The 2018 Korean Heart Rhythm Society Guidelines for Integrated Management of Korean patients with Nonvalvular Atrial Fibrillation / 대한내과학회지

Atrial fibrillation (AF) is the most common form of sustained arrhythmia in elderly patients. However, AF is often detected during health screening, or accidentally during testing for other diseases; some patients lack clinical symptoms. Nevertheless, AF increases the incidence of ischemic stroke and other thrombotic events, and compromises cardiovascular prognosis in terms of heart failure, dementia, and hospitalization. Therefore, initial AF management should be performed at the point of primary care, not only in specialized medical centers. We wish to propose a five-step management protocol for AF. We review the evidence supporting integrated management by primary care physicians new to AF, and by specialized physicians who often diagnose and manage AF. Further, we also outline a structured goal-based follow-up protocol; this is an important part of integrated management.

Laparoscopic Right Hemicolectomy and Cholecystectomy for a Cholecystocolic Fistula

A cholecystocolic fistula (CF) is an uncommon complication of the gallbladder and colonic disease. We report a case of a CF that was successfully managed by using a laparoscopic right hemicolectomy and cholecystectomy. A 49-yr-old woman was admitted to the Department of Internal Medicine because of intermittent and progressive right upper quadrant pain. She was obese (body mass index: 34 kg/m2) and had a previous history of three abdominal surgeries. She was diagnosed with a CF by using abdominal computed tomography. The fistula between the gallbladder and the hepatic flexure of the colon was also characterized by using technetium-99m diisopropyl iminodiacetic acid ((99m)Tc-DISIDA) cholescintigraphy, a double-contrast Barium enema, and colonoscopy. Multiple polyps with severe inflammation were observed around the orifice of the fistula. Because of the risk of malignancy and appendicolith on CT, a laparoscopic en block excision of the gallbladder and the right colon following adhesiolysis was performed. The postoperative course was uneventful, and the patient was discharged on postoperative day 9. This case shows that the laparoscopic combined resection is safe and effective in the experienced hands of the laparoscopic surgeon even though a CF has traditionally been considered as a contraindication to laparoscopic surgery. While the incidence of successful management of biliary-enteric fistulas through laparoscopic repair is increasing, this is the first report of a laparoscopic combined resection of a CF in an obese patient with severe intraabdominal adhesion.