Incidentally Discovered Deep Neck Infection in a Septic Patient / 대한구급학회지

We incidentally discovered a case of deep neck infection during the treatment of a patient who presented with complaints of decreased consciousness, abdominal distension, and electrolyte imbalance. The patient had neither clinical symptoms nor radiologic findings indicative of deep neck infection; rather, the findings indicated intra-abdominal sepsis and adrenal crisis, for which the symptomatic treatment was provided. When the expected improvement was not observed, we retrospectively reviewed the patient's test records and discovered deep neck infection. Empiric parenteral antibiotic therapy and infection source control, as appropriate for this patient, were administered within 72 hours of hospital admission, without which the condition may have proved fatal. In this report we discuss the best approach for the management of unresolved infectious disease and review the clinical features of deep neck infection.

Use of video-assisted thoracoscopic surgery to retrieve a broken guidewire / 대한외과학회지

Subclavian venous catheterization was once widely used for volume resuscitation, emergency venous access, chemotherapy, parenteral nutrition, and hemodialysis. However, its use has drastically reduced recently because of life-threatening complications such as hemothorax, pneumothorax. In this case, a patient admitted for a scheduled operation underwent right subclavian venous catheterization for preoperative, intraoperative, and postoperative volume resuscitation and parenteral nutrition. The procedure was performed by an experienced senior resident. Despite detecting slight resistance during the guidewire insertion, the resident continued the procedure to the point of being unable to advance or remove it, then attempted to forcefully remove the guidewire, but it broke and became entrapped within the thorax. We tried to remove the guidewire through infraclavicular skin incision but failed. So video-assisted thoracoscopic surgery was used to remove the broken guidewire. This incident demonstrates the risks of subclavian venous catheterization and the importance of using a proper and gentle technique.

Pinch-off syndrome / 대한외과학회지

Subclavian venous catheterization was previously frequently performed, but because of life-threatening complications such as hemothorax, pneumothorax, mediastinal hematoma, and myocardial injury, its use has become less common. However, this practice has some advantages in patient mobility, secured dressing, and rapidity and adequacy of vascular access. In some situations where patient comfort is an especially important consideration, such as with totally implantable venous port insertion for chemotherapy, the subclavian route can be a good choice if an experienced and well-trained faculty is available. The authors have had recent experience with pinch-off syndrome-in other words, spontaneous catheter fracture-in 3 patients who had undergone venous port implantation through the right subclavian route. Through these cases, we intend to review the dangers of subclavian venous catheterization, the causes of pinch-off syndrome, and its clinical presentation, progress, treatments, and prevention.

The Clinical Significance of Scored CT Findings for Pre-operative Prediction of Lateral Cervical Lymph Node Metastasis in Thyroid Cancer / 대한내분비외과학회지

PURPOSE: Although ultrasound is routinely used for pre-operative evaluation of neck nodes in patients with papillary thyroid carcinoma, CT is also widely used. We designed a prediction score of lateral cervical lymph node metastasis (PSLCNM) for improving diagnostic ability of CT. The purpose of our study was to determine the clinical significance of the PSLCNM. METHODS: A total of 124 patients with thyroid carcinoma who underwent surgery of lateral cervical lymph node dissection after pre-operative CT evaluation were enrolled in this study. We retrospectively evaluated the diagnostic ability between CT findings by one radiologist and PSLCNM for prediction of lateral lymph node metastasis. RESULTS: In terms of predicting lateral cervical node metastasis, the positive predictive value of CT findings of indeterminate, suspicious, or metastatic nodes were 37.5% (21/56), 68.3% (28/41), 85.7% (18/21). Those of 1, 2, 3, 4 in sum of PSLCNM were 34% (16/47), 60% (30/50), 91% (10/11), 100% (10/10). CONCLUSION: Prediction of lateral cervical node metastasis using PSLCNM showed a better result than conventional CT findings and could decrease unnecessary surgical procedures and postoperative complications in the surgery of thyroid cancer.

