Fournier's gangrene in a rectal cancer patient.

INTRODUCTION: Fournier's gangrene (FG) is caused by a variety of causes, but FG led by rectal cancer is rare. PRESENTATION OF CASE: A 62-year-old man presented with perineal pain for several days. Multiple black spots on the scrotum and perineum surrounded by erythema were found on a physical exam. Computed tomography showed diffuse air density with subcutaneous edema in the perineum, scrotum, anus, and left lower abdominal wall and showed 4.1 cm-size mass in anus. He was diagnosed with FG caused by rectal cancer. He underwent extensive debridement of the perineum, scrotum, medial buttocks, and diverting loop colostomy of transverse colon. After repeated debridement of some residual necrotic tissue, abdominal perineal resection was performed after 24 days after initial surgery. The patient received reconstruction surgery of the soft tissue defect and discharged on postoperative day 84. He is being followed up without any recurrence for 10 months. CONCLUSION: Prompt clinical diagnosis and urgent surgical management are crucial for patient's favorable outcome. The patient in our case study could be recovered by a combined modality therapy we provided.

Mechanical intestinal obstruction following laparoscopic inguinal hernia repair in a patient with abdominal cocoon syndrome.

Abdominal cocoon syndrome (ACS) is a rare condition characterized by partial or complete encasement of small intestine by a thick fibro-collagenous membrane. A 65-year-old man presented to the surgical department with left inguinal. He underwent laparoscopic transabdominal preperitoneal inguinal hernia. When we inserted a trocar into the peritoneal cavity, the small intestine was injured and repaired immediately. We identified a fibrotic membrane covering the small intestine, which was found as ACS. Two weeks later after discharge, he presented to the emergency department with mechanical intestinal obstruction. Conservative treatment had no effect on the patient and membrane excision, adhesiolysis and small intestine resection with anastomosis were performed. Unfortunately, the patient was hospitalized for a long time with bowel leakage and discharged on postoperative day 48. The preoperative diagnosis is quite challenging and most cases are diagnosed intraoperatively. When finding the ACS during the operation, careful attention should be needed.

An unusual case of dedifferentiated leiomyosarcoma of the primary mesentery mimicking ovarian cancer.

Dedifferentiated leiomyosarcoma of the primary mesentery is extremely rare. We report a case of dedifferentiated leiomyosarcoma (LMS) of the primary mesentery mimicking ovarian cancer. A 62-year-old woman presented with progressive low abdominal pain. Pelvic magnetic resonance imaging (MRI) revealed a large adnexal mass with carcinomatosis peritonei. Laboratory examination revealed an elevated serum level WBC 46,520/uL (Ref. 4,000~11,000/uL), PLT 687,000/uL (Ref. 140,000~400,000/uL), CA-125 69.1 U/mL (Ref. 0~35 U/mL), and beta-hCG 43.1 mIU/mL (Ref. 0~5 mIU/mL) level. The patient underwent exploratory laparotomy under suspicion of ovarian cancer. We observed a 20-25 cm-sized huge pedunculated subserosal mass arising from the mesentery, and other masses with sizes of 15-20 cm were adherent to peritoneum and ileocecal region. There was a multiple seeding metastasis in the omentum and bowel mesentery. A frozen section revealed malignancy originating from the mesentery, and thus, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymph node dissection, and mass excision were performed. Subsequent histopathologic examination resulted in a final diagnosis of dedifferentiated leiomyosarcoma of the mesentery. The patient was transferred to a department of hemato-oncologist for additional managements. Doxorubicin was used for adjuvant chemotherapy.

SLC2A2 (GLUT2) as a novel prognostic factor for hepatocellular carcinoma.

High rates of glucose transport via solute carrier (SLC2A, GLUT) family members are required to satisfy the high metabolic demands of cancer cells, and because of this characteristic of cancer cells 2-18fluoro-deoxy-D-glucose (18FDG)-PET has become a powerful diagnostic tool. However, its sensitivity for hepatocellular carcinoma (HCC) is lower than for other malignancies, which suggests SLC2A family members are differentially expressed in HCC. In the present study, the expression patterns of SLC2A family members in tumor tissues and their associations with HCC progression were analyzed using data obtained from The Cancer Genome Atlas (TCGA). It was found that the expression of SLC2A2 (GLUT2) was higher in HCC than those of other members of the SLC2A family. The associations of the expression levels of SLC2A family members and previously known prognostic factors with clinical stages were examined using the T-test or the Mann-Whitney U test, and interestingly, SLC2A2 expression was found to be associated with an advanced clinical stage (p = 0.0015). Furthermore, Kaplan-Meier analysis using the log-rank or the Gehan-Breslow-Wilcoxon test showed SLC2A2 expression was positively associated with overall survival (p < 0.001, Gehan-Breslow-Wilcoxon test and p = 0.0145 by multivariate Cox regression). The prognostic significance of SLC2A2 was similar in both early and late stages. However, it was more significant in HCC patients without alcohol consumption history and hepatitis C infection. Taken together, SLC2A2 was associated with clinical stages and independently associated with overall survival in patients with HCC. We suggest that SLC2A2 be considered a new prognostic factor for HCC.

