Effect of bupivacaine on postoperative pain and analgesics use after single-incision laparoscopic appendectomy: double-blind randomized study

PURPOSE: Local anesthetics can decrease postoperative pain after appendectomy. This study sought to verify the efficacy of bupivacaine on postoperative pain and analgesics use after single-incision laparoscopic appendectomy (SILA).METHODS: Between March 2014 and October 2015, 68 patients with appendicitis agreed to participate in this study. After general anesthesia, patients were randomized to bupivacaine or control (normal saline) groups. The assigned drugs were infiltrated into subcutaneous tissue and deep into anterior rectus fascia. Postoperative analgesics use and pain scores were recorded using visual analogue scale (VAS) by investigators at 1, 8, and 24 hours and on day 7. All surgeons, investigators and patients were blinded to group allocation.RESULTS: Thirty patients were allocated into the control group and 37 patients into bupivacaine group (one patient withdrew consent before starting anesthesia). Seven from the control group and 4 from the bupivacaine group were excluded. Thus, 23 patients in the control group and 33 in the bupivacaine group completed the study. Preoperative demographics and operative findings were similar. Postoperative pain and analgesics use were not different between the 2 groups. Subgroup analysis determined that VAS pain score at 24 hours was significantly lower in the bupivacaine group (2.1) than in the control group (3.8, P = 0.007) when surgery exceeded 40 minutes. During immediate postoperative period, bupivacaine group needed less opioids (9.1 mg) than control (10.4 mg).CONCLUSION: Bupivacaine did not decrease pain and analgesics use. When surgery exceeded 40 minutes, bupivacaine use might be associated with less pain and less analgesics use.

Omental Torsion and Infarction Secondary to Omental Hernia in the Right Inguinal Canal

Omental torsion secondary to inguinal hernia has rarely been reported as a cause of acute abdominalpain. However, in our case, omental infarction due to prolonged inguinal hernia-associatedomental torsion led to the formation of a large omental mass with marginal fibrosis, andthe patient presented with chronic abdominal pain. A 74-year-old man presented with complaintsof lower abdominal pain for 1 month; subsequently, bilateral inguinal hernias wereidentified through inguinal ultrasonography. CT scans revealed that the greater omentum wastrapped within the right inguinal canal, leading to omental torsion. The greater omentum, distalto the pedicle, appeared as a 30 cm-sized oblong fibrofatty mass in the right lower abdomenand pelvic cavity. Laparoscopic omentectomy with hernia repair was successfully performed.

Outcomes of surgical treatments for rectovaginal fistula and prognostic factors for successful closure: a single-center tertiary hospital experiences

PURPOSE: Rectovaginal fistula can result from various causes and diverse surgical procedures have developed as a result. We investigated the outcomes of surgical treatments for rectovaginal fistula according to causes and procedures. METHODS: Between 1998 and 2016, 92 patients underwent 128 operations for rectovaginal fistula. Prospectively collected data were recorded, and a retrospective review was conducted. RESULTS: The median age was 49 years, and low fistula occurred in 58 patients (63.0%). The most common cause was radiation therapy, followed by pelvic operation, birth injury, perineal operation, cancer invasion, and trauma. The most common procedure during the first operation was diverting ostomy alone, followed by transanal rectal advancement flap, sphincteroplasty with perineoplasty, bowel resection, fistulectomy with seton placement, and Martius flap. Thirty-one patients (33.7%) experienced successful closure after the first operation. Repeated operations were performed in 16 patients (17.4%), including gracilis muscle transpositions, stem cell injections, and Martius flaps. The overall success rate was 42.4% (n = 39). Radiation therapy and pelvic operation as cause of fistula were significantly poor prognostic factors (P = 0.010, P = 0.045) and Crohn disease had a tendency for poor prognostic factors (P = 0.058). CONCLUSION: Radiation therapy and pelvic operation for cancer were more common causes than birth injury, and these causes of rectovaginal fistula were the most important prognostic factors. An individualized approach and repeated surgeries with complex or newly developed procedures, even among high-risk causes of fistula, may be necessary to achieve successful closure.