Analysis of Postoperative Pathological Findings of Graves' Disease / 대한내분비외과학회지

PURPOSE: The diagnosis of Graves' disease can be clinically made by the findings of hyperthyroidism combined with eye signs or a diffusely enlarged goiter. The pathological findings of Graves' disease are hypertrophy and hyperplasia of the thyroid follicles. Surgical treatment for Graves' disease is indicated for patients with a suspicion of cancer, a large goiter, medical failure, patient preference or severe ophthalmopathy. The aim of this study is to determine the diagnostic accuracy of clinically diagnosed Graves' disease on the basis of the postoperative pathologic findings. METHODS: We performed a retrospective analysis of the medical records of the patients who were diagnosed as having Graves' disease since Jan 2000 at St. Mary's Hospital, The Catholic University of Korea. To confirm the pathological findings in this study, the patients who underwent surgical treatment were enrolled, and their preoperative diagnostic tests were also reviewed. RESULTS: A total of 57 patients with Graves' disease underwent surgery due to medical failure in 45 (78.9%), ophthalmopathy in 25 (43.8%), huge goiter in 4 (7%), suspicion of cancer in 4 (7%), and others in 4 (7%). Thirty nine (68.4%) patients were female and total thyroidectomies were performed in 52 (91.2%) patients. The pathological reports of the thyroid specimens showed diffuse hyperplasia in 53 (92.9%), nodular hyperplasia in 2 (3.5%), Lymphocytic thyroiditis in 1 (1.8%) and Hashimoto's thyroiditis in 1 (1.8%). The diagnostic accuracy of preoperative antimicrosomal Ab, anti-TSHR Ab and a technetium 99m thyroid scan was 73.8%, 86.0% and 69.7%, respectively. Papillary carcinoma was identified in 6 patients (10.5%). CONCLUSION: The microscopic findings of 5 patients (7.0%) who were diagnosed clinically as having Graves' disease were not compatible with the criteria for a pathological diagnosis. Surgical treatment and confirmation of the exact pathology should be performed for the appropriate treatment.

Clinical Analysis of Endoscopic Thyroidectomy by the Axillary Approach for Papillary Thyroid Microcarcinoma / 대한내시경복강경외과학회지

PURPOSE: The aim of this study is to evaluate the feasibility and surgical outcomes of endoscopic thyroidectomy by the axillary approach for treating papillary thyroid microcarcinoma (PTMC). METHODS: We analyzed 56 patients who underwent endoscopic thyroidectomy by the axillary approach for treating PTMC between May 2002 and October 2008 at Bucheon ST hospital. We evaluated the operation type, the tumor size, the operative time, the hospital days, the number of retrieved lymph nodes and the complications. RESULTS: All the patients except one were women. The mean age was 40.5+/-8.7 years. All the procedure was performed by one surgeon and endoscopic thyroidectomy was done by the axillary approach. There was no conversion to open surgery. The type of operation was classified according to the extent of the surgery. The mean operative time for lobectomy and isthmectomy with CLND (24 cases) and total thyroidectomy with CLND (5 cases) was 142.5+/-40 minutes and 270+/-84.3 minutes, respectively. The mean tumor size was 0.66+/-0.46 cm. The mean number of retrieved lymph nodes was 3.7+/-2.4. The mean number of hospital days was 3.7+/-1.4 days. There were no serious complications. There were no tumor recurrence and the mean follow-up was 50.7 months. All the patients were satisfied with the cosmetic results. CONCLUSION: Endoscopic thyroidectomy by the axillary approach for PTMC is feasible and safe. Although a larger series and longer follow up are necessary, endoscopic thyroidectomy can be a alternative treatment method for selected patients with PTMC.

Laparoscopic Appendectomy with a Single Incision in a Single Institute

PURPOSE: The laparoscopic appendectomy has become popular for the treatment of acute appendicitis. A single-incision laparoscopic appendectomy offers better cosmesis. We present the results of single-incision laparoscopic appendectomies in our hospital as initial experience. METHODS: A single-incision laparoscopic appendectomy was performed in 75 patients at The Catholic University of Korea, Bucheon St. Mary's hospital. The operating time, operation type, hospital stay, surgical morbidities, and body mass index were compared. RESULTS: This retrospective study revealed equal operation times in both the suppurative and the perforated appendicitis group. There was an increase in the hospital stay in the perforated appendicitis group. The postoperative complication rate was 4%, and the median operation time was 58.55 +/- 31.79 minutes. CONCLUSION: The single-incision laparoscopic appendectomy was easy and safe procedure for treating acute appendicitis. There were no differences in degree of inflammation and body mass index.

