Synchronous Quadruple Colon Cancer With Two Lesions Previously Obscured by Ischemic Colitis, Plus Bladder Cancer and Thymoma: A Case Report

Synchronous quadruple colorectal cancer (CRC) is extremely rare without genetic alterations. We present a case of synchronous quadruple CRC with 2 lesions previously obscured by ischemic colitis. A 73-year-old woman was admitted to our emergency department. An abdominal computed tomography revealed ischemic colitis and irregular wall thickening of the sigmoid colon and sigmoid-descending junction, suspicious of 2 colon cancers. A colonoscopy examination revealed a fungating mass 20 cm from the anal verge, as well as ischemic colitis spanning the mucosa from the sigmoid colon to the transverse colon. The patient underwent laparoscopic Hartmann procedure. Pathologic examination confirmed both lesions as adenocarcinomas with microsatellite stable. Seven months postoperatively, instead of a laparoscopic Hartmann reversal, a laparoscopic total colectomy was performed due to the continued presence of severe ischemic colitis. The pathologic report suggested the presence of 2 distinct invasive adenocarcinomas in the descending colon without genetic alterations such as microsatellite instability.

Tumor grade 2 as the independent predictor for lymph node metastasis in 10–20 mm sized rectal neuroendocrine tumor

Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.

Synchronous Quadruple Colon Cancer With Two Lesions Previously Obscured by Ischemic Colitis, Plus Bladder Cancer and Thymoma: A Case Report

Synchronous quadruple colorectal cancer (CRC) is extremely rare without genetic alterations. We present a case of synchronous quadruple CRC with 2 lesions previously obscured by ischemic colitis. A 73-year-old woman was admitted to our emergency department. An abdominal computed tomography revealed ischemic colitis and irregular wall thickening of the sigmoid colon and sigmoid-descending junction, suspicious of 2 colon cancers. A colonoscopy examination revealed a fungating mass 20 cm from the anal verge, as well as ischemic colitis spanning the mucosa from the sigmoid colon to the transverse colon. The patient underwent laparoscopic Hartmann procedure. Pathologic examination confirmed both lesions as adenocarcinomas with microsatellite stable. Seven months postoperatively, instead of a laparoscopic Hartmann reversal, a laparoscopic total colectomy was performed due to the continued presence of severe ischemic colitis. The pathologic report suggested the presence of 2 distinct invasive adenocarcinomas in the descending colon without genetic alterations such as microsatellite instability.

Regional Anesthesia for Abdominal Surgery in a Patient with Severe Chronic Respiratory Failure: A Case Report

General anesthesia is associated with a risk for postoperative pulmonary complications. The risk is even higher in patients with chronic respiratory failure, and postoperative mortality rates are high. Proper perioperative anesthetic management is important in such patients. Therefore, it is essential to optimize the patient’s physical status before anesthesia and to determine the optimal anesthesia technique based on the pre-anesthesia evaluation of the patient’s pulmonary function. We successfully performed abdominal surgery under spinal anesthesia in a patient with severe chronic respiratory failure.

Anesthetic Management for Spine Surgery in a Patient with Left Internal Carotid Artery Occlusion and Penetrating Aortic Ulcer: A Case Report

A key challenge of anesthesia is to provide patients with safe and optimized anesthetic management to improve prognosis and minimize mortality and morbidity. To this end, the anesthesiologist should comprehensively understand the patient’s physical status through pre-anesthetic assessment and carefully monitor the patient during surgery. Several types of novel patient-monitoring devices may be useful to achieve this purpose. We report a case of anesthetic management in a patient with left internal carotid artery occlusion and penetrating aortic ulcer.

