Various Applications of Purse-String Suture and Its Cosmetic Outcome in Cutaneous Surgical Defects

Background@#Purse-string suture is a simple technique to reduce wound size and to achieve complete or partial closure of skin defects. @*Objective@#To classify situations in which purse-string sutures can be utilized and to assess the long-term size reduction and cosmetic outcome of the final scar. @*Methods@#Patients (93 from Severance hospital and 12 from Gangnam Severance hospital) in whom purse-string sutures were used between January 2015 and December 2019 were retrospectively reviewed. Wound site, final reconstruction method, repair duration, final wound size, and Vancouver scar scale were assessed. @*Results@#A total of 105 patients were reviewed. Lesions were located on the trunk (48 [45.7%]), limbs (32 [30.5%]), and face (25 [23.8%]). Mean ratio of wound length/primary defect length was 0.79±0.30. Multilayered purse-string suture showed the shortest duration from excision to final repair (p<0.001) and most effectively minimized the scar size (scar to defect size ratio 0.67±0.23, p=0.002). The average Vancouver scar scale measured at the latest followup visit at least 6 months postoperatively was 1.62, and the risk of hypertrophic scarring was 8.6%. There was no significant difference in the Vancouver scar scale and the risk of hypertrophic scarring between the different surgical method groups. @*Conclusion@#Purse-string sutures can be utilized in many stages of reconstruction to effectively reduce scar size without compromising the final cosmetic outcome.

Clinicopathologic significance of the delta-like ligand 4, vascular endothelial growth factor, and hypoxia-inducible factor-2α in gallbladder cancer

Background@#Gallbladder cancer (GBC) is usually detected in advanced stages with a low 5-year survival rate. Delta-like ligand 4 (DLL4), vascular endothelial growth factor (VEGF), and hypoxia-inducible factor-2alpha (HIF2α) have been studied for their role in tumorigenesis and potential for therapeutic target, and multiple clinical trials of the agents targeting them are ongoing. We investigated the expression of these markers in surgically resected GBC and tried to reveal their association with the clinicopathologic features, mutual correlation of their expression, and prognosis of the GBC patients by their expression. @*Methods@#We constructed the tissue microarray blocks of 99 surgically resected GBC specimens and performed immunohistochemistry of DLL4, VEGF, and HIF2α. We used the quantitative digital image analysis to evaluate DLL4 and VEGF expression, while the expression of HIF2α was scored manually. @*Results@#The expression of VEGF and HIF2α showed a significant trend with tumor differentiation (p= .028 and p= .006, respectively). We found that the high DLL4 and VEGF expression were significantly correlated with lymph node metastasis (p= .047, both). The expression of VEGF and HIF2α were significantly correlated (p < .001). The GBC patients with low HIF2α expression showed shorter recurrence-free survival than those with high HIF2α expression. @*Conclusions@#This study suggested the possibility of the usage of DLL4 and VEGF to predict the lymph node metastasis and the possibility of VEGF and HIF2α to predict the expression level mutually. Further studies may be needed to validate our study results and eventually accelerate the introduction of the targeted therapy in GBC.

Treatment Results of Tissue Grafting in Vitiligo: A Single-Center Retrospective Analysis for 11 Years / 대한피부과학회지

Background@#Vitiligo is an acquired depigmentary disorder characterized by the destruction of melanocytes via an autoimmune-mediated process. Treatments can be categorized into nonsurgical and surgical methods. Prognostic factors of surgical management in vitiligo have not been widely studied in the Korean population. @*Objective@#To investigate the prognostic factors of tissue grafts in vitiligo. @*Methods@#We retrospectively analyzed patients who underwent tissue grafting for vitiligo between January 2010 and December 2020. Medical records and clinical photographs were reviewed, and demographics, disease characteristics, and treatment outcomes were collected. @*Results@#A total of 195 cases were evaluated, and among them, 86 (44.1%) showed 75% improvement, and 49 (25.1%) showed 50% to 74% improvements 3 months after surgery. Statistical analyses showed that the prognosis of tissue grafting was significantly different according to vitiligo subtype, recipient site, and grafting method. The focal and segmental type, head and neck sites, and suction blister grafting showed favorable results compared with the non-segmental type, sites other than the head and neck, and punch grafting. Age and adjuvant phototherapy did not affect the clinical outcomes. @*Conclusion@#This study proposes several clinical factors that affect the outcomes of skin grafting in vitiligo.

