First-generation therapy for varicose veins: medication, compression, sclerotherapy, and stripping

Improving the understanding varicose veins (VV) is increasing due to life extension and concerns regarding quality of life. Recently, endovascular treatment has become more common, even in mild cases. Excessive procedures are often performed before conservative and non-surgical treatments. We aimed to explain the efficacy of medication, compression, sclerotherapy, and stripping of treatments and to consider the appropriate indications for many treatment methods, including endovascular procedures.Current Concepts: Venoactive drugs can be used as first-line agents for symptoms, such as edema, at all stages of varicose vein. These are effective adjuvant agents and can help achieve compression before and after procedures. Compression therapy is effective for skin change and ulcers and is excellent for the improvement of symptoms. Sclerotherapy has been widely used as an adjuvant treatment, but recently, its indications have been expanded for non-invasive causes. Traditional high ligation and stripping is still the recommended treatment option for recurrent or complicated varicose veins.Discussion and Conclusion: The patients’ symptoms should be evaluated more critically than assessing only the venous reflux using ultrasound. Additionally, objective evaluation of various causes of lower extremity discomfort should be considered. Treatment according to appropriate indications, such as medication, compression, sclerotherapy, stripping, and endovascular therapy, can improve the patients’ quality of life and prevent complications.

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study

Purpose@#Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. @*Methods@#A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. @*Results@#A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. @*Conclusion@#There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

The Management of Retained Rectal Foreign Body

Purpose@#Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose management guideline for such cases based on our experience. @*Methods@#We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demographic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes. @*Results@#All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2), or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp (n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann operation was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused postextraction anorectal functional and anatomical evaluation and psychological counseling. @*Conclusion@#Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be used for FB retrieval and the therapeutic algorithm applicable in such cases.

Endovenous Intervention of May-Thurner Syndrome with Thrombus beyond Iliac Vein Stenosis

PURPOSE: With the increase in the incidence of venous thrombosis, interest in May-Thurner syndrome (MTS) accompanying iliac vein compression has increased. Some patients with MTS have inferior vena cava thrombosis or thrombosis beyond iliac vein stenosis (TBIVS). This study aimed to identify the characteristics of MTS with TBIVS including pulmonary embolism (PE) and post-thrombotic syndrome (PTS) compared to those of MTS without TBIVS. MATERIALS AND METHODS: Thirty-five patients with deep vein thrombosis associated with MTS were treated between March 2012 and February 2016. Demographic data, medical history, computed tomography findings (iliac vein size of stenosis and stenotic ratio compared with the other side), and clinical outcomes (preoperative PE and PTS) were retrospectively collected and reviewed by dividing into groups with or without TBIVS. RESULTS: Eight of the 35 patients with MTS had TBIVS. The group with TBIVS had a statistically significantly greater iliac vein size (P<0.001) and ratio (P=0.001). PE was more prevalent in the group with TBIVS (63% vs. 15%, P=0.007). However, no statistically significant intergroup difference in PTS prevalence was found. CONCLUSION: The presence of mild iliac vein stenosis in MTS can be used to predict TBIVS and the requirement for more attention to PE.

Trends in endovascular aneurysm repair research: bibliometric analysis from 1994 to 2017

PURPOSE: Since endovascular aneurysm repair (EVAR) was first introduced in 1991, it has undergone rapid technical and quantitative developments. We analyzed the characteristics and trends of EVAR research through bibliometric analysis. METHODS: Comprehensive online searches focused on EVAR were performed from January 1994 to August 2017. The following information was collected: title, year of publication, countries' contribution, authorship, subspecialty, institution, subject category, and top 10 cited articles. RESULTS: A significant increase was demonstrated globally in the number of annual publications on EVAR. The highest number of publications was from the United States (n = 849, 35.08%), followed by England (n = 343, 14.17%), and the institutions with highest number of publications were Stanford University (n = 61, 2.52%) and Skane University Hospital Malmo (n = 45, 1.86%). The Journal of Vascular Surgery published approximately one quarter of the total publications. Vascular surgeons produced the most publications (n = 1871, 78.14%), followed by radiologists (n = 377, 15.58%) and cardiologists (n = 73, 3.02%). The most studied topics on EVAR were complications and procedures. The number of publications on complex EVAR and EVAR in juxtarenal aneurysm has increased more from 2013 to 2017 (5.1%, 9.5%) compared with from 1998 to 2002 (2.1%, 1.8%). CONCLUSION: Our bibliometric analysis showed the characteristics and trends of publications on EVAR over a period of 25 years. The results of the bibliometric analysis revealed the quantitative improvements of publications and the qualitative improvements in challenging EVAR.