Tumor grade 2 as the independent predictor for lymph node metastasis in 10–20 mm sized rectal neuroendocrine tumor

Purpose@#Rectal neuroendocrine tumors (NETs) <10 mm are endoscopically resected, while those ≥20 mm are treated with radical surgical resection. The choice of treatment for 10–20 mm sized rectal NETs remains controversial. This study aimed to verify factors predicting lymph node metastasis (LNM) of 10–20 mm sized rectal NET and utilize them to decide upon the treatment strategy. @*Methods@#Twenty-eight patients with 10–20 mm sized rectal NETs treated at Pusan National University Yangsan Hospital from January 2009 to September 2020 were divided into LNM (+) and LNM (–) groups, and their respective data were analyzed. @*Results@#Seven patients (25%) had LNM while 21 patients (75%) did not. Endorectal ultrasound findings showed tumor size was significantly larger in the LNM (+) than in the LNM (–) group (15 mm vs. 10 mm, P=0.018); however, pathologically, there was no significant difference in tumor size (13 mm vs. 11 mm, P=0.109). The mitotic count (P=0.011), Ki-67 index (P=0.008), and proportion of tumor grade 2 patients (5 cases, 71% vs. 1 case, 5%; P=0.001) were significantly higher in the LNM (+) group. In multivariate analysis, tumor grade 2 was the independent factor predicting LNM (odds ratio, 61.32; 95% confidence interval, 3.17–1,188.64; P=0.010). @*Conclusion@#Tumor grade 2 was the independent factor predicting LNM in 10–20 mm sized rectal NETs. Therefore, it could be considered as the meaningful factor in determining whether radical resection is necessary.

Perianal extragastrointestinal stromal tumor

An extragastrointestinal stromal tumor (EGIST) is a gastrointestinal stromal tumor that arises outside of the gastrointestinal tract. Most EGISTs are located in the omentum, mesentery, and retroperitoneum. The occurrence of an EGIST at the perianal region is very rare. Herein, we report our experience with EGISTs in the perianal area and review the literature. A 70-year-old man presented to our hospital with a 2-year history of anal discomfort. A pelvic magnetic resonance imaging scan showed a homogenous, well-defined, soft tissue density mass. The patient underwent mass excision, and the pathological examination confirmed that the mass was an EGIST. The size of the tumor was 4.3×3.2 cm, and the mitotic count was 1 per 50 high-power fields. The tumor cells were immunohistochemically positive for KIT and CD34 but were negative for S-100 and alpha-smooth muscle actin. There were no other abnormal findings in the gastrointestinal tract; upon pathological review, this case was confirmed as perianal EGIST. Therefore, EGIST should be considered as a differential diagnosis of perianal masses.

Perianal extragastrointestinal stromal tumor

An extragastrointestinal stromal tumor (EGIST) is a gastrointestinal stromal tumor that arises outside of the gastrointestinal tract. Most EGISTs are located in the omentum, mesentery, and retroperitoneum. The occurrence of an EGIST at the perianal region is very rare. Herein, we report our experience with EGISTs in the perianal area and review the literature. A 70-year-old man presented to our hospital with a 2-year history of anal discomfort. A pelvic magnetic resonance imaging scan showed a homogenous, well-defined, soft tissue density mass. The patient underwent mass excision, and the pathological examination confirmed that the mass was an EGIST. The size of the tumor was 4.3×3.2 cm, and the mitotic count was 1 per 50 high-power fields. The tumor cells were immunohistochemically positive for KIT and CD34 but were negative for S-100 and alpha-smooth muscle actin. There were no other abnormal findings in the gastrointestinal tract; upon pathological review, this case was confirmed as perianal EGIST. Therefore, EGIST should be considered as a differential diagnosis of perianal masses.

Anesthetic Experience of Unexpected Change to One-Lung Ventilation with Bronchial Blocker

One-lung ventilation is an anesthesiological technique to accomplish surgical visualization during thoracic surgical procedures, and is often required unexpectedly during surgery. Traditionally the double lumen tube is considered the gold standard for lung separation. Despite being equally feasible for standard situations, there are special populations and circumstances requiring the use of a bronchial blocker to establish one-lung ventilation. We have experienced unexpected change to one-lung ventilation with bronchial blocker. A 40-year-old (158 cm, 48 kg) woman was scheduled for emergency exploratory laparotomy due to panperitonitis. A sudden diaphragmatic perforation occurred during the operation. Since oxygen saturation was reduced, intraoperative tube change was not available. Therefore, one-lung ventilation was done with bronchial blockers. After the bronchial blocker was placed, one-lung ventilation was well maintained and the operation was terminated successfully.