Analysis of the Korean Cases of Nonrecurrent Laryngeal Nerve / 대한내분비외과학회지

PURPOSE: This study was performed to readjust the clinical implications of a nonrecurrent laryngeal nerve by assessing the reported Korean cases of a nonrecurrent laryngeal nerve. METHODS: We analyzed the cases of nonrecurrent laryngeal nerve that have been reported in Korea between 1997 and 2008 by reviewing the literature. An internet search was conducted in the NDSL (National Digital Science Library) and the Korean Medical Database. RESULTS: The data included 3 men and 25 women with an average age of 45.1 (age range: 28~58). All the cases were right-sided, and the incidence rate was 0.38% and 0.86% in two articles, respectively. There was a type I variation in 4 cases (17.4%), type IIa in 19 cases (82.6%), and the others are unknown. Twenty-five cases (89.3%) had the vascular anomaly called arteria lusoria. Only 8 cases (28.6%) were preoperatively predicted as possibly having a nonrecurrent laryngeal nerve. Iatrogenic nerve injury developed in 1 case (3.57%) with a type I variation during the postoperative period. CONCLUSION: A similar tendency for the incidence rate, the genderratio, the type distribution and vascular anomaly was observed when comparing the Korean reports with those reports of overseas. The nonrecurrent laryngeal nerve can be preoperatively predicted if proper attention is given when vascular anomaly is noted on CT or USG, and injury will be avoided by intraoperatively following the standard operation technique. There is currently an increasing incidence of thyroid diseases, and so adequate attention must be given to the possibility of a nonrecurrent laryngeal nerve and its management.

Synchronous Carcinoma Showing Thymus-like Elements (CASTLE) of the Thyroid Combined with Rectal Carcinoma: Report of a Case and Review of the Literature / 대한내분비외과학회지

Carcinoma showing thymus-like elements (CASTLE) is a rare neoplasm arising from the thyroid gland. This tumor is thought to originate from ectopic thymic tissue or remnants related to thymic development in or adjacent to the thyroid gland and usually located in the lower two-thirds of the thyroid gland. The patient was a 66-year-old man admitted to our hospital with rectal carcinoma for surgery. He had undergone a right upper lobectomy of the lung for the pulmonary tuberculosis 35 years previously. He underwent a chest computed tomography (CT) pre-operatively, and an incidental nodule of the thyroid gland was detected. Based on aspiration cytology of the nodule, the lesion was suspected to be an anaplastic carcinoma. He underwent a low anterior resection and thyroid lobectomy for a double primary neoplasm. On the final pathologic examination, the thyroid lesion was shown to be CASTLE. Therefore, completion thyroidectomy with lymph node dissection of the central compartment and radiotherapy were performed, and there was no evidence of recurrence 15 months postoperatively.

Safety of the Completion Thyroidectomy in the Management of Well-Differentiated Thyroid Carcinoma

PURPOSE: Completion thyroidectomy is the removal of any thyroid tissue that remains after less than total thyroidectomy. The purpose of the present study is to review the processes and pathologic results leading to completion thyroidectomy, and to determine the degree of increased morbidity with completion thyroidectomy. METHODS: The hospital records of 60 patients treated from January 1981 to December 2000 were retrospectively reviewed. RESULTS: The subjects were 48 women and 12 men with ages ranging from 17 to 72 years (mean 46.3 years). Initial pathologic results were 46 cases of papillary carcinoma (76.6%), 12 of follicular carcinoma (20%), one of medullary carcinoma and one of Hurthle cell carcinoma. Initial operations were lobectomy in 51 cases, bilateral subtotal thyroidectomy in 6 and enucleation in 3. Completion thyroidectomies were performed due to tumor recurrence in 32 cases, confirmed malignancy following permanent sections in 21 and others in 7. Twenty-one of the cases were performed within 6 months after initial operations. Residual or recurrent carcinoma was found in 36 cases of the completion thyroidectomy specimens (60%). Postoperative complications were as follows: transient and permanent recurrent laryngeal nerve palsy occurred in 1 (1.7%) and 2 (3.3%) cases, respectively, transient and permanent hypoparathyroidism occurred separately in 15 (25%) and 4 (6.7%) cases, respectively, and there was one case of hematoma (1.7%) and one of wound infection (1.7%). There was no correlation between complications and the interval between initial surgery and reoperation. CONCLUSION: Completion thyroidectomy could be performed with minimal morbidity and might prevent the development of regional recurrence by eliminating an unsuspected focus of cancer. The surgeon should not feel obligated to perform a total thyroidectomy if the diagnosis of cancer is not secure, because the second stage operation can be performed over a wide time interval, allowing the physician and patient considerable latitude for decision making.

