Diffuse peritonitis due to perforation of pyometra is relatively rare. We experienced three cases of this type of peritonitis between 1993 and 1999. Three women aged 77, 83 and 91 years had mild abdominal pain, slight fever and defecation for nearly one week. Following these, severe abdominal symptoms developd. These patients underwent emergency laparotomy as they were diagnosed with diffuse peritonitis. At first, intestinal perforation was suspected, but perforation of pyometra was confirmed when lapasortomy was done. On preoperative examinations, physical findings were scanty in comparison with hemological ones, and free air on abdominal X-ray films was not detected. Thus, we failed to establish the preoperative diagnosis. The prognosis was very poor in two of the three patients. One was with advanced cervical cancer and the other was in multiple organ failure on admission. Differential diagnosis of this disease is important for the management of acute abdominal diseases in elderly women.

We report a case of successful treatment for bladder hemorrhage with intravesical alum irrigation. A 60 s woman, who had renal pelvis carcinoma and moderate renal dysfunction（eGFR＝48 mL／min／1.73 m²）, was hospitalized to our palliative care unit, for pain control of her lumber metastasis. During hospitalization, the patient showed dysuria and a lot of intravesical blood coagulum, which was caused from bladder metastasis. After bladder flushing, continuous bladder irrigation with saline was started. However, when we reduced the irrigation speed, dysuria appeared again. Thus, we started intravesical alum irrigation. Six days after this irrigation has started, we stopped the irrigation because no gross hematuria was seen any more. On the blood test done ninth day after irrigation, serum alminium level was 0.4μg／dL（normal value＜0.8μg／dL）. Three months after discharge from the hospital, the patient died, however, no gross hematuria or anuria were seen up to that time. Serious adverse effects with intracesical alum irrigation were reported in patients with renal dysfunction. However, if the renal dysfunction was moderate, intravesical alum irrigation with reduced doses seem to be safe and effective.

Problems with postoperative respiratory management of three patients after division of double aortic arch are described. Tracheomalacia was present in two of three cases with intracardiac anomalies of different types. Intracardiac anomalies of each patient were as follows: Patient 1, ventricular septal defect (VSD), atrial septal defect and pulmonary valve stenosis (PS); Patient 2, VSD, corrected transposition of the great arteries with PS; Patient 3, VSD with pulmonary hypertension (PH). In patient 1 and 2, no concomitant surgical intervention was performed for tracheomalacia. In these patients respiratory support had been continued for 41 and 60 days respectively. In patient 3, remaining VSD with PH was the cause of unexpected respiratory problem even after the successful division of the double aortic arch, and necessitated emergency VSD closure 49 days after the initial operation. The patient was extubated on postoperative day 12. Tracheomalacia is a life-threatening problem even after surgical division of the double aortic arch. Although prolonged respiratory support was needed, our two cases were successfully extubated without concomitant surgical intervention of tracheomalacia. Severe cases should be operated on simultaneously with the relief of vascular ring and tracheomalacia. Intracardiac anomalies are also the causes of prolonged intubation. Patient 3 should have been treated by pulmonary artery banding along with the division of aortic arch. In conclusion, precise evaluation of the existence and severity of the tracheomalacia and intracardiac anomalies is of utmost importance to overcome postoperative respiratory failure and for eventual satisfactory results.

A 61-year-old woman had extracardiac unruptured aneurysms of the right and noncoronary sinuses of Valsalva, detected incidentally on electrocardiogram taken for a physical checkup. Two-dimensional echocardiography revealed that the sizes of the aneurysm of the right and noncoronary sinuses were 41×40 and 38×28mm respectively, but the shape of left coronary sinus was almost normal. The aortic valve leaflet was normal and the diameter of the aortic annulus and sinotubular junction was 23 and 27mm respectively. The Doppler color-flow echocardiogram showed moderate aortic regurgitation which resulted in prolapse of the right aortic cusp due to deformity of the annulus. We performed modified aortic root remodeling using a tailored Dacron graft to preserve the native aortic valve. Right and noncoronary sinuses of Valsalva were all excised with a small button of the aortic wall around the ostia of the right coronary artery. The left coronary sinus was left as it was. Then each commissure received sub-commissural annuloplasty and was pulled up. The defect of Valsalva was reconstructed with a 26mm Dacron tube graft, the proximal end of which was tailored to a scallop shape and that correspond to left coronary sinus was excised. The right coronary artery was reimplanted utilizing the Carrel patch method. Although we needed additional CABG to the right coronary artery and IABP support due to vasospasm of the right coronary artery, the postoperative course was uneventful. Echocardiography of the aortic valve before discharge showed a normal function without regurgitation.