Liver transplantation in Jehovah's Witnesses: two cases report / 대한마취과학회지

Liver transplantation is especially challenging in patients who are Jehovah's Witnesses because their religious beliefs prohibit the receipt of blood products. We present two cases of living donor liver transplantation performed in adult Jehovah's Witnesses in South Korea without the use of blood products. In the first case, preoperative erythropoiesisstimulation therapy increased hemoglobin levels from 8.1 to 13.1 g/dl after 9 weeks. In the second case, hemoglobin levels increased from 7.4 to 10.8 g/dl after 6 months of erythropoiesis-stimulation therapy. With the combination of acute normovolemic hemodilution, intraoperative cell salvage, and use of transfusion alternatives, liver transplantation was successfully performed without transfusion of blood products.

Isolated Unilateral Hypoglossal Nerve Palsy Following Transoral Endotracheal Intubation for Endoscopic Sinus Surgery

Hypoglossal nerve palsy is a rare complication of endotracheal intubation. The mechanism of nerve palsy is mainly attributed to stretching or compression of the nerve during airway manipulation. The cuff pressure can also contribute to the occurrence of hypoglossal nerve palsy. Since it is often accompanied by other cranial nerve palsies, meticulous overall cranial nerve examination is necessary. The main treatment is supportive with respiratory monitoring. The prognosis is favorable. Majority of patients achieve nearly full recovery of nerve function. Here, we report a case of unilateral hypoglossal nerve palsy following usual, uneventful endotracheal intubation and review the literature.

Development of the Geop-Pain questionnaire for multidisciplinary assessment of pain sensitivity / 대한마취과학회지

BACKGROUND: To assess the multidisciplinary aspects of pain, various self-rating questionnaires have been developed, but there have not been sufficient relevant studies on this topic in South Korea. The aim of this study was to develop a new pain sensitivity-related questionnaire in the Korean language that would be simple and would well reflect Koreans' senses. METHODS: A new pain assessment questionnaire was developed through a pre-survey on "geop", which is the Korean word expressing fear, anxiety, or catastrophizing. We named the new assessment questionnaire the Geop-Pain Questionnaire (GPQ). The GPQ was composed of 15 items divided into three categories and rated on a 5-point scale. As a preliminary study, internal consistency and test-retest reliability analyses were conducted. Subsequently, 109 individuals completed the GPQ along with three pain-related questionnaires translated into Korean (Pain Sensitivity Questionnaire [PSQ], Pain Anxiety Symptoms Scale [PASS], and Pain Catastrophizing Scale [PCS]), and the correlations were analyzed. RESULTS: All items in the GPQ showed appropriate internal consistency, and the test-retest reliability analysis showed no statistically significant differences. The correlations between the GPQ and the existing questionnaires revealed that the GPQ scores had mid-positive correlations with the PSQ scores and strong positive correlations with the PASS and PCS scores. CONCLUSIONS: This study attempted to develop a questionnaire assessing pain sensitivity multidimensionally using the Korean word geop for the first time. The self-rating GPQ showed high correlations with the existing questionnaires and demonstrated potential to be utilized as a pain prediction index in clinical practice.

Anesthetic Experience of Spinal Anesthesia after Sedation in Un-cooperated Elderly Patients

Regional anesthesia is mostly used in operations on the lower abdomen or lower extremities in elderly patients. It shows nearly no difference in long-term outcomes compared to general anesthesia, but it is used more often because of the several advantages. However, during the regional anesthetic procedures, the patient must cooperate and has to be lateral decubitus position without physical movement. Therefore, in the case of the patients who are not cooperated, it may be not easy to perform regional anesthesia. In this study, we present 3 case reports that regional anesthesia after sedation is performed in un-cooperated patients. Regional anesthesia after sedation may be a good method to improve outcomes in un-cooperated elderly patients.