Acute Care Surgery Model for Emergency Cholecystectomy

PURPOSE: Acute care surgery (ACS) models have evolved worldwide over the last decade. However, South Korea has an established trauma system and does not consider the ACS model. This study compares the management and outcome of emergency cholecystectomy in the ACS model to those of traditional on-call attending surgeon model for emergency surgery. METHODS: Retrospectively collected data for patients who underwent emergency cholecystectomy from May 2013 to January 2015 was analyzed to compare data from a traditional on-call system (OCS) and ACS. RESULTS: One hundred and twenty-four patients were enrolled in the study (62 patients ACS vs. 62 patients OCS). Hospital stay (days) (ACS=4.29±2.49 vs. OCS=4.82±4.48, p=0.46) and stay in emergency room (minutes) (ACS=213.10±113.99 vs. OCS=241.10±150.73, p=0.20) did not differ significantly between groups. Operation time (minutes) was significantly shorter in the ACS than OCS group (389.97±215.21 vs. 566.35±290.14, p<0.001). Other clinical variables (sex, open-conversion rate, whether the operation was performed at night/holiday, intensive care unit admission rate) did not differ between groups. There was no mortality and readmission. CONCLUSION: The implementation of the ACS led to shorter operation time and no increase of postoperative mortality and complication.

Rectourethral Fistula: Systemic Review of and Experiences With Various Surgical Treatment Methods

PURPOSE: A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation or trauma. Although various surgical procedures for the treatment of an RUF have been described, none has gained acceptance as the procedure of choice. The aim of this study was to review our experience with surgical management of RUF. METHODS: The outcomes of 6 male patients (mean age, 51 years) with an RUF who were operated on by a single surgeon between May 2005 and July 2012 were assessed. RESULTS: The causes of the RUF were iatrogenic in four cases (two after radiation therapy for rectal cancer, one after brachytherapy for prostate cancer, and one after surgery for a bladder stone) and traumatic in two cases. Fecal diversion was the initial treatment in five patients. In one patient, fecal diversion was performed simultaneously with definitive repair. Four patients underwent staged repair after a mean of 12 months. Rectal advancement flaps were done for simple, small fistula (n = 2), and flap interpositions (gracilis muscle flap, n = 2; omental flap, n = 1) were done for complex or recurrent fistulae. Urinary strictures and incontinence were observed in patients after gracilis muscle flap interposition, but they were resolved with simple treatments. The mean follow-up period was 28 months, and closure of the fistula was achieved in all five patients (100%) who underwent definitive repairs. The fistula persisted in one patient who refused further definitive surgery after receiving only a fecal diversion. CONCLUSION: Depending on the severity and the recurrence status of RUF, a relatively simple rectal advancement flap repair or a more complex gracilis muscle or omental flap interposition can be used to achieve closure of the fistula.

Rectal Perforation Caused by Anal Stricture After Hemorrhoid Treatment

Inappropriate therapies for hemorrhoids can lead to various complications including anorectal stricture. We report a patient presenting with catastrophic rectal perforation due to severe anal stricture after inappropriate hemorrhoid treatment. A 67-years old man with perianal pain visited the emergency room. The hemorrhoids accompanied by constipation, had tortured him since his youth. Thus he had undergone injection sclerotherapy several times by an unlicensed therapist and hemorrhoidectomy twice at the clinics of private practitioners. His body temperature was as high as 38.5degrees C. The computed tomographic scan showed a focal perforation of posterior rectal wall. The emergency operation was performed. The fibrotic tissues of the anal canal were excised. And then a sigmoid loop colostomy was constructed. The patient was discharged four days following the operation. This report calls attention to the enormous risk of unlicensed injection sclerotherapy and overzealous hemorrhoidectomy resulting in scarring, progressive stricture, and eventual rectal perforation.

Does T3 Subdivision Correlate with Nodal or Distant Metastasis in Colorectal Cancer?