A Survey of Physician’s Awareness Regarding the Prescription and Side Effects of Topical Steroids / 대한피부과학회지

Background@#Topical steroids are the most commonly prescribed anti-inflammatory agents in dermatology, and patients often experience various adverse events of topical steroid application. Patients’ awareness of adverse effects and understanding of coping strategies for these unwanted events are pivotal elements for the safe use of topical steroids. @*Objective@#This study aimed to assess the prescribing pattern of topical steroids and patient education for safe use by dermatologists and non-dermatology specialists in Korea. @*Methods@#A questionnaire was sent to dermatologists, pediatricians, and other specialists through an online survey.A total of 444 answers were analyzed; then, the numbers were adjusted according to the nationwide proportion of specialists prescribing topical steroids. The total number of respondents was set to 720 after the adjustment. @*Results@#Dermatologists prescribed topical steroids to 49% of their patients, while other specialist doctors prescribed to 6.4% of the patients. Mid-potency steroids were most commonly prescribed (52.9%), followed by low/weak potency (37.6%), in adjusted analysis. Overall, 12.5% of all respondents and 14.5% of dermatologists reported adverse events due to topical steroids within the last month. The physicians spent 2.1 minutes on average (2.0 minutes for dermatologists) for patient education on proper use of topical steroids. The majority (79.1%) of physicians informed patients of the fact that the prescription contained steroids, while some were reluctant to disclose this information because of the negative perception about steroids in the general population. @*Conclusion@#This survey provides thorough information on the current status of prescription, counseling condition, doctors’ perception of patients’ knowledge of adverse events, and proper use of topical steroids.

Pharmacological therapeutics in androgenetic alopecia

Androgenetic alopecia (AGA) is the most common type of hair loss and affects both men and women. Male pattern hair loss shows characteristic frontal recession and vertex baldness, whereas female pattern hair loss produces diffuse alopecia over the mid-frontal scalp. AGA is mediated by increased androgen susceptibility in affected scalp hairs. 5α-Reductase converts testosterone into dihydrotestosterone, a potent androgen, in the scalp. Both androgen receptors and 5α-reductase have higher expression levels in the balding scalp than in non-affected regions. Increased androgen susceptibility induces hair follicle miniaturization, which leads to the progressive loss of thicker terminal hairs in the balding scalp. Currently, topical minoxidil and oral 5α-reductase inhibitors, such as finasteride and dutasteride, are approved options for the pharmacological treatment of AGA. Topical minoxidil remains the mainstay of therapy for mild to moderate AGA in both men and women. The daily intake of 1-mg finasteride or 0.5-mg dutasteride shows better efficacy than topical minoxidil in regard to hair regrowth in male AGA. Anti-androgens can be used in female AGA wit clinical and biochemical evidence of hyperandrogenism. Patients may be overwhelmed and confused by the variety of treatment options for AGA management, including over-the-count drugs with low evidence quality. Therefore, physicians must be aware of the current guidelines for the management of AGA based on evidence-based approaches to select better options for patients.

Multiple Actinic Keratoses within Vitiliginous Patches in a Patient with Non-segmental Vitiligo / 대한피부과학회지

A 74-year-old man visited our department with complaints of multiple asymptomatic erythematous scaly crusted patches on the scalp. He had non-segmental vitiligo with the extent of over 20% of the body surface area for 30 years. Biopsies showed hyperkeratosis, foci of atypical, pleomorphic keratinocytes along the basal cell layer, and marked solar elastosis, consistent with actinic keratosis (AK). Melan-A and Fontana-Masson staining showed absence of melanin and melanocytes. Despite conflicting data on the prevalence of skin cancers in patients with vitiligo, it is known that vitiligo does not increase nor decrease the risk of skin cancer. Recent studies have reported that patients with vitiligo lesions show increased epidermal expression of wild-type p53 protein than healthy controls. However, a few cases of skin cancer have been reported in patients with vitiligo. Here, we report a case of AK developing in vitiligo lesions. Dermatologists should not overlook the possible occurrence of AK or skin cancers in sun-exposed vitiliginous skin.

