Factors Predicting the Need for Early Surgical Intervention for Small Bowel Obstruction.

PURPOSE: Small bowel obstruction (SBO) is a common disease that requires hospitalization. The most common cause of SBO is postoperative adhesion. Delayed timing of operations in patients who need surgical intervention results in mortality or morbidity. A number of studies on SBO have established criteria for emergency surgery. However, few objective clinical parameters are available for screening patients who need a delayed operation. Therefore, we analyzed factors that affect the clinical course of SBO to select appropriate therapeutic plans for reducing the risk of complications in these patients. METHODS: We investigated the clinical characteristics of patients admitted to the surgery department of our hospital between January 1, 2015, and December 31, 2016, who were diagnosed with SBO. Patients were divided into an operative treatment group (n = 12) and a conservative treatment group (n = 96). We compared clinical characteristics between the 2 groups. RESULTS: The operative treatment group underwent more operations before SBO than the conservative treatment group (P = 0.007). Initial leukocyte counts (P = 0.004) and C-reactive protein (CRP) levels (P = 0.028) were elevated in the operative group. Body mass index (BMI) was lower in the operative group (P = 0.013). CONCLUSION: The number of operations before SBO, leukocyte counts, CRP levels, and BMI were useful parameters for selecting patients who needed an urgent operation for SBO.

Unmodifiable Clinicopathological Risk Factors of Shoulder Tip or Subcostal Pain after Laparoscopic Appendectomy.

Purpose: Appendectomy, which comprises most benign intra-abdominal surgeries, is currently assisted by laparoscopy in most cases. However, many patients complain of postoperative shoulder or subcostal pain after laparoscopic surgery. In some cases, the pain lasts even several weeks after surgery. This study aimed to analyze unmodifiable clinicopathological factors of patients who underwent laparoscopic appendectomy and to minimize preoperative and postoperative discomfort. Methods: Patients admitted for laparoscopic appendectomy for acute appendicitis with an American Society of Anesthesiology (ASA) grades I and II, and ages 12~70 years were enrolled in the study. Postoperative shoulder or subcostal pain was assessed using the visual analogue scale (VAS) for pain and analyzed with the clinicopathological factors of the patients, including age, sex, weight, height, body mass index (BMI), and abdominal circumference (AC) difference. Results: Of the 124 patients, 40 complained of postoperative shoulder or subcostal pain with a VAS score of ≥4. The risk of the postoperative shoulder or subcostal pain increased in women (p=0.001). From a univariate analysis, the risk of postoperative shoulder or subcostal pain increased with lower height, weight and BMI (p=0.002, p=0.001, p=0.012) and with greater AC difference (p=0.012). However, a multivariate analysis showed that lower weight was the only risk factor of postoperative pain (p=0.005). Conclusion: The risk of postoperative shoulder or subcostal pain after laparoscopic appendectomy was significantly increased with lower weight.

Safety and Efficacy of Arterial Closure Devices in an Office-Based Angiosuite.

INTRODUCTION: We aimed to compare the safety and efficacy of 5 arterial closure devices in an outpatient endovascular surgery center. METHODS: We retrospectively reviewed all cases using femoral arterial access performed between January 2012 and December 2013. Five different arterial closure devices (AngioSeal, Perclose, StarClose, ExoSeal, and Mynx) were used by 7 endovascular surgeons. All femoral arteries were accessed with 6F sheaths under ultrasound guidance. All patients received systemic anticoagulation with sodium heparin (70 IU/kg). Sheath-shot angiograms of all arterial punctures were taken before deploying closure devices. Device failure was defined as any partial or complete failure requiring additional closure assistance. Minor complication was defined as any event that occurred because of incomplete hemostasis but did not result in hospitalization, including hematoma, hypotension, bleeding, arterial dissection, or extended recovery. Major complication was defined as any event that occurred because of incomplete hemostasis requiring inpatient management. Any device failure was identified per device and per surgeon. Device safety, efficacy, and relationships between other variables were analyzed using a binomial logistic regression. Results with P values < 0.05 were considered to be statistically significant. RESULTS: During the study period, there were a total of 3142 endovascular procedures, including 1976 arterial cases (62.9%). Out of 1898 femoral artery punctures, closure devices were used in 1810 (95.4%), which forms the basis of this report. Device failure occurred in 151 cases (8.34%), and minor complications occurred in 53 cases (2.93%). There were 11 hospitalizations (0.61%). AngioSeal had both the lowest device failure rate (3.5%) and minor complication rate (1.3%). Our data showed a significant difference between the respective arterial closure devices for device failure rate (P = 0.007) and minor complication rate (P = 0.049), but not for major complication rate (P = 0.199). No significant difference was observed between surgeons for device failure (P = 0.798), minor complication (P = 0.218), or major complication rate (P = 0.899). CONCLUSIONS: With the lowest device failure and minor complication rate, AngioSeal is a consistently well-performing arterial closure device in the office surgical suite setting.

