The Potential Role of Presepsin in Predicting Severe Infection in Patients with Diabetic Foot Ulcers.

Background/Objectives: Diabetic foot ulcers are one of the complications in patients with diabetes, which can be caused by infection, neuropathy, and blood vessel disorder. Among them, infection is the most common cause, and if it becomes worse, amputation may be necessary. So, it is important to detect and treat infections early, and determining indicators that can confirm infection is also important. Known infection markers include white blood cells (WBCs), the erythrocyte sediment rate (ESR), C-reactive protein (CRP), and procalcitonin, but they are not specific to diabetic foot ulcers. Presepsin, also known as soluble CD14, is known to be an early indicator of sepsis. Recent studies have reported that presepsin can be used as an early indicator of infection. This study investigated whether presepsin could be used as an early marker of severe infection in patients with diabetic foot ulcers. Methods: We retrospectively studied 73 patients who were treated for diabetic foot ulcerations from January 2021 to June 2023 at Yeungnam University Hospital. Results: Out of a total of 73 patients, 46 patients underwent amputations with severe infections, and the WBC level, ESR, and CRP, procalcitonin, and presepsin levels were significantly higher in the group of patients who underwent amputations. The cutoff of presepsin, which can predict serious infections that need amputation, was 675 ng/mL. A regression analysis confirmed that presepsin, HbA1c, and osteomyelitis significantly increased the risk of severe infections requiring amputation. Conclusions: Presepsin will be available as an early predictor of patients with severe infections requiring amputations for diabetic foot ulcerations.

Predictive Factors of Severe Dissection after Balloon Angioplasty for Femoropopliteal Artery Disease.

BACKGROUND: Arterial dissection is one of the mechanisms of balloon angioplasty. Although some degree of dissection is unavoidable, severe dissection that impedes blood flow decreases patency and increases the need for additional procedures. To improve the results of angioplasty, it is necessary to understand the factors related to severe dissection and make efforts to reduce its occurrence. This study aimed to elucidate the predictive and protective factors associated with severe dissection in femoropopliteal balloon angioplasty. METHODS: This was a retrospective, single-center, nonrandomized study. A total of 409 limbs were studied in 334 patients with symptomatic femoropopliteal lesions treated between 2010 and 2019. Dissections after initial balloon angioplasty were classified according to the Kobayashi dissection classification (grade A: no dissection; B: mild dissection <1/3 of the lumen; C: severe dissection, ≥1/3 of the lumen) into the nonsevere dissection group (grades A and B), and severe dissection group (grade C). We compared clinical, procedural and lesion-related characteristics between the 2 groups. Factors with statistical significance in univariate analyses were entered into a multivariate logistic regression model to identify independent predictive factors of severe dissection. RESULTS: Severe dissection occurred in 237 limbs and nonsevere dissection in 172 limbs. In univariate analyses, the predictive factors of severe dissection were TransAtlantic