Evaluation of the American Joint Committee on Cancer (AJCC) 8th Edition Staging System for Hepatocellular Carcinoma in 1,008 Patients with Curative Resection / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Recently, the 8th edition staging system of the American Joint Committee on Cancer (AJCC) for hepatocellular carcinoma (HCC) was released, including a change in T category. We aimed to validate the new AJCC system. @*Materials and Methods@#The predictive value of the new AJCC was validated in comparison to the previous edition, in a total 1,008 patients who underwent curative resection for HCC as initial treatment. @*Results@#The 2-year area under the curve values for recurrence-free survival (RFS) and overall survival (OS) were comparable in the 7th and 8th editions. Stage migration was observed in 63 patients (6.3%); from T2 to T1a for 44 patients and from T3 to T4 for 19 patients. The RFS and OS were not different between T1a and T1b in the 8th edition. For solitary tumors ≤ 2 cm, those with microvascular invasion had lower RFS and OS values than those without although they were all classified as T1a in the 8th edition. Tumors involving a major branch of the portal or hepatic vein (T4 by the 8th edition and T3b by the 7th edition) had shorter RFS and OS than multifocal tumors, at least one of which was > 5 cm (T3 by the 8th edition and T3a by the 7th edition). @*Conclusion@#The AJCC 8th edition staging system for HCC showed comparable predictive performance to the 7th edition. It is desirable in a future revision to consider sub-stratification of solitary tumors ≤ 2 cm (T1a) depending on the presence of vascular invasion, which is not included in the 8th edition.

A Rare Case of Adenosquamous Carcinoma Arising in the Background of IgG4-Related Lung Disease

IgG4-related disease is a systemic inflammatory disease and is known as IgG4-related lung disease (IgG4-RLD) when it involves the respiratory system. Primary lung cancer arising from a background of IgG4-RLD is very rare. Herein, we report a case of adenosquamous carcinoma arising from the background of IgG4-RLD and presenting as an interstitial lung disease pattern. A 66-year-old man underwent lobectomy under the impression of primary lung cancer. Grossly, the mass was ill-defined and gray-tan colored, and the background lung was fibrotic. Microscopically, tumor cells showed both squamous and glandular differentiation. Dense lymphoplasmacytic infiltration with fibrosis and obliterative phlebitis were seen in the background lung. IgG4 immunohistochemical stain showed diffuse positivity in infiltrating plasma cells. Primary lung adenosquamous carcinoma has not been reported in a background of IgG4-RLD. Due to the rarity of IgG4-RLD, physicians must follow patients with IgG4-RLD over long periods of time to accurately predict the risk of lung cancer.

False-negative Hepatobiliary Scintigraphy for Biliary Atresia / 대한핵의학회잡지

We present the case of a patient with biliary and duodenal atresia who showed false-negative hepatobiliary scintigraphy results. The patient was born at 37 weeks and 2 days of gestation. Her mother had undergone amnioreduction after detection of a double-bubble ultrasound sign in the fetal abdomen. At 2 days of age, total serum bilirubin level was elevated. On hepatobiliary scintigraphy 4 days later, the gallbladder was visualized from 30 min and it showed duodeno-gastric reflux at 240 min. After 24 h, the radiotracer was almost washed out in the hepatic parenchyma, but there was retention in the gastroduodenal junction. Because the biliary to duodenal transit was visible, biliary atresia seemed unlikely. Abdominal ultrasonography at 7 days of age showed a small dysmorphic gallbladder, but triangular cord sign was not definite. Magnetic resonance cholangiography revealed atretic gallbladder. Although cystic and common bile ducts were visible, the proximal common hepatic bile duct was not visible. The next day, serum total bilirubin levels remained elevated (17.1 mg/dl) with direct bilirubin level of 1.2 mg/dl. Kasai portoenterostomy with duodeno-duodenostomy was performed at 10 days of age. Histopathological evaluation showed a fibrous obliteration of the common bile duct, consistent with that of biliary atresia.

False-negative Hepatobiliary Scintigraphy for Biliary Atresia / 대한핵의학회잡지

We present the case of a patient with biliary and duodenal atresia who showed false-negative hepatobiliary scintigraphy results. The patient was born at 37 weeks and 2 days of gestation. Her mother had undergone amnioreduction after detection of a double-bubble ultrasound sign in the fetal abdomen. At 2 days of age, total serum bilirubin level was elevated. On hepatobiliary scintigraphy 4 days later, the gallbladder was visualized from 30 min and it showed duodeno-gastric reflux at 240 min. After 24 h, the radiotracer was almost washed out in the hepatic parenchyma, but there was retention in the gastroduodenal junction. Because the biliary to duodenal transit was visible, biliary atresia seemed unlikely. Abdominal ultrasonography at 7 days of age showed a small dysmorphic gallbladder, but triangular cord sign was not definite. Magnetic resonance cholangiography revealed atretic gallbladder. Although cystic and common bile ducts were visible, the proximal common hepatic bile duct was not visible. The next day, serum total bilirubin levels remained elevated (17.1 mg/dl) with direct bilirubin level of 1.2 mg/dl. Kasai portoenterostomy with duodeno-duodenostomy was performed at 10 days of age. Histopathological evaluation showed a fibrous obliteration of the common bile duct, consistent with that of biliary atresia.