Perioperative Serum Carcinoembryonic Antigen Ratio Is a Prognostic Indicator in Patients With Stage II Colorectal Cancer.

PURPOSE: The aim of this study was to evaluate whether the perioperative carcinoembryonic antigen (CEA) ratio could be used as a determinant for adjuvant therapy after curative surgery in stage II colorectal cancer. METHODS: Data for 119 patients with stage II colorectal cancer who underwent radical surgery between 2010 and 2013 were collected. The perioperative CEA ratio was defined as the postoperative/preoperative serum CEA level, and the patients were grouped according to their perioperative CEA ratios: high ratio (≥0.5) and low ratio (<0.5). Overall survival rates were calculated, and their prognostic significances were analyzed. RESULTS: The overall survival rates of the high and the low perioperative CEA groups were 68.2% and 86.8%, respectively (P = 0.033). In patients with normal preoperative CEA levels (<5 ng/mL), the high perioperative CEA ratio group showed a worse survival rate than the low perioperative CEA ratio group (71.7% vs. 100.0%, P = 0.007). In patients with high preoperative CEA levels (≥5 ng/mL), the high perioperative CEA ratio group showed a worse survival rate than the low perioperative CEA ratio group (33.3% vs. 75.0%, P = 0.036). In the multivariate analysis, perioperative CEA ratio (P = 0.046), age (P = 0.034), and venous invasion (P = 0.015) were independent prognostic factors for survival. CONCLUSION: The perioperative CEA ratio is a prognostic indicator for stage II colorectal cancer. Patients with normal preoperative serum CEA levels might also be considered for adjuvant therapy if their perioperative CEA ratios are higher than 0.5.

Predictive Factors Affecting the Clinical Course of Patients With Diverticulitis: Who Needs Hospital Management?

PURPOSE: The aim of this study is to determine the predictable factors that affect the clinical course, especially the hospital stay, the operation performed, and to determine factors that will be helpful in deciding whether in-hospital or outpatient treatment is appropriate. METHODS: We retrospectively collected medical data for patients who had been diagnosed with acute diverticulitis at Inje University Sanggye Paik Hospital between January and December 2016. In total, 117 patients were enrolled in this study. We examined clinical factors, including age, sex, body mass index, pain, body temperature, white blood cell count, C-reactive protein, nil per os (NPO) time, hospital duration, computed tomography (CT) findings, location of diverticulitis, operation performed, and presence of comorbidity (e.g., hypertension and diabetes mellitus). RESULTS: In the multivariate analysis, the statistically significant factor related with hospital duration was the presence of perforation on the CT scan (P < 0.001). Longer NPO time was related with pain score (>7) (P = 0.011). Operations were mainly performed in patients with left-sided colonic diverticulitis (P = 0.012). CONCLUSION: We suggest a perforation finding on the CT scan, a severe pain score at least above 7 on a numeric rating pain scale, and a left-sided lesion are absolute indications for in-hospital management.

Treatment outcomes and lessons learned from 5134 cases of outpatient office-based endovascular procedures in a vascular surgical practice.