Comparison of the Serum Cholesterol, Insulin Resistance and Markers of Metabolic Syndrome Based on Hepatitis C Virus RNA / 農村醫學 地域保健

OBJECTIVES: We compared the difference of lipid, insulin resistance and metabolic markers based on HCV RNA in Korean adults. METHODS: This was a cross-sectional study of 222 subjects visited the health promotion center of Pusan national university hospital from 2004 to 2007. Subjects were anti-HCV antibody positive and were performed RT-PCR for HCV RNA. The HCV RNA (+) group were 85 subjects, HCV RNA (−) control group were 115 subjects, and the HCV RNA (−) but past positive group were 22 subjects. We performed anthropometry, anti-HCV, RT-PCR, plasma concentrations of insulin, total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglyceride. RESULTS: BMI, waist circumference, blood pressure, fasting plasma glucose, triglyceride, HDL cholesterol, insulin resistance such as HOMA-IR and QUICKI were not significantly different between HCV RNA positive and negative groups. The serum total cholesterol and LDL cholesterol level were significantly lower in the HCV RNA positive group than in the negative group (186.24±37.63 vs 197.22±37.23 mg/dl, p=0.041, 111.66±34.06 vs 121.38±35.50 mg/dl, p=0.042). After adjusting age and sex, high total cholesterol (≥ 200mg/dl) (adjusted OR=0.51, 95%CI 0.28-0.94, p=0.03) and high LDL cholesterol (≥ 130mg/dl) (adjusted OR=0.46, 95%CI 0.24~0.87, p=0.02) were inversely associated with being HCV RNA positive (p<0.05). CONCLUSIONS: The serum total cholesterol and LDL-cholesterol level were significantly lower in HCV RNA (+) group than in HCV RNA (−) group, but not in HCV RNA (−) but past positive group. Prospective cohort studies are needed to clarify the relationship between HCV RNA and metabolic markers.

Reduction in mechanical allodynia in complex regional pain syndrome patients with ultrasound-guided pulsed radiofrequency treatment of the superficial peroneal nerve

The superficial peroneal nerve is vulnerable to damage from ankle sprain injuries and fractures as well as surgery to this region. And it is also one of the most commonly involved nerves in complex regional pain syndrome type II in the foot and ankle region. We report two cases of ultrasound-guided pulsed radiofrequency treatment of superficial peroneal nerve for reduction of allodynia in CRPS patients.

Regulation of CYP1A1 and Inflammatory Cytokine by NCOA7 Isoform 4 in Response to Dioxin Induced Airway Inflammation / 결핵및호흡기질환

BACKGROUND: Aryl hydrocarbon receptor (AhR), a ligand-dependent transcription factor, binds to a wide variety of synthetic and naturally occurring compounds. AhR is involved in the regulation of inflammatory response during acute and chronic respiratory diseases. We investigated whether nuclear receptor coactivator 7 (NCOA7) could regulate transcriptional levels of AhR target genes and inflammatory cytokines in 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)-treated human bronchial epithelial cells. This study was based on our previous study that NCOA7 was differentially expressed between normal and chronic obstructive pulmonary disease lung tissues. METHODS: BEAS-2B and A549 cells grown under serum-free conditions were treated with or without TCDD (0.15 nM and 6.5 nM) for 24 hours after transfection of pCMV-NCOA7 isoform 4. Expression levels of cytochrome P4501A1 (CYP1A1), IL-6, and IL-8 were measured by quantitative real-time polymerase chain reaction. RESULTS: The transcriptional activities of CYP1A1 and inflammatory cytokines were strongly induced by TCDD treatment in both BEAS-2B and A549 cell lines. The NCOA7 isoform 4 oppositely regulated the transcriptional activities of CYP1A1 and inflammatory cytokines between BEAS-2B and A549 cell lines. CONCLUSION: Our results suggest that NCOA7 could act as a regulator in the TCDD-AhR signaling pathway with dual roles in normal and abnormal physiological conditions.