Erratum: Identification of Epithelial-Mesenchymal Transition-related Target Genes Induced by the Mutation of Smad3 Linker Phosphorylation

The original version of this article contained error in the URL of the SUPPLEMENTARY MATERIALS.

Identification of Epithelial-Mesenchymal Transition-related Target Genes Induced by the Mutation of Smad3 Linker Phosphorylation

BACKGROUND: Smad3 linker phosphorylation plays essential roles in tumor progression and metastasis. We have previously reported that the mutation of Smad3 linker phosphorylation sites (Smad3-Erk/Pro-directed kinase site mutant constructs [EPSM]) markedly reduced the tumor progression while increasing the lung metastasis in breast cancer. METHODS: We performed high-throughput RNA-Sequencing of the human prostate cancer cell lines infected with adenoviral Smad3-EPSM to identify the genes regulated by Smad3-EPSM. RESULTS: In this study, we identified genes which are differentially regulated in the presence of Smad3-EPSM. We first confirmed that Smad3-EPSM strongly enhanced a capability of cell motility and invasiveness as well as the expression of epithelial-mesenchymal transition marker genes, CDH2, SNAI1, and ZEB1 in response to TGF-β1 in human pancreatic and prostate cancer cell lines. We identified GADD45B, CTGF, and JUNB genes in the expression profiles associated with cell motility and invasiveness induced by the Smad3-EPSM. CONCLUSIONS: These results suggested that inhibition of Smad3 linker phosphorylation may enhance cell motility and invasiveness by inducing expression of GADD45B, CTGF, and JUNB genes in various cancers.

Aucubin Promotes Differentiation of Neural Precursor Cells into GABAergic Neurons

Aucubin is a small compound naturally found in traditional medicinal herbs with primarily anti-inflammatory and protective effects. In the nervous system, aucubin is reported to be neuroprotective by enhancing neuronal survival and inhibiting apoptotic cell death in cultures and disease models. Our previous data, however, suggest that aucubin facilitates neurite elongation in cultured hippocampal neurons and axonal regrowth in regenerating sciatic nerves. Here, we investigated whether aucubin facilitates the differentiation of neural precursor cells (NPCs) into specific types of neurons. In NPCs cultured primarily from the rat embryonic hippocampus, aucubin significantly elevated the number of GAD65/67 immunoreactive cells and the expression of GAD65/67 proteins was upregulated dramatically by more than three-fold at relatively low concentrations of aucubin (0.01 µM to 10 µM). The expression of both NeuN and vGluT1 of NPCs, the markers for neurons and glutamatergic cells, respectively, and the number of vGluT1 immunoreactive cells also increased with higher concentrations of aucubin (1 µM and 10 µM), but the ratio of the increases was largely lower than GAD expression and GAD immunoreactive cells. The GABAergic differentiation of pax6-expressing late NPCs into GABA-producing cells was further supported in cortical NPCs primarily cultured from transgenic mouse brains, which express recombinant GFP under the control of pax6 promoter. The results suggest that aucubin can be developed as a therapeutic candidate for neurodegenerative disorders caused by the loss of inhibitory GABAergic neurons.

Trends in the utilization of dental outpatient services affected by the expansion of health care benefits in South Korea to include scaling: a 6-year interrupted time-series study

PURPOSE: This study utilized a strong quasi-experimental design to test the hypothesis that the implementation of a policy to expand dental care services resulted in an increase in the usage of dental outpatient services. METHODS: A total of 45,650,000 subjects with diagnoses of gingivitis or advanced periodontitis who received dental scaling were selected and examined, utilizing National Health Insurance claims data from July 2010 through November 2015. We performed a segmented regression analysis of the interrupted time-series to analyze the time-series trend in dental costs before and after the policy implementation, and assessed immediate changes in dental costs. RESULTS: After the policy change was implemented, a statistically significant 18% increase occurred in the observed total dental cost per patient, after adjustment for age, sex, and residence area. In addition, the dental costs of outpatient gingivitis treatment increased immediately by almost 47%, compared with a 15% increase in treatment costs for advanced periodontitis outpatients. This policy effect appears to be sustainable. CONCLUSIONS: The introduction of the new policy positively impacted the immediate and long-term outpatient utilization of dental scaling treatment in South Korea. While the policy was intended to entice patients to prevent periodontal disease, thus benefiting the insurance system, our results showed that the policy also increased treatment accessibility for potential periodontal disease patients and may improve long-term periodontal health in the South Korean population.

