Laparoscopic common bile duct exploration for elderly patients: as a first treatment strategy for common bile duct stones / 대한외과학회지

PURPOSE: Common bile duct (CBD) stone is a relatively common disease in elderly patients. There have been many reports about the efficacy and safety of LCBDE. But for elderly patients, only a few studies about its efficacy and safety exist. The aim of this study is to evaluate the efficacy, safety and the surgical outcome of LCBDE in patients who are 70 years or older and compare the results with those of the younger group. METHODS: From January 2000 to November 2009, 132 patients underwent LCBDE. We divided these patients into two groups according to age and conducted a retrospective analysis. The elderly group included patients who were 70 years old or older (n = 64), and the younger group included those who were younger than 70 (n = 68). The elderly group was compared to the younger group with respect to their clinical characteristics, operation time, postoperative hospital stay, open conversion rate, first meal time, postoperative complication, recurrence rate and mortality. RESULTS: The elderly group showed high American Society of Anesthesiologists score (2.2 vs. 1.9) (P = 0.003), preoperative morbidity (47 vs. 29) (P 0.05). CONCLUSION: LCDBE is a safe and effective treatment modality for CBD stones not only for younger patients but also for elderly patients.

Combined Operation of Laparoscopic Cholecystectomy during Laparoscopic Appendectomy in Patient with Chronic Gallbladder Disease

PURPOSE: Laparoscopic cholecystectomy (LC) for asymptomatic gallbladder disease has been increasing since 1990 due to the development of LC technique. Moreover, it might be considered when someone with asymptomatic gallbladder disease needs emergency operation due to acute abdomen such as acute appendicitis. The aim of this study is to identify the efficacy of concurrent laparoscopic appendectomy with cholecystectomy. METHODS: From January 1997 to June 2009, 40 patients underwent laparoscopic appendectomy with cholecystectomy at Ewha Womans University Mokdong Hospital. 40 patients were enrolled in this study. We analyzed, retrospectively, clinical and diagnostic information, time and open conversion rate in operation, length of postoperation hospital stay, and complication rate. RESULTS: The mean age was 44.53+/-15.34 and male to female ratio was 1 to 1.86. 5% of all patients underwent abdominal surgery and 20% of all patients had associated diseases. Most common associated symptoms and final diagnosis were right lower abdominal pain (72.5%) and simple gallbladder stone (62.5%). Mean operation time was 98.75+/-33.14 min. and there was no open conversion. Mean length of postoperation hospital stay was 5+/-2 days. There was one (2.5%) postoperative complication. CONCLUSION: Combined operation of laparoscopic cholecystectomy during laparoscopic appendectomy can be a good modality for patients with chronic gallbladder disease.

Analysis of Risk Factors for Low Bone Mineral Density in Patients with Inflammatory Bowel Disease / 대한소화기학회지

BACKGROUND/AIMS: Several clinical risk factors for low bone mineral density (BMD) in the patients with inflammatory bowel disease (IBD) have been suggested. However, its prevalence and pathophysiology in Korean population have not been fully studied. The aim of this study was to investigate the prevalence and risk factors for low BMD in Korean IBD patient. METHODS: BMD of the lumbar spine and femur was evaluated using dual-energy X-ray absorptiometry in 30 patients with IBD. Biochemical parameters of bone metabolism, such as serum calcium, phosphorus, osteocalcin, and deoxypyridinoline were measured. The associations between low BMD and clinical parameters such as disease duration, disease activity, drug history, body mass index (BMI), and others were evaluated retrospectively using medical records. RESULTS: Low BMD at the lumbar spine or femur was observed in 63.3% of the patients, and there was no significant difference between the patients with Crohn's disease and ulcerative colitis. Clinical and biochemical parameters were irrelevant to BMD. In the patients without glucocorticoid treatment prior to BMD measurement, already 50.0% of patients had low BMD. CONCLUSIONS: Low BMD is a common feature in Korean IBD patients, even those who do not use glucocorticoid. The multiple factors may be involved in the pathogenesis of low BMD. Therefore, BMD should be examined in all IBD patients, irrespective of glucocorticoid treatment.

