cortisol levels 30 min after operation. Both BE and cortisol declined to preoperative values within 24 h after surgery. Our study showed significant BE and cortisol responses to surgical stress in infants, but not in newborns. Factors such as age-related differential responses to the same anesthetic technique, duration of operation, and developmental differences in stress response are considered responsible for the differences.

Adhesive small-bowel obstruction in children

Seventy-one episodes of adhesive small-bowel obstruction (ASBO) in 57 children were reviewed to define the relationship of treatment methods to clinical conditions and to examine the place of conservative treatment. Thirteen children received urgent operations on the day of admission because of signs of suspected strangulation or complete obstruction. The remaining 58 episodes underwent initial conservative treatment, which was successful in 35 while 23 required subsequent surgical intervention, an overall incidence of operation in 36 of the 71 (50.7%) episodes of ASBO. Seven episodes required bowel resection, strangulation was found in 3 (4.2%), and mortality occurred in 1 (1.7%) due to delayed operation. Patients with more than one previous successfully treated occurrence of ASBO were significantly more likely to respond to conservative treatment (71.4% vs. 54.4%, P <0.05). Those patients who had undergone laparotomies twice or more before the episode were more likely to be successfully treated by conservative treatment than those who underwent laparotomy only once before (80% vs. 52.4%, P <0.01). Whether or not the treatment of the previous occurrences of ASBO was surgical, we found that the initial treatment of any further episode could be conservative except when evidence of a complete or strangulated bowel obstruction developed.

Retrograde intussusception after Roux-en-Y hepaticojejunostomy for choledochal cyst

The authors report the first documented case of a retrograde jejunojejunal intussusception after a Roux-en-Y hepaticojejunostomy for choledochal cyst in a 2-year-old girl. She suffered from obstructive jaundice and ileus; the jaundice was alleviated but the ileus worsened after conservative treatment, and abdominal computed tomography demonstrated an intussusception and gangrene of the bowel. Surgery confirmed the presence of a retrograde jejunojejunal intussusception at the previous end-to-side anastomosis, with a dilated Roux limb and proximal duodenojejunal segment. Intestinal obstruction in a jaundiced child following Roux-en-Y anastomosis may be due to a retrograde intussusception as well as a stricture of the hepaticojejunostomy or adhesive ileus.

Gastric volvulus complicating left hepatic lobectomy

A 9-month-old male infant underwent a left hepatic lobectomy for hepatoblastoma. Gastric volvulus developed postoperatively and was corrected at a second laparotomy. Although left hepatic lobectomy is not an uncommon surgical procedure, this may be the first documented case of gastric volvulus complicating such a procedure.

Acute promyelocytic leukemia presenting as Fournier's syndrome in infancy

Fourniers syndrome (FS) is occassionaly encountered in surgical practice. We report a 4-month-old female with acute promyelocytic leukemia (APL) presenting as FS. This case is interesting in two aspects: the early onset of the APL and its presentation as FS, which is the first such case reported in the literature.

Congenital urethral fistula with incomplete penoscrotal transposition

A unique case of congenital urethral fistula at the penoscrotal junction with incomplete penoscrotal transposition is reported. The embryological basis and surgical repair of the abnormality are briefly discussed.

Why not choledochal cyst

With excision as a standard procedure for treating choledochal cyst, early diagnosis becomes a central issue in reducing morbidity and mortality from that disorder. In a retrospective analysis of 35 patients treated over a 10-year period, we found the diagnosis was delayed for an average of 11.9 months from the beginning of presenting symptoms. Three factors were responsible: (1) a random combination of non specific presenting symptoms such as pain and vomiting or jaundice and hepatomegaly frequently led to a diagnosis such as acute pancreatitis or hepatitis, in which conservative treatment was considered most appropriate; (2) the three parameters commonly used to diagnose acute pancreatitis (serum amylase, lipase, and Cam/Ccr) may all be elevated in patients with a choledochal cyst; and (3) a combination of several noninvasive examinations such as radionuclide cholescintigraphy, ultrasonography, and upper gastrointestinal X-rays may fail to diagnose some difficult cases of choledochal cyst. To obviate such problems, we recommend a routine ultrasound examination of biliary tract in children with recurrent or progressive obstructive jaundice or unexplained acute pancreatitis. When these noninvasive examinations fail to solve the problem, endoscopic retrograde cholangiopancreatography should be considered.

Why not choledochal cyst?: A diagnostic dilemma in congenital bile duct dilatation

With excision as a standard procedure for treating choledochal cyst, early diagnosis be- comes a central issue in reducing morbidity and mortality from that disorder. In a retrospective analysis of 35 patients treated over a 10-year peri- od, we found the diagnosis was delayed for an av- erage of 11.9 months from the beginning of pre- senting symptoms. Three factors were responsi- ble: (1) a random combination of non specific presenting symptoms such as pain and vomiting or jaundice and hepatomegaly frequently led to a diagnosis such as acute pancreatitis or hepatitis, in which conservative treatment was considered most appropriate; (2) the three parameters com- monly used to diagnose acute pancreatitis (serum amylase, lipase, and Cam/Ccr) may all be elevat- ed in patients with a choledochal cyst; and (3) a combination of several noninvasive examinations such as radionuclide cholescintigraphy, ultrason- ography, and upper gastrointestinal X-rays may fail to diagnose some difficult cases of choledo- chal cyst. To obviate such problems, we recom- mend a routine ultrasound examination of the bil- iary tract in children with recurrent or progressive obstructive jaundice or unexplained acute pan- creatitis. When these noninvasive examinations fail to solve the problem, endoscopic retrograde cholangiopancreatography should be considered.