Immediate re-insertion of non-autologous materials in revision augmentation rhinoplasty.

OBJECTIVE: This paper aims to study whether immediate re-insertion of non-autologous augmentation material in revision augmentation rhinoplasty is a safe surgical strategy creating a successful and functional aesthetic outcome. STUDY DESIGN: Retrospective review and analysis of medical records. SETTING: Tertiary referral hospital. SUBJECTS AND METHODS: A retrospective analysis of 11 consecutive patients who had undergone removal of previous augmentation material and immediate re-insertion of non-autologous material in revision augmentation rhinoplasty was performed. Demographics, surgical approaches, augmentation materials, material-related complications, time interval between surgeries, surgical outcome, and follow-up period were included in the analysis to evaluate our surgical strategy. RESULTS: A successful surgical outcome with respect to both functional and aesthetic aspects was obtained in nine of the 11 enrolled patients. In 1 patient, there was a recurrence of material-related complication, while another patient experienced unsatisfactory graft displacement. The unsuccessful cases had 2 common features in that silicone and endonasal approaches were used in the primary and revision surgeries, respectively. CONCLUSION: Removal of previous augmentation material and immediate re-insertion of non-autologous material for dorsal augmentation in revision rhinoplasty is feasible with respect to functional and aesthetic aspects of patient outcome.

Treatment outcomes of sinonasal adenoid cystic carcinoma: 30 cases from a single institution.

OBJECTIVE: To establish the clinical features and prognostic factors of sinonasal adenoid cystic carcinoma (ACC). MATERIAL AND METHODS: Thirty patients with histopathological diagnosis of sinonasal ACC who were treated at Severance Hospital between 1990 and 2010 were included in this retrospective chart review study. RESULTS: The 5-year disease-specific survival and disease-free survival rates were 75.3% and 37.2%, respectively. The maxillary sinus (63.3%) and nasal cavity (23.3%) were the most common sites of primary tumour. Most patients were diagnosed with advanced-stage (III/IV) disease (80.0%) and had undergone surgery and postoperative radiotherapy (70.0%). The most common histopathological subtype was cribriform type (40.9%). Local recurrence rate and distant metastasis rates were 26.7% and 23.3%, respectively. The mean time from primary treatment to recurrence was 44.5 months. Sinonasal ACC patients with stage IV and T4 disease had significantly worse survival than those with low stage and T disease. Patients with local recurrence had worse disease-specific survival than those with distant recurrence. Distant metastasis was associated with disease-free survival but not disease-specific survival. CONCLUSION: Despite the frequent occurrence of distant metastasis, early diagnosis and effective local control seemed to be the most important factors influencing the survival of sinonasal ACC.

A rare case of interdigitating dendritic cell sarcoma in the nasal cavity.

Interdigitating dendritic cell sarcoma (IDCS) is an extremely rare neoplasm that mainly arises from the lymphoid tissues of the immune system. Although this neoplasm typically occurs anywhere along the lymph nodes, it can also be found at extranodal sites, especially in the head and neck. We experienced a rare case of extranodal IDCS in the nasal cavity, a location that has not been previously reported. A 73-year-old woman presented with a polyp-like mass in the nasal cavity and underwent endoscopic sinus surgery. A histologic study confirmed the mass as IDCS by immunohistochemistry with S-100 antibody, and postoperative adjuvant radiotherapy was administered. Although the incidence is extremely rare, this case suggests that extranodal IDCS should be considered in the differential diagnosis of nasal cavity masses.

Treatment outcomes of juvenile nasopharyngeal angiofibroma according to surgical approach.

OBJECTIVE: This is a retrospective study to assess treatment outcomes according to stage and surgical approach in advanced juvenile nasopharyngeal angiofibroma (JNA). METHODS: We retrospectively evaluated 20 JNA patients diagnosed and treated at our hospital. We only enrolled advanced disease with Radkowski stages greater than I and with minimum follow-up of 1 year (range 1-8.5). RESULTS: Recurrence or remnants were observed in 7 patients out of 20 patients (35.0%) who underwent primary surgical resection of advanced JNA and the mean interval to recurrence was 15.6 months (range 6-38). A recurrence rate according to a different stage was as follows: 33.3% in stage IIa, 33.3% in stage IIb, 50.0% in stage IIc and no recurrence in stage III. An endoscopic approach was chosen in 4 patients among these patients, four were classified as stage IIb tumors, one as a stage IIc tumor, with a recurrence rate of 25.0%, but no recurrence found in stage IIa disease. A midfacial degloving approach was used in 7 patients, with a recurrence rate of 42.9% and maxillary swing approach was taken in 3 patients with complete control. Postoperative complications required interventions occurred in 14.8%, more in the invasive maxillary swing or infratemporal fossa approaches. CONCLUSIONS: Although selecting minimal invasive or invasive approaches is equivocal, we recommend using the endoscopic approach or a midfacial degloving approach for the treatment of JNA extended to the pterygopalatine fossa. For stage III, aggressive surgery is preferable to guaranty a complete resection even if postoperative complications are more frequent. For a stage IIc, we could choose between a minimally invasive approach or a more aggressive one balancing between the possibility of salvage surgery in the future and the occurrence of postoperative healing problems.