A Clinical Review of 332 Cases of Total Thyroidectomy / 대한내분비외과학회지

PURPOSE: Although has become increasingly acceptable to perform total thyroidectomy for bilateral and multiple benign nodules, diffuse toxic goiter, and thyroid cancers, surgeons continue to debate whether the potential benefits outweigh the potential complications of this procedure. The aim of this study was to evaluate the safety, effectiveness and complications of total thyroidectomy for malignant and benign thyroid diseases. METHODS: The medical records from 332 patients who had undergone total thyroidectomy for malignant and benign diseases between January 1990 and December 1999 at St. Mary's Hospital and St. Vincent's Hospital were reviewed retrospectively. RESULTS: Of the 332 patients, 121 had had benign disease and 211 had had carcinomas. Female patients were predominate, being 6.4 times the number of males. The incidence rate by age peaked in the 4th decade for patients. Masses of below 2 cm in diameter were the second most common size (30.8%) and 2 to 5 cm occupied more than half (51%). Of the 211 thyroid carcinomas, histologic types were papillary in 185 patients (87.7%), follicular in 21 (10%), anaplastic in 3 (1.5%), medullary in 1 (0.5%) and lymphoma in 1 (0.5%). Of the 121 benign disease, 71 (58.7%) were benign multiple nodular goiters, 23 (19%) toxic diffuse goiter, and there were 18 cases (14.9%) of Hashimoto thyroiditis and 9 (7.4%) of adenomatous goiter. Among the 211 patients who underwent total thyroidectomy for thyroid malignancy, anterior compartment lymph node dissection was performed in 53 patients (25.1%). Modified radical neck dissection was done in 31 cases, due to suspicions of local lymph node invasion during the operation. Radical neck dissection was done in 10 cases with palpable cervical nodes. The most common complication was early postoperative hypocalcemia 108 (32.5%), most of which was transient and sixty-three percent of which was symptomatic. It usually persisted less than 7 days, and the difference in incidence of post-operative hypocalcemia between benign disease and malignancy was not significant. The other complications were hoarseness (13%), bleeding (3%) and the recurrent laryngeal nerve injury (1.5%). CONCLUSION: Total thyroidectomy can be performed without additional risk compared with subtotal thyroidectomy for bilateral benign and malignant thyroid diseases, if done meticulously.

Superior Lumbar Hernia: A case report

A lumbar hernia is a rare clinical disease entity which arises from the superior or the inferior lumbar triangle. The causes are congenital, traumatic, previous operation, and so on, but spontaneous occurrence is also encountered. We had a occasion to treat a 34-year-old female patient with a left superior lumbar hernia filled with retroperitoneal fats in a sac. The relatively large defect of the transversalis fascia was repaired with a PTFE (polytetrafluoroethylene) graft and an overlying approximation of external oblique and latissimus dorsi muscle. We report on this case with a brief review of the literature.

Superior Lumbar Hernia: A case report

A lumbar hernia is a rare clinical disease entity which arises from the superior or the inferior lumbar triangle. The causes are congenital, traumatic, previous operation, and so on, but spontaneous occurrence is also encountered. We had a occasion to treat a 34-year-old female patient with a left superior lumbar hernia filled with retroperitoneal fats in a sac. The relatively large defect of the transversalis fascia was repaired with a PTFE (polytetrafluoroethylene) graft and an overlying approximation of external oblique and latissimus dorsi muscle. We report on this case with a brief review of the literature.