PURPOSE: We analyzed the clinical data of T3 colorectal cancer patients to assess whether T3 subdivision correlates with node (N) or metastasis (M) staging and stage-independent factors. METHODS: Five hundred fifty-five patients who underwent surgery for primary colorectal cancer from January 2003 to December 2009 were analyzed for T3 subdivision. T3 subdivision was determined by the depth of invasion beyond the outer border of the proper muscle (T3a, 5 to 15 mm; T3d, >15 mm). We investigated the correlation between T3 subdivision and N, M staging and stage-independent prognostic factors including angiolymphatic invasion (ALI), venous invasion (VI) and perineural invasion (PNI). RESULTS: The tumors of the 555 patients were subclassified as T3a in 86 patients (15.5%), T3b in 209 patients (37.7%), T3c in 210 patients (37.8%) and T3d in 50 patients (9.0%). The nodal metastasis rates were 39.5% for T3a, 56.5% for T3b, 75.7% for T3c and 74.0% for T3d. The distant metastasis rates were 7.0% for T3a 9.1% for T3b, 27.1% for T3c and 40.0% for T3d. Both N and M staging correlated with T3 subdivision (Spearman's rho = 0.288, 0.276, respectively; P < 0.001). Other stage-independent prognostic factors correlated well with T3 subdivision (Spearman's rho = 0.250, P < 0.001 for ALI; rho = 0.146, P < 0.001 for VI; rho = 0.271, P < 0.001 for PNI). CONCLUSION: Subdivision of T3 colorectal cancer correlates with nodal and metastasis staging. Moreover, it correlates with other prognostic factors for colorectal cancer.

Analysis of Risk Factors for the Development of Incisional and Parastomal Hernias in Patients after Colorectal Surgery

PURPOSE: The purpose of this study was to evaluate the overall rate and risk factors for the development of an incisional hernia and a parastomal hernia after colorectal surgery. METHODS: The study cohort consisted of 795 consecutive patients who underwent open colorectal surgery between 2005 and 2007 by a single surgeon. A retrospective analysis of prospectively collected data was performed. RESULTS: The overall incidence of incisional hernias was 2% (14/690). This study revealed that the cumulative incidences of incisional hernia were 1% at 12 months and 3% after 36 months. Eighty-six percent of all incisional hernias developed within 3 years after a colectomy. The overall rate of parastomal hernias in patients with a stoma was 6.7% (7/105). The incidence of parastomal hernias was significantly higher in the colostomy group than in the ileostomy group (11.9% vs. 0%; P = 0.007). Obesity, abdominal aortic aneurysm, American Society of Anesthesiologists score, serum albumin level, emergency surgery and postoperative ileus did not influence the incidence of incisional or parastomal hernias. However, the multivariate analysis revealed that female gender and wound infection were significant risk factors for the development of incisional hernias female: P = 0.009, wound infection: P = 0.041). There were no significant factors related to the development of parastomal hernias. CONCLUSION: Our results indicate that most incisional hernias develop within 3 years after a colectomy. Female gender and wound infection were risk factors for the development of an incisional hernia after colorectal surgery. In contrast, no significant factors were found to be associated with the development of a parastomal hernia.

Operative Treatment with a Laparotomy for Anorectal Problems Arising from a Self-Inserted Foreign Body

An anorectal foreign body can cause serious complications such as incontinence, rectal perforation, peritonitis, or pelvic abscess, so it should be managed immediately. We experienced two cases of operative treatment for a self-inserted anorectal foreign body. In one, the foreign body could not be removed as it was completely impacted in the anal canal. We failed to remove it through the anus. A laparotomy and removal of the foreign body was performed by using an incision on the rectum. Primary colsure and a sigmoid loop colostomy were done. A colostomy take-down was done after three months. The other was a rectal perforation from anal masturbation with a plastic device. We performed primary repair of the perforated rectosigmoid colon, and we didea sigmoid loop colostom. A colostomy take-down was done three months later. Immediate and proper treatment for a self-inserted anorectal foreign body is important to prevent severe complications, and we report successful surgical treatments for problems caused by anorectal foreign bodies.