Double reversing Z-plasty with inferiorly widening stomaplasty for the management of tracheostomal stenosis.

OBJECTIVES: To present a surgical technique for the management of tracheostomal stenosis: double reversing Z-plasty with inferiorly widening stomaplasty. METHODS: This study was a retrospective review of five patients (four males, one female) submitted for tracheostomal widening procedure using "double reversing Z-plasty with inferiorly widening stomaplasty" at our department between May 2003 and April 2009. Skin incision was made on each lateral side of the stoma. The skin flap was elevated, and the subcutaneous and scar tissue at the infrastomal area was removed along with the redundant skin. Vertical incision was made on each side of the trachea as a mirror image, and the trachea was splayed. The inferiorly mobilized trachea was sutured to the new tissue bed inferior to the stoma, and both skin flaps were secured to the depths of the tracheal cut (double reversing Z-plasty). RESULTS: All five patients showed widened tracheostoma without any complications, and their phonatory prostheses functioned well after the procedure. In no case was it necessary to keep the tracheal tubes beyond the first day after the surgery. CONCLUSION: This technique, "double reversing Z-plasty with inferiorly widening stomaplasty", provides a safe procedure for enlarging the tracheostomal size and easing the excessive tension without disturbing the posterosuperior stomal profile and the tracheoesophageal puncture for phonatory prosthesis.

Treatment outcomes of sinonasal inverted papillomas according to surgical approaches.

CONCLUSIONS: The midfacial degloving approach is a favorable option for advanced sinonasal inverted papilloma with a fair recurrence rate, and can replace the lateral rhinotomy approach, which is considered too invasive for benign tumor due to its facial scar. OBJECTIVE: This study aimed to assess the treatment outcomes of advanced sinonasal inverted papillomas according to surgical approaches over a 20-year period. MATERIAL AND METHODS: We retrospectively reviewed clinic, operative, radiologic, and pathologic records of patients with surgically treated sinonasal inverted papilloma, and compared recurrence rates of patients treated with the endoscopic approach, midfacial degloving approach, and lateral rhinotomy approach in each Krouse stage of inverted papilloma. RESULTS: A total of 114 patients were diagnosed and treated surgically for the sinonasal inverted papilloma. The follow-up period ranged from 10 months to 12 years (mean 2.8 years). The overall recurrence rate was 23.7% (27/114). Among the patients classified as Krouse stage III, 33.3% (9/27) of the endoscopic approach group, 11.1% (2/18) of the midfacial degloving approach group, and 25.0% (2/8) of the lateral rhinotomy approach group had recurrences.

[Two cases of systemic amyloidosis presenting with abnormalities in liver function tests].

Systemic amyloidosis results from the deposition of insoluble, fibrous amyloid proteins. It occurs mainly in the extracellular spaces of multiple organs and tissues including the kidney, heart, and liver. Although amyloid deposition in the liver is common in patients with systemic amyloidosis, clinically apparent liver disease is relatively rare. Indeed, most patients with systemic amyloidosis manifest only minimal to moderate hepatomegaly and trivial abnormalities in liver function tests. Recently, we experienced two cases of patients who presented with abnormalities in liver function tests and hepatomegaly as manifestations of systemic amyloidosis. We report these cases with a review of the relevant literatures.

[Assessment of quality of life and associated factors in patients with chronic viral liver disease].

BACKGROUND/AIMS: The aim of this study was to measure health related quality of life (HRQOL) in patients with chronic viral hepatitis or cirrhosis and to determine factors associated with more severe impairment. METHODS: We conducted a cross-sectional study in which we documented patients' demographic and clinical characteristics and measured their HRQOL using the Korean version of Short Form-36. A total of 375 patients were enrolled in the study. We compared patients' HRQOL with that of 750 participants in a control group and assessed the association of HRQOL impairment with clinical parameters. RESULTS: In all except two domains (physical functioning, bodily pain) of SF-36, HRQOL scores were significantly lower in the patient group than in the control group (p<0.001). The difference was more prominent in those domains reflective of mental, rather than physical, health. When patient group was classified as noncirrhosis, Child A, B, or C according to modified Child-Pugh classification, severe liver disease was associated with a lower HRQOL score. Interestingly, scores of domains reflective of mental health were decreased from the early stage of disease (noncirrhosis or Child-Pugh A). Those of domains reflective of physical health, however, were decreased only in advanced stages of disease (Child-Pugh B or C). There are weak but significant correlations between SF-36 scores and age, serum albumin, serum bilirubin, and prothrombin time, but no correlation with histologic activity, transaminase level, disease duration, virus type (HBV or HCV) and HBV DNA level. CONCLUSIONS: Compared with the control group, patients with chronic viral hepatitis or cirrhosis showed substantial impairment of HRQOL, which is further affected by worsening disease severity. More concern about HRQOL should be warranted in the evaluation of health change due to disease progression or therapeutic trial.