Plasma Fibronectin Levels in Patients with Psoriasis / 대한피부과학회지

Fibronectin(FN) is a physiologic glycoprotein presenton cell surface and in connective tissue, extracellular matrix and plasma. Increased plasma FN levels have been reported in the patients with psoriasis, connective tissue disease, internal malignancy, squamous cell carcinoma and basal cell carcinoma. The author investigated the plasma FN levels in 30 patients (males 13, female 17) with psoriasis and 23 healthy subjects (male 13, female 10) by gelatin sepharose 4B affinity chromatography and Laurells rocket immunoelectrophoresis method. The results were as follows : Plasrna JN levels were 450.4+/-80.3pg/ml in the patients with psoriasis and 334.0-51.3pg/ml in healthy subjects. There was no relationship between age graups and sex. Plasrna FN levels in the patients with psoriasis were higher than those of healthy subjects(p<0.001). There was no relationship between the levels of plasma FN and clinical severity of psoriasis.

A Case of Verruca Vulgaris Treated with Etretinate ( Tigason R ) / 대한피부과학회지

Etretinate is a synthetic retinoic acid which has been reported effective in hyperkeratotic disorders. Recently, it has also been tried, on a limited number, for the treatment of viral wart. A 33-year-old male patient presented with multiple, tender, confluent, verrucous lesions on the scalp, both hands and feet of 4 years duration. Before coming to us, he had been treated with intralesional injection of bleomycin and electrodesiccation with little effect. We started etretinate therapy in a daily dose of 70mg(1mg /kg). After 3 weeks treatment, most of his skin lesions were flattened and softened: but an abrupt elevation of serum aminotransferases was noticed, which was normalized soon after cessation of medication. Unfortunately, the drug stop page aggravated most of skin lesions. After two weeks of withdrawal we started again the drug in a daily dose of 30mg and observed a good response without hepatic dysfunction.

A Statistical Review of Benign Tumors of the Skin for the Past 10 Years / 대한피부과학회지

We have reviewed the 503 cases of benign skin tumors which were confirmed by histopathological study from January 1977 to July 1987 in the Dermatologic Department of Kyungpook National University Hospital. The result were summarized as follows . l. Among the total of 26,690 dermatologic out patients, 503 cases(1.9%) were diagnosed as having benign skin tumors. The number of benign skin tumors has shown a noticeable increase in the last several years. 2. The tumors were found mainly in ages ranging from the 2nd to 5th decade, most commonly in the 3rd decade(124 cases, 24.7%). 3. Aceording to Lever's elasaification, the tumors were divided into the following 7 groupa . tumors and cyets of the epidermis(35.2%), melanocytic tumors(16.5%), tumors of vaecular tissues(13.3%), tumora of epidermal appendages(11.1%), tumors of fibrous tissue(8.9%), tumors of neura.l tiasue(7.6%) and tumors of fatty, muscular and osseous tiseue(7.4%) in decreasing orders. 4. The 14 common tumors in order of frequency were as follows epidermal cyst (17.l% ),:melanocytic nevus(16.5%), neurofibroma(7.6%), congenital hemangioma(6.4%), nevus sebaceous(6.0%), lipoma(5.2%),seborrheic keratosis(4,8%), linear epidermal nevus(4.6%), steatocystoma mutiplex(2.8%), dermatofibroma(2.6%), hypertrophic scar and keloid.(2.6%), granuloma pyogenicum(2.4% ), keratoacanthoma(2.0%) and syringoma (2,0%). 5. The predilection sites of seborrheic keratosis, keratoacanthoma, syringoma and melanocytic nevus were the face, linear epidermal nevus, dermatofibroma and granuloma pyogenicum were located on the extremities. 6. The duration of tumors from the presumed time of onset to the first visit was within 1 year for epidermal cyst, keratoacanthoma and granuloma pyogenicum, over 10 years for nevus sebaceous, congenital emangioma and neurofibroma. 7. Diagnostic accuracy was higher in melanocytic nevus, congential hemangioma, nevus sebaceous and neurofibroma and lower in steatocystoma multiplex, dermatofibroma, keratoacanthoma, lipoma and epidermal cyst.