Introduction The office-based endovascular facility has increased in number recently due in part to expedient patient experience. This study analyzed treatment outcomes of procedures performed in our office-based endovascular suite. Methods Treatment outcomes of 5134 consecutive procedures performed in our office-based endovascular suites from 2006 to 2013 were analyzed. Five sequential groups (group I-V) of 1000 consecutive interventions were compared with regard to technical success and treatment outcomes. Results Our patients included 2856 (56%) females and 2267 (44%) males. Procedures performed included diagnostic arteriogram, arterial interventions, venous interventions, dialysis access interventions, and venous catheter management, which were 1024 (19.9%), 1568 (30.6%), and 3073 (60.0%), 621(12.1%), and 354 (6.9%), respectively. The complication rates for group I, II, III, IV, and V were 3%, 1.5%, 1%, 1.1%, and 0.7%, respectively. The complication rate was higher in group I when compared to each of the remaining four groups ( p < 0.05). Nine patients (0.18%) died within the 30-day period following their procedures, and none were procedure related. Conclusions Endovascular procedure can be performed safely in an office-based facility with excellent outcomes. Lessons learned in establishing office-based endovascular suites with efforts to reduce procedural complications and optimize quality patient care are discussed.

Different Effects of Orbital Shear Stress on Vascular Endothelial Cells: Comparison with the Results of In Vivo Study with Rats.

PURPOSE: An attempt was made to characterize the orbital shear stress by comparing the effects of orbital shear stress on vascular endothelial cells (ECs) with the results of animal experiments. MATERIALS AND METHODS: In the laboratory study, cultured ECs of well were distinguished by center and periphery then exposed to orbital shear stress using an orbital shaker. In the animal study, arteriovenous (AV) fistulas were made at the right femoral arteries of Sprague-Dawley rats to increase the effect of the laminar flow. The condition of the stenosis was given on the left femoral arteries. The protein expression of inducible nitric oxide synthase (iNOS) and Akt phosphorylation were observed and compared. RESULTS: Under orbital shear stress, ECs showed an increase in iNOS protein expression and phosphorylation of Akt but most of the protein expressions derived from the periphery. When compared to the animal study, the increased expression of iNOS protein and phosphorylation of Akt were observed in the sample of AV fistula conditions and the iNOS protein expression was decreased in the stenosis conditions. CONCLUSION: Orbital shear stress did not show the characteristics of a pure turbulent shear force. By comparing the observation with the morphological changes of vascular ECs and site-specific protein expression on the results of animal experiments, uniform directional lamina shear stress forces were expressed at the periphery.

Comparison of compliance of adjuvant chemotherapy between laparoscopic and open surgery in patients with colon cancer.

PURPOSE: Many studies have shown that the completion of adjuvant chemotherapy improves the survival rate. Recently, laparoscopic surgery has been used to treat patients with colon cancer. We analyzed the relationship between the completion of adjuvant chemotherapy and the operation method. METHODS: We retrospectively analyzed the medical records of 147 patients diagnosed with colon cancer from January 1, 2009, to May 31, 2012. The numbers of patients who underwent laparoscopic and open surgery were 91 and 56, respectively. We analyzed the relationship between the operation method and various factors such as the completion rate of chemotherapy, the patient's age, gender, and physical activity, the postoperative hospital stay, the start time of chemotherapy, and the patient's body mass index (BMI), TNM stage, and type of health insurance. RESULTS: In the laparoscopic surgery group, the postoperative hospital stay (13.5 ± 14.82 days vs. 19.6 ± 11.38 days, P = 0.001) and start time of chemotherapy (17.7 ± 17.48 days vs. 23.0 ± 15.00 days, P = 0.044) were shorter, but the percent complete of chemotherapy (71/91 [78.0%] vs. 38/56 [67.8%], P = 0.121), and survival rate (88/91 [96.7%], 47/56 [83.9%], P = 0.007) were higher than they were in the open surgery group. Patients who were elderly, had a low BMI, and a high American Society of Anesthesiologists score were less likely to complete adjuvant chemotherapy than other patients were. CONCLUSION: Laparoscopic surgery shows a shorter postoperative hospital stay, a shorter start time of chemotherapy, and a higher survival rate. Laparoscopic surgery may be expected to increase compliance of chemotherapy and to improve survival rate.

Comparison of CVF (Cyclophosphamide+Vinorelbine+5-Fluorouracil) and CMF (Cyclophosphamide+Methotrexate+5-Fluorouracil) Adjuvant Chemotherapy in Early Breast Cancer.