Clinical Manifestations of Superior Mesenteric Venous Thrombosis in the Era of Computed Tomography

PURPOSE: Thrombosis of the portal vein, known as pylephlebitis, is a rare and fatal complication caused by intraperitoneal infections. The disease progression of superior mesenteric venous thrombosis (SMVT) is not severe. This study aimed to determine the clinical features, etiology, and prognosis of SMVT. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients with SMVT from March 2000 to February 2017. We obtained a list of 305 patients through the International Classification of Disease-9 code system and selected 41 patients with SMVT with computed tomography. Data from the medical records included patient demographics, comorbidities, review of system, laboratory results, clinical courses, and treatment modalities. RESULTS: The causes of SMVT were found to be intraperitoneal inflammation in 27 patients (65.9%), malignancy in 7 patients (17.1%), and unknown in 7 patients (17.1%). Among the patients with intraperitoneal inflammation, 14 presented with appendicitis (51.9%), 7 with diverticulitis (25.9%), and 2 with ileus (7.4%). When comparing patients with and without small bowel resection, the differences in symptom duration, bowel enhancement and blood culture were significant (P=0.010, P=0.039, and P=0.028, respectively). CONCLUSION: SMVT, caused by intraperitoneal inflammation, unlike portal vein thrombosis including pylephlebitis, shows mild prognosis. In addition, rapid symptom progression and positive blood culture can be the prognostic factors related to extensive bowel resection. Use of appropriate antibiotics and understanding of disease progression can help improve the outcomes of patients with SMVT.

Evaluation of postoperative lymphocele according to amounts and symptoms by using 3-dimensional CT volumetry in kidney transplant recipients

PURPOSE: To analyze the risk factors for postoperative lymphocele, for predicting and preventing complications. METHODS: We evaluated 92 kidney transplant recipients with multidetector CT (MDCT) at 1-month posttransplantation. From admission and 1-month postoperative records, data including diabetes, dialysis type, immunosuppressant use, steroid pulse therapy, and transplantation side were collected. Lymphocele volume was measured with 3-dimensional reconstructed, nonenhanced MDCT at one month postoperatively. The correlations between risk factors and lymphocele volume and between risk factors and symptomatic lymphocele (SyL) were analyzed. The cutoff was calculated by using the receiver operating characteristic (ROC) curve for SyL volume. RESULTS: Among 92 recipients, the mean volume was 44.53 ± 176.43 cm³ and 12 had SyL. Univariable analysis between risk factors and lymphocele volume indicated that donor age, retransplantation, and inferiorly located lymphocele were statistically significant. The ROC curve for SyL showed that 33.20 cm³ was the cutoff, with 83.3% sensitivity and 93.7% specificity. On univariable analysis between risk factors and SyL, steroid pulse, inferiorly located lymphocele, and >33.20 cm³ were statistically significant. Multivariable analysis indicated that steroid pulse, >33.20 cm³, and serum creatinine level at one month were significant factors. CONCLUSION: Risk factors including donor age, retransplantation, steroid pulse therapy, and inferiorly located lymphocele are important predictors of large lymphoceles or SyL. In high-risk recipients, careful monitoring of renal function and early image surveillance such as CT or ultrasound are recommended. If the asymptomatic lymphocele is >33.20 cm³ or located inferiorly, early interventions can be considered while carefully observing the changes in symptoms.

Evaluation of postoperative lymphocele according to amounts and symptoms by using 3-dimensional CT volumetry in kidney transplant recipients