A case of leprosy associated with bone marrow involvement and renal failure / 대한내과학회지

Leprosy is caused by acid fast bacilli (AFB). It usually affects the skin, nerve segments close to the skin, and mucous membranes of the upper respiratory tract. However, it can also involve other areas including lymph nodes, bone marrow, liver, and spleen. A 75-year-old male was admitted to hospital with general edema and dizziness, accompanied by pancytopenia and renal failure. The bone marrow biopsy showed a marke increased in histiocytes and copious blue-gray fine debris containing AFB on special staining. He was diagnosed with lepromatous leprosy. We report a case of lepromatous leprosy that manifested as chronic renal failure and bone marrow involvement.

Acute Fibrinous and Organizing Pneumonia Following Hematopoietic Stem Cell Transplantation

A 60-year-old man presented with cough, sputum, and dyspnea. He had a history of acute myeloid leukemia and hematopoietic stem cell transplantation with chronic renal failure. Chest CT scans showed miliary nodules and patchy consolidations. Histological examination revealed numerous fibrin balls within the alveoli and thickening of the alveolar septum, both of which are typical pathological features of acute fibrinous and organizing pneumonia (AFOP). We report the first case of AFOP following allogeneic hematopoietic stem cell transplantation.

Clinical Characteristics of Primary Epiploic Appendagitis

BACKGROUND/AIMS: Primary epiploic appendagitis (PEA) is a rare cause of focal abdominal pain in otherwise healthy patients. Patients with acute abdominal pain are often misdiagnosed clinically as acute appendicitis or diverticulitis. The purpose of this study was to describe the clinical presentation and characteristic computed tomography (CT) findings of PEA. METHODS: We reviewed the clinical records and CT images of 23 consecutive patients in Korea who presented with acute abdominal pain between January 2005 and February 2009 and had radiologic signs of PEA. RESULTS: Twenty-three patients (7 females and 16 males; average age, 42+/-14 years) were diagnosed with symptomatic PEA. Abdominal pain localized to the left (8 patients [44.5%]) and right (10 patients [55.5%]) lower quadrants as the leading symptom. CT findings specific for PEA were present in all patients except one. The symptoms resolved within 1 week (mean, 3.5 days) with or without antibiotic treatment. CONCLUSIONS: In patients with localized, sharp, acute abdominal pain not associated with other symptoms, such as nausea, vomiting, fever or atypical laboratory values, the diagnosis of PEA should be considered and the diagnosis confirmed by CT scan.

Acute Respiratory Distress Syndrome after Topotecan Therapy in a Patient with Small Cell Lung Cancer / 결핵및호흡기질환

Small cell lung cancer is characterized by an aggressive clinical course and a high tendency for early dissemination in spite of a good chemotherapy response. Topotecan is a topoisomerase I inhibitor, and it is used as second-line treatment for small cell lung cancer. The reported dose-limiting adverse reactions to topotecan are mainly hematologic. Yet pulmonary toxicity associated with topotecan is known to be rare. We report here on a case that showed the development of acute respiratory distress syndrome during the 3rd cycle of topotecan chemotherapy in a patient with small cell lung cancer. He developed dyspnea and respiratory failure, and the chest CT scan revealed diffuse ground-glass opacity that was probably due to chemotherapy-related pulmonary toxicity. He finally died of acute respiratory distress syndrome.

The Usefulness of Endotoxin for Detection of Mucosal Injury in Intestinal Obstruction