PURPOSE: Our study aimed to evaluate the feasibility of adjuvant cyclophosphamide/vinorelbine/5-fluorourail (CVF) chemotherapy as an alternative to cyclophosphamide/methotrexate/5-fluorouracil (CMF) chemotherapy for treating early breast cancer. METHODS: One hundred and forty-nine patients were randomly assigned to CMF or CVF adjuvant chemotherapy for treating their early stage breast cancer between September 2000 and December 2007. The disease-free survival (DFS), the overall survival (OS), and the toxicity profiles of both groups were compared. RESULTS: Sixty-seven patients underwent CMF chemotherapy whereas 82 patients underwent CVF chemotherapy. The DFS and OS were 88 months (95% confidence interval [CI], 76-101 months) and 94 months (95% CI, 83-104 months), respectively for the CMF group, and 97 months (95% CI, 93-101 months), and 101 months (95% CI, 98-104 months), respectively for the CVF group. However, those survival gains of the CVF group were not statistically significant (p-value=0.069 for the DFS and 0.99 for the OS). The CVF group showed a favorable toxicity profile in terms of the grade 3/4 hematologic toxicities as compared to that of the CMF group. CONCLUSION: Clinical outcome of CVF chemotherapy was comparable to CMF with a favorable toxicity profiles. However, it is difficult to conclude the feasibility of CVF regimen because of small number of studied patients.

[A case of Chlamydia trachomatis peritonitis mimicking tuberculous peritonitis].

Lymphocytic ascites with low serum-ascites albumin gradient (SAAG) are observed mainly in tuberculous peritonitis, peritoneal carcinomatosis, and pancreatic disease. However, pelvic inflammatory disease (PID) induced generalized peritonitis causing diffuse ascites has been rarely described. We report a 26-year old female patient, who was diagnosed as generalized peritonitis with diffuse ascites due to Chlamydia trachomatis infection. Gynecologic examination did not show the clue of PID and in the analysis of ascites, low SAAG, predominant lymphocyte count and high level of adenosine deaminase were noted. Although the best impression was tuberculous peritonitis on the base of these findings, the laparoscopic finding was consistent with PID and the PCR for C. trachomatis infection in cervical swab was positive. This case suggests that C. trachomatis peritonitis should be considered as a rare cause of low SAAG and lymphocytic ascites in sexually active women and should be intensively evaluated including laparoscopic examination.

Comparison of 6 cycles versus 4 cycles of neoadjuvant epirubicin plus docetaxel chemotherapy in stages II and III breast cancer.

BACKGROUND: This phase III clinical study was designed to investigate whether 6 cycles of epirubicin plus docetaxel (ED) is more effective than 4 cycles of ED as neoadjuvant chemotherapy (NC) in patients with stage II or III breast cancer. PATIENTS AND METHODS: Women with breast cancer that had tumors larger than 3 cm were prospectively randomized to receive 4 or 6 cycles of epirubicin 75 mg/m(2) and docetaxel 75 mg/m(2) every 3 weeks. The primary end point was the clinical response to NC. RESULTS: A total of 176 patients were randomly assigned, and 150 patients were assessable for efficacy and toxicity. Groups were well balanced for clinicopathologic parameters. The median age was 42 years (range 30-58). Overall clinical response was observed in 72% with ED4 and 82% with ED6. pCR was observed in 11% with ED4 and in 24% with ED6 (p=0.047). 47% of the ED4 group underwent breast conserving surgery (BCS) whereas 58% of ED6 group underwent BCS. Grade 3/4 neutropenia was observed in 27% in ED4 and 31% in ED6. Febrile neutropenia occurred in 17% with ED4 and 19% with ED6. Grade 3 mucositis was observed in 8% with ED4 and in 6% with ED6. CONCLUSION: Six cycles of ED enhanced the rates of pCR and BCS compared with 4 cycles without increasing treatment-related toxicities.

Management of periprosthetic femoral fractures.

We followed up 37 periprosthetic fractures to assess the factors related to the outcomes and the loosening of prostheses. The average union time is 3.1 months (range, 2-6.2 months). The most common types were fractures around the stem tip and displaced (89.1%). In our study, the loosening rate (32.4%) was low compared with other reports. These might be due to the cementless stem, but the difference was not significant (P>.05). After management of the fracture with a plate, we noted 5 complications: 2 nonunion and 3 refractures. The causes of these complications were related to screw in the level of the stem tip. Therefore, in the management of fractures with plates, we do not recommend using a screw in the area of the stem tip but rather using a cerclage proximally and bone graft. If stem was unstable or stability was uncertain, and the arthroplasty did not function well previously, revision with a distal fluted stem showed an early bony union.