Successful Localization Using ⁶⁸Ga-DOTATOC PET/CT of a Phosphaturic Mesenchymal Tumor Causing Osteomalacia in a Patient with Concurrent Follicular Lymphoma / 대한핵의학회잡지

Diagnosing tumor-induced osteomalacia is often challenging because conventional imaging modalities may fail to locate the responsible tumor. This report describes the ability of ⁶⁸Ga-DOTATOC PET/CT to successfully distinguish between the responsible phosphaturic mesenchymal tumor and concurrent lymphoma lesions. A 52-year-old man with bone pain for several years was diagnosed with a vitamin D-resistant hypophosphatemic osteomalacia. Whole body ¹⁸F-FDG PET/CT revealed multiple enlarged hypermetabolic lymph nodes in his bilateral cervical, axillary, mediastinal, abdominal, pelvic, and inguinal regions. Core needle biopsy of the right cervical lymph node confirmed the diagnosis of follicular lymphoma. However, lymphoma was not considered the cause of osteomalacia. ⁶⁸Ga-DOTATOC PET/CT before chemotherapy showed a small nodule with intensely increased uptake in the right inguinal region, which was distinguished from the other enlarged lymph nodes. The nodule was surgically removed and histopathologically consistent with phosphaturic mesenchymal tumor. After surgery, the patient's serum phosphorus and alkaline phosphatase levels normalized without nutritional supplement.

Treatment Outcomes and Risk Factors for In-Hospital Mortality in Patients with Acute Aortic Occlusion

PURPOSE: The aims of the present study are to determine the outcomes after acute aortic occlusion (AAO) and analyze the risk factors for in-hospital mortality. MATERIALS AND METHODS: We retrospectively analyzed 24 patients who were diagnosed with AAO from 2002 to 2017 in our registered data. Demographic and radiologic characteristics of AAOs were retrospectively collected. Perioperative treatment outcomes including in-hospital mortality were also assessed and the risk factors of in-hospital mortality were analyzed. RESULTS: The median symptom duration was 21 hours. Five patients had complete paraplegia and 10 patients (41.7%) were initially evaluated for central nervous system disorders instead of acute arterial occlusion. The etiology was determined to be aortoiliac thrombosis in 17 patients (70.8%) and embolic occlusion in 7. Surgical revascularization was performed in 23 patients, and one patient did not receive any treatment. The overall in-hospital mortality was 34.8% (8/23) and 30-day mortality was 26.1%. In the univariate analysis, age (P=0.040), preoperative renal insufficiency (serum creatinine over 1.5 mg/dL at the time of presentation) (P=0.008), postoperative acute kidney injury (need for dialysis or an increase in serum creatinine of >50.0% within 48 hours) (P=0.006), combined external iliac artery occlusion (P=0.019) and combined bilateral internal iliac artery occlusion (P=0.039) were associated with in-hospital mortality. CONCLUSION: A substantial number of AAO patients were initially evaluated for a central nervous system lesion, which led to a delay in diagnosis. Thus, vascular examinations should always be performed in every patient presenting with lower limb neurologic deficits. Age, perioperative renal function, and combined iliac artery occlusion were associated with the prognosis of AAOs.

Adventitial Cystic Disease of the Iliac Artery with a Connection to the Hip Joint

More than 700 adventitial cystic diseases (ACDs) have been reported in the literature, with most cases affecting the popliteal artery in young men. Here, we describe our treatment and etiologic consideration of a patient who presented with an ACD of the external iliac artery, known to be an extremely rare location. On preoperative imaging, the ACD had a connection to the nearby hip joint and was treated with resection of the affected segment, including ligation of the joint connection and interposition with a prosthetic graft. The pathogenesis of ACDs is not fully understood; however, we believe that joint connections are important in their development and treatment.