PURPOSE: To analyze the risk factors for postoperative lymphocele, for predicting and preventing complications. METHODS: We evaluated 92 kidney transplant recipients with multidetector CT (MDCT) at 1-month posttransplantation. From admission and 1-month postoperative records, data including diabetes, dialysis type, immunosuppressant use, steroid pulse therapy, and transplantation side were collected. Lymphocele volume was measured with 3-dimensional reconstructed, nonenhanced MDCT at one month postoperatively. The correlations between risk factors and lymphocele volume and between risk factors and symptomatic lymphocele (SyL) were analyzed. The cutoff was calculated by using the receiver operating characteristic (ROC) curve for SyL volume. RESULTS: Among 92 recipients, the mean volume was 44.53 ± 176.43 cm³ and 12 had SyL. Univariable analysis between risk factors and lymphocele volume indicated that donor age, retransplantation, and inferiorly located lymphocele were statistically significant. The ROC curve for SyL showed that 33.20 cm³ was the cutoff, with 83.3% sensitivity and 93.7% specificity. On univariable analysis between risk factors and SyL, steroid pulse, inferiorly located lymphocele, and >33.20 cm³ were statistically significant. Multivariable analysis indicated that steroid pulse, >33.20 cm³, and serum creatinine level at one month were significant factors. CONCLUSION: Risk factors including donor age, retransplantation, steroid pulse therapy, and inferiorly located lymphocele are important predictors of large lymphoceles or SyL. In high-risk recipients, careful monitoring of renal function and early image surveillance such as CT or ultrasound are recommended. If the asymptomatic lymphocele is >33.20 cm³ or located inferiorly, early interventions can be considered while carefully observing the changes in symptoms.

Hand-assisted Laparoscopic Donor Surgery for Living Donor Pancreas and Kidney Transplantation: A Single Center Experience / 대한이식학회지

BACKGROUND: In this era of donor shortage, use of organs from living donors has increased significantly. Nonetheless, less than 1% of pancreas transplantations involve living donors, despite the immunological benefits, reduced cold ischemic time, and decreased waiting time. One reason for the paucity of donors is the high morbidity after open surgery. Using hand-assisted laparoscopic donor surgery (HALDS) can be a favorable technique for living donors. METHODS: Using HALDS, we performed three Simultaneous pancreas-kidney transplantations (SPKs) involving living donors. Two donors were women; one was a man. RESULTS: Their mean age was 34.3±4.7 years, and their body mass index was 23.2±2.36 kg/m². The mean operation time was 241±19.0 minutes and the mean cold-ischemic time of the kidney was 42.7±9.8 minutes, while that of the pancreas was 64.3±5.2 minutes. One donor developed a pancreatic fistula, which was controlled using conservative management. The donors' pancreatic and renal functions were well preserved postoperatively. CONCLUSIONS: HALDS for SPKs can be performed without significant complications if the surgeon has sufficient skill.

Acute ileofemoral artery thromboembolism due to left ventricle thrombi with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a very rare cause of peripheral artery thromboembolism. It is especially rare to show symptoms of acute limb ischemia without chest symptoms during a hospital visit. In this case, a rare case of SCAD led to left heart failure and caused left ventricle thrombi, which in turn caused peripheral thromboembolism.

Hybrid Repair of Type III Thoracoabdominal Aortic Aneurysm with Pre-Occluded Visceral Arteries / 대한혈관외과학회지

As experiences with endovascular aortic devices increases over time, hybrid repair for the treatment of thoracoabdominal aortic aneurysms (TAAA) by using a combination of thoracoabdominal endovascular aneurysm repair and visceral revascularization has been reported with acceptable result. A 55-year-old man with type III TAAA involving visceral arteries has been treated successfully with tube stent-graft followed by right renal revascularization that was facilitated by a rare anatomic configuration. The authors present a type III TAAA patient with rare anatomic configuration of the visceral arteries successfully treated with hybrid endovascular-surgical TAAA repair.

Negative pressure wound therapy for inguinal lymphatic complications in critically ill patients / 대한외과학회지

PURPOSE: In this study, we investigated the therapeutic potential of regulated negative pressure vacuum-assisted wound therapy for inguinal lymphatic complications in critically ill, liver transplant recipients. METHODS: The great saphenous vein was harvested for hepatic vein reconstruction during liver transplantation in 599 living-donor liver transplant recipients. Fourteen of the recipients (2.3%) developed postoperative inguinal lymphatic complications and were treated with negative pressure wound therapy, and they were included in this study. RESULTS: The average total duration of negative pressure wound therapy was 23 days (range, 11 to 42 days). Complete resolution of the lymphatic complications and wound healing were achieved in all 14 patients, 5 of whom were treated in hospital and 9 as outpatients. There was no clinically detectable infection, bleeding or recurrence after an average follow-up of 27 months (range, 7 to 36 months). CONCLUSION: Negative pressure wound therapy is an effective, readily-available treatment option that is less invasive than exploration and ligation of leaking lymphatics and provides good control of drainage and rapid wound closure in critically ill patients.