Intraoperative Detection of Rate Dependent Left Bundle Branch Block

Rate dependent left bundle branch block (RDLBBB) is an uncommon case. RDLBBB is defined as an intraventricular conduction defect that may return, if only temporarily, to sinus rhythm at lower heart rates. It appears when the heart rate exceeds a certain critical value. Although RDLBBB is usually benign, its diagnosis and treatment have clinical importance for association of RDLBBB and myocardial ischemia and infarction. Therefore, in the case of detection of intraoperative RDLBBB, a clear differentiation should be done as soon as possible. Also it is important to start appropriate treatment and to do clinical follow-up examination. We report a case of intraoperative RDLBBB during general anesthesia for laparoscopic cholecystectomy in 82 years old female patient who has a history of hypertension.

Male Chronic Pelvic Pain Syndrome

Male chronic pelvic pain syndrome (MCPPS) is defined as chronic pain, pressure, or discomfort localized to the pelvis, perineum, or genitalia of males lasting more than 3 months that is not due to readily explainable causes. Other names for the disorder include prostatodynia and chronic nonbacterial (abacterial) prostatitis, although it is unclear how the symptoms relate to the prostate. And it appears to be extensive variability in clinical presentation and may result in chronic neuropathic pain and neuromuscular pain. Therefore patients with MCPPS should be cared by multimodal treatment including antihyperalgesics, antidepressants and pain intervention procedures such as caudal block. We report successful care in two men with MCPPS.

Current practice in hemodynamic monitoring and management in high-risk surgery patients: a national survey of Korean anesthesiologists / 대한마취과학회지

BACKGROUND: Hemodynamic optimization improves postoperative outcomes in high-risk surgery patients. The monitoring of cardiac output (CO) and dynamic parameters of fluid responsiveness can guide hemodynamic optimization. We conducted a survey to assess the current hemodynamic monitoring and management practices of Korean anesthesiologists during high-risk surgery. METHODS: E-mails containing a link to our survey, which consisted of 33 questions relating to hemodynamic monitoring during high-risk surgery, were sent to 3,943 members of the Korean Society of Anesthesiologists (KSA). The survey web page was open from December 30, 2011 to March 31, 2012. RESULTS: A total of 139 anesthesiologists responded during the survey period. Invasive arterial pressure (97.2%) and central venous pressure (93.4%) were routinely monitored. CO was monitored in 58.5% of patients; stroke volume variations were monitored in 50.9% of patients. However, CO was consistently optimized by < 20% of anesthesiologists. An arterial pressure waveform-derived CO monitor was the most frequently used device to monitor CO (79.0%). Blood pressure, urine output, central venous pressure, and clinical experience were considered to be the best indicators of volume expansion than CO or dynamic parameters of fluid responsiveness. CONCLUSIONS: The survey revealed that KSA members frequently monitor CO and dynamic parameters of fluid responsiveness during high-risk surgery. However, static indices were used more often to judge volume expansion. The current study reveals that CO is not frequently optimized despite the relatively high incidence of CO monitoring during high-risk surgery in Korea.

Complete atrioventricular nodal block after propofol administration in an elderly patient undergoing total knee replacement arthroplasty: A case report / 대한마취과학회지

Complete atrioventricular (AV) block is defined as a dissociation of atrial and ventricular activities. Complete AV block that occurs during the perioperative period is difficult to reverse and usually requires implantation of a pacemaker. Propofol does not affect a normal AV conduction system but may act as a trigger for AV block. It can also potentiate vagal stimulation factors and reduce sympathetic activity. We report a case of complete AV block that may have been related to administration of propofol.