Successful Localization Using ⁶⁸Ga-DOTATOC PET/CT of a Phosphaturic Mesenchymal Tumor Causing Osteomalacia in a Patient with Concurrent Follicular Lymphoma / 대한핵의학회잡지

Diagnosing tumor-induced osteomalacia is often challenging because conventional imaging modalities may fail to locate the responsible tumor. This report describes the ability of ⁶⁸Ga-DOTATOC PET/CT to successfully distinguish between the responsible phosphaturic mesenchymal tumor and concurrent lymphoma lesions. A 52-year-old man with bone pain for several years was diagnosed with a vitamin D-resistant hypophosphatemic osteomalacia. Whole body ¹⁸F-FDG PET/CT revealed multiple enlarged hypermetabolic lymph nodes in his bilateral cervical, axillary, mediastinal, abdominal, pelvic, and inguinal regions. Core needle biopsy of the right cervical lymph node confirmed the diagnosis of follicular lymphoma. However, lymphoma was not considered the cause of osteomalacia. ⁶⁸Ga-DOTATOC PET/CT before chemotherapy showed a small nodule with intensely increased uptake in the right inguinal region, which was distinguished from the other enlarged lymph nodes. The nodule was surgically removed and histopathologically consistent with phosphaturic mesenchymal tumor. After surgery, the patient's serum phosphorus and alkaline phosphatase levels normalized without nutritional supplement.

Differential Tissue-specific and Pathway-specific Anti-obesity Effects of Green Tea and Taeumjowitang, a Traditional Korean Medicine, in Mice

BACKGROUND: Traditional medicines have been leveraged for the treatment and prevention of obesity, one of the fastest growing diseases in the world. However, the exact mechanisms underlying the effects of traditional medicine on obesity are not yet fully understood. METHODS: We produced the transcriptomes of epididymal white adipose tissue (eWAT), liver, muscle, and hypothalamus harvested from mice fed a normal diet, high-fat-diet alone, high-fat-diet together with green tea, or a high-fat-diet together with Taeumjowitang, a traditional Korean medicine. RESULTS: We found tissue-specific gene expression patterns as follows: (i) the eWAT transcriptome was more significantly altered by Taeumjowitang than by green tea, (ii) the liver transcriptome was similarly altered by Taeumjowitang and green tea, and (iii) both the muscle and hypothalamus transcriptomes were more significantly altered by green tea than Taeumjowitang. We then applied integrated network analyses, which revealed that functional networks associated with lymphocyte activation were more effectively regulated by Taeumjowitang than by green tea in the eWAT. In contrast, green tea was a more effective regulator of functional networks associated with glucose metabolic processes in the eWAT. CONCLUSIONS: Taeumjowitang and green tea have a differential tissue-specific and pathway-specific therapeutic effect on obesity.

Effect of Clinical Suspicion by Referral Physician and Early Outcomes in Patients with Acute Superior Mesenteric Artery Embolism

PURPOSE: To investigate the pattern of referral of patients with superior mesenteric artery embolism (SMAE) and its effect on outcomes, and to evaluate the risk factors for bowel infarction. MATERIALS AND METHODS: This retrospective study included 66 consecutive patients diagnosed with acute SMAE between January 2001 and June 2016. Appropriate diagnosis by the referring physician was defined if the referral letter indicated that acute mesenteric ischemia was suspected or had been diagnosed at the referral center. Surgical delay was defined as the interval between symptom onset and surgery for definitive treatment. RESULTS: Among 54 patients transferred from other centers, 26 patients (48.1%) were diagnosed appropriately by the referring physician. The rate of appropriate diagnosis was differed significantly by the use of computed tomography (CT) scan at referral center (25/35 with CT and 1/19 without CT, P=0.00). The surgical delay was significantly longer in patients without appropriate diagnosis compared with the patients with appropriate diagnosis (53.5±52.3 hours vs. 28.8±23.6 hours, P=0.04). Initially, 56 patients received surgical treatment with 31 underwent bowel resection due to infarction, 6 received conservative treatment, and the remaining 4 patients refused any treatment. The surgical delay, abdominal distension, tenderness, rebound tenderness, and level of C-reactive protein were associated with bowel infarction at initial operation. Overall in-hospital mortality was 32%. CONCLUSION: A high index of suspicion with appropriate diagnostic modality, such as CT scan is crucial in patients with SMAE for reducing surgical delay as a risk factor of bowel infarction.