PURPOSE: The treatment outcome of an intestinal obstruction depends on the early recognition and emergent operation of a strangulated intestinal obstruction. Endotoxin is a lipopolysaccharide component of the cell wall of gram negative bacteria that normally exist in the intestinal lumen. When a strangulated obstruction occurs, the endotoxin passes transluminally into the peritoneal cavity and blood stream. A disruption of the mucosal barrier is an important putative cause in this pathogenesis. This study investigated the relationship between the endotoxin level and progress of an intestinal obstruction to a strangulated obstruction. METHODS: 25 adult male Sprague-Dawley rats (200~250 g) were divided into 3 groups, the control group, simple obstruction group, and closed loop obstruction group. An intestinal obstruction was induced using a silk tie. Blood samples and obstructed bowel wall specimens were obtained at 24, 48 and 72 hours after surgery. The endotoxin and IL-6 levels were examined, and all specimens were reviewed by a pathologist for mucosal damage after H-E staining. RESULTS: In the obstruction groups, dilated bowel loops at the proximal end of the obstruction site was identified but there were no ischemic changes. The endotoxin and IL-6 levels were similar regardless of the obstruction types and times. There were no differences between the three groups in the degree of mucosal damage. However, according to the endotoxin level, the groups with an endotoxin level < 0.2 EU/ml showed mild mucosal damage. The severity of mucosal damage increased with increasing endotoxin level. CONCLUSION: There is a positive relationship (r(2)=0.673, P-value=0.002) between the endotoxin level and mucosal damage. This suggests the possibility of using endotoxin as a predictive factor for the detection of mucosal injury in an intestinal obstruction. However, a larger scale will be needed to confirm the statistical significance.

Clinicopathologic Characteristics of Mucinous Gastric Adenocarcinoma

PURPOSE: Clinicopathological characteristics of mucinous gastric adenocarcinomas (MGC) are unclear. Also, whether the surgical results of a MGC are unfavorable is still controversial. A tumor is defined as a MGC when more than 30% of the tumor area has mucin pools. Also, MGC are subdivided into the well-differentiated (WD) and poorly differentiated (PD) types, according to the degree of glandular formation of the tumor cells. To clarify the significance of MGC, the clinicopathological profiles and prognoses of patients were studied. METHODS: Thirty-four patients with MGC and 1, 036 with non-mucinous gastric adenocarcinomas (NMGC) who were operated on between 1992 and 2002 at the Department of Surgery, Hanyang University Hospital, were included. Patients were evaluated with regard to age, gender, tumor location, size, depth of wall invasion, lymph node status, distant metastasis, stage at presentation, lymphatic and vascular permeation, operative curability, and preoperative serum levels of CEA and CA19-9. RESULTS: MGC tumors, compared with NMGC tumors, had larger sizes (8.0 vs. 5.9 cm), more frequent incidences of T2 or more invasion (91 vs. 66%), positive lymph node metastasis (85 vs. 57%), distant metastasis (18 vs. 6%), stage III and IV (74 vs. 45%), noncurative surgery (32 vs. 10%), lymphatic permeation (88 vs. 63%), and abnormal serum CEA level (32 vs. 14%). However, the overall survival rate of those patients with a MGC was not significantly different from that of those with a NMGC. With a MGC, there was no significant correlation between the degree of mucin content and the prognosis. Conversely, the survival rate was higher in the WD than in the PD types (100 vs. 45%, P=0.0185). CONCLUSION: The mucinous histological type itself is of no prognostic significance in patients with gastric carcinomas. The biological behavior of MGC is determined by the degree of glandular formation of the tumor cellss (i.e., histologic differentiation).

Paraganglioma Arising from Retroperitoneum, Mediastinum

A paraganglioma that arises from the Retroperitoneum, mediastinum is an extra-adrenal form of pheochromcytoma. Extra-adrenal pheochromocytomas can occur at any site in the abdomen where chromaffin tissue is located and have been found in the paravertebral ganglia, the organ of Zuckerkandl, and the urinary bladder. An extra-adrenal pheochromocytomas can arise from a collection of para-aortic, paraganglion cells located at the origin of the inferior mesenteric artery, This collection of paraganglia was first described in fetuses by Zuckerkandl in 1901 and has subsequently been referred to as the organ of Zuckerkandl. Extra-adrenal pheochromocytoma generally secrete norepinephrine, not epinephrine, because there is an absence of the enzyme phenyl- ethanolamine-N-methyl transferase. Therefore symptoms are related to the production of norepinephrine. Extra-adrenal pheochromocytomas pursue a more aggressive course than their adrenal counterparts. It was found to metastasize in approximately 20% to 40% of cases, compared with only a 2% to 10% rate of metastasis in all adrenal tumors. We report on a three case of paragangliomas that had a functional and non-functional paraganglioma of the organ of Zuckerkandl and a case of a non-functional paraganglioma of the posterior mediastinum.