Jejuno-jejunal fistula induced by magnetic necklace ingestion / 대한외과학회지

We describe the case of a 19-year-old mentally challenged woman who developed jejuno-jejunal fistula following ingestion of a magnetic necklace. This case report demonstrates the necessity of prompt treatment when the ingested intestinal foreign body is suspected to be multiple magnets, even if there are no sharp edges; and even when it seems the object could be evacuated spontaneously. Ingested magnets are capable of attracting each other across the bowel wall, leading to serious intestinal complications such as pressure necrosis, perforation, fistula formation, or intestinal obstruction.

Toremifene as an Adjuvant Hormone Therapy for Estrogen Receptor Positive early Breast Cancer: Therapeutic Efficacy and Effect on Endometrium / 한국유방암학회지

PURPOSE: This study was conducted to evaluate the use of toremifene as an adjuvant hormonal therapy for estrogen recepter (ER) positive early breast cancer patients in terms of therapeutic efficacy and effect on endometrium as compared with tamoxifen. METHODS: Between January 2001 and December 2003, 451 patients with stage 0, I and II breast cancer, received adjuvant hormone therapy that consisted of either tamoxifen (N=387) or toremifene (N=64). The recurrence rate and survival rate were compared between two groups and the incidence of of endometrial event was evaluated in 273 of the patients. RESULTS: The median follow up period was 57 months and the median hormonal therapy period was 51 months. During the follow up period, there were 3 (2.0%) recurrence in the stage I tamoxifen group, 19 recurrences (8.7%) and 3 deaths (1.4%) in the stage II tamoxifen group (n=219), however there were no instances of recurrence or death in all of the toremifene group. In addition, endometrial cancer developed in 2 patients in the tamoxifen group, but in no patients in toremifene group during the follow up period. Further 21 of the patients who began treatment using tamoxifen changed to toremifene due to adverse side effects. The toremifene was well tolerated by 15 of the patients that changed treatment regimes. CONCLUSION: Toremifene was found to be as effective and safe as tamoxifen, when used as an adjuvant hormonal therapeutic agent in ER-positive early breast cancer, therefore toremifene may be a good option in place of tamoxifen for patients who are experiencing adverse effects as a result of tamoxifen treatment.

Combined Angioplasty and Femorofemoral Bypass in the Treatment of Unilateral Iliac Arterial Occlusive Disease

PURPOSE: The purpose of this article is to analyze the results of combined agioplasity and femorofemoral bypass in patients with unilateral iliac arterial occlusive disease. METHOD: During the 11-year period from 1990 to 2000, 44 patients with iliac artery occlusion and a hemodynamically significant contralateral iliac artery stenosis were treated by using a combination of percutaneous transluminal angioplasity (PTA) and femorofemoral bypass (n=18) as well as aortobifemoral bypass (n=12) and iliofemoral bypass (n=14) at Korea university medical center. PTA was performed if the lesions in the donor iliac artery were less than 3 cm in length with no more than one well-localized lesion in either the common or external iliac artery, or both. Stent was deployed for suboptimal PTAs. The femorofemoral bypass was done within 3 to 5 days after PTA or stenting. RESULT: The mean age was 61.2 years. The Indications of femorofemoral bypass were hypertension, ischemic heart disease, chronic obstructive lung disease, old age (>75), cancer, and previous abdominal operation. The complication rate of the combination treatment was lower than that of the others. Primary patency rate at 1 and 3 years were 89%, 78% for aortobifemoral bypass, 83%, 66% for iliofemoral bypass, and 77%, 65% for femorofemoral bypass, respectively. CONCLUSION: The combination of PTA with or without stent deployment and femorofemoral bypass can be a useful option for treating iliac occlusion and contralateral iliac stenosis in patients with severe comorbid illness, advanced age, and intra-abdominal pathology. Angioplasity can allow more widespread use of femorofemoral bypass in these patients.