A rare case of left coronary ostial stenosis following aortic valve replacement (AVR) was reported. A 67-year-old man had undergone AVR for aortic stenosis and regurgitation. During the procedure basket tip cannula was utilized for selective coronary perfusion. He began to complain of chest pain 4 months after surgery, and coronary arteriography revealed a 99% stenosis at the left coronary ostium. Emergency coronary artery bypass grafting (CABG) to the LAD using a saphenous vein graft was successfully performed. The angina pectoris developing after AVR suggests that coronary ostial injury was caused by selective coronary perfusion cannula. The disease progresses rapidly in the absence of sufficient collaterals, and emergency CABG is needed to prevent critical myocardial infarction and sudden death.

From January 1979 through May 1982, 36 premature infants less than 2.5kg and less than 35 weeks of gestation, including 24 patients with respiratory distress syndrome, underwent ligation of patent ductus arteriosus (PDA) due to being unresponsive to medical treatment. Ten patients died postoperatively mainly from intracranial hemorrhage and necrotizing enterocolitis. Surviving 26 patients were examined for developmental sequelae based on questionnaire survey. One infant died of respiratory failure secondary to severe bronchopulmonary dysplasia 28th month after operation. We found no evidence of recurrent ductal patency following ligation during the follow-up period. Twenty four patients exhibited normal motor and mental development to attend the ordinary elementary school everyday, but one patient shows mental retardation. Most of patients suffered from the frequent upper respiratory infection in childhood to require rehospitalization. There are no patients with hoarseness, but 2 patients developed funnel chest and one required the operation. One third of the patients had ophthalmological handicap (myopia or strabismus). Surgical ligation of PDA in premature infants seems to reduce the duration of postoperative mechanical ventilation and the incidence of bronchopulmonary dysplasia. Analyzing long-term follow-up indicates that infants who undergo PDA ligation grow almost normally and do not appear to be at increased risk for sensorineural handicaps. Therefore we emphasize that surgical ligation of PDA is an effective and appropriate treatment of choice for significant PDA in premature infants.

A 63-year-old woman who was diagnosed a having impending rupture of abdominal aortic aneurysm underwent urgent anatomic reconstruction. Histopathological findings revealed abscess formation around the aneurysmal wall, and a definitive diagnosis of mycotic aneurysm was established. Successful management of this rare aortic disease depends on early accurate diagnosis, control of infection and careful surgical management.

Mandibular chronic osteomyelitis with diffuse osteosclerosis is recognized as an intractable infectious disease. We emplyed decortication and intra-arterial infusion of antibiotics in 6 cases. Decortication on the affected mandible was performed with retrocatherization to the superficial temporal artery of affected side under general anesthesia. Antibiotics, IPM/CS or FOMX was used through the artery for 4-11 days. In addition, we administered FOMX, PIPC intravenously for 8-17 days. CT and MRI were taken postoperatively. The postoperative follow-up period ranged from 1 year and 6 months to 2 years and 5 months. Postoperative MR showed that bone marrow signal was recovered to approximately normal in 4 cases. High signal area of bone marrow and osteosclerosis image remained in 2 cases, but showed improvement. The results were satisfactory without recurrence in all of 6 cases.
Anesthesia, General ; Anti-Bacterial Agents ; Arteries ; Bone Marrow ; Communicable Diseases ; Follow-Up Studies ; Infusions, Intra-Arterial ; Mandible ; Osteomyelitis ; Osteosclerosis ; Recurrence ; Temporal Arteries

Clinical course and outcome of 34 patients with peripheral and visceral artery aneuryms, operated during 1975-1990, were analysed. There were 24 males and 10 females. Ages ranged from 14 to 87, with an average of 55 years. Peripheral aneurysms located most frequently in the lower extremity, and the incidence of various origin of the aneurysms were as follows: 14 in femoral, 5 in popliteal, 4 in internal iliac, 3 in subclavian, 2 in common iliac arteries, and 1 in each of vertebral, radial, splenic, renal and anterior tibial artery. Most common cause of aneurysm was arteriosclerosis. Multiple aneurysms were found in 59% of sclerotic type and in most of these with bilateral aneurysms in the iliac, femoral and popliteal. Ruptured aneurysms were seen in 26% of this series. Most of the aneurysms in the extremities were totally excised without difficulty, while the aneurysms in common iliac and internal iliac were opened with partial excision or obliterated with endoaneurysmorrhaphy. Arterial reconstruction was performed using saphenous vein graft or synthetic vascular graft, excepting that the internal iliac artery itself was not reconstructed. The early operative results were satisfactory, but late results showed two death and three complications of cardiovascular system. Therefore, careful follow up of the postoperative patients was recommended.