Development of a Critical Pathway for Patients with Lumbar Laminectomy / 성인간호학회지

The purpose of this study was to develop a critical pathway for case management of patients who have received Lumbar Laminectomy because of low back pain, arm and leg numbness, and radiating pain in the leg. For this study, a preliminary critical pathway was developed through a review of the literature including five critical pathways which are currently being used in the USA. In order to identify the overall service contents required by these patients, 30 cases were analyzed. These cases were taken from medical records of those with Lumbar Laminectomy between January, 1998 and December, 1998 in the department of neurosurgery at the Pusan National University Hospital in Pusan. An expert validity test was done for the preliminary critical pathway, a clinical validity test was also done using 12 patients with Lumbar Laminectomy between October 1, 1999 and January 31, 2000. After these processes, the final critical pathway was developed. The results are summarized as follows. 1. The vertical axis of the critical pathway includes the following eight items: assessment, consultation, diet, test, medication, treatment, activity, education/ discharge planning. The horizontal axis includes the time from the start of hospitalization to discharge. Analysis of the 30 medical records was done. analysis of the service contents showed the horizontal axis of the preliminary critical pathway was set from hospitalization to the 12th post operation day and the vertical axis was set to include eight items, the contents which should have occurred, according to the time frames of the horizontal axis. 2. As a result of the expert validity test, it was found that among the 233 items, 203 showed over 88% agreement and 30 of them showed less than 88% agreement, which were then revised or deleted from the critical pathway. At the preliminary meeting for the clinical validity test, the time of hospitalization on the horizontal axis was shortened to the 10th post operation day. A clinical validity test was done with 12 patients with Lumbar Laminectomy. All the cases progressed according to the critical pathway although some variances were noted in assessment, consultation, test, medication, and treatment. 3. Based on these results, a final critical pathway was determined. In conclusion, this critical pathway is partially applicable to the care of patients with Lumbar Laminectomy and needs further investigation.

Clinicopathological Characteristics of Recurred Gastric Cancer Patients after Curative Surgery

PURPOSE: More than half of the gastric cancer patients are diagnosed at an advanced stage, and many of them recur in spite of curative surgery. Because of that fact, analysis of the characteristics of recurrence and development of a more effective treatment are urgent problems. METHODS: One hundred gastric cancer patients who recurred after curative surgery were enrolled for this study, and 518 patients living without recurrence were used as a control group. Various clinicopathological factors were compared between the recurred and the non-recurred groups. RESULTS: Among the 100 recurred patients, peritoneal seeding (P/S) was found in 46 patients, hematogenous spread (H-S) in 20 patients, loco-regional recurrence (LR-R) in 15 patients mixed type in 19 patients. Depth of invasion, lymph node metastasis, incidence of total gastrectomy, preoperative CA19-9 level, lymphatic and venous invasion, and tumor size were significantly different between the recurred and the non-recurred groups. In cases with P/S and H-R, undifferentiated tumors were more frequent than differentiated tumors to the contrary differentiated tumors were more common in LR-R. More than 80% of the recurrences were emerged within 2 years after surgery. At the time of recurrence, the serum levels of CEA and CA 19-9 were positive of 45% and 45% of the patients respectively. In P/S, patients with operative treatment survived longer than patients receiving other kinds of treatment (p=0.019), and chemotherapy effectively lengthened the survival in mixed type recurrence (p=0.018). CONCLUSION: The two years following surgery was the most important period for recurrence, and lymphatic invasion was related to such early recurrence with a statistical significance. Measurement of the serum levels of tumor markers was useful for the detection of recurrence. Operative treatment or chemotherapy was effective for lengthening the period of survival after recurrence in some types of recurrence.

A case of bilateral tubal pregnancy / 대한산부인과학회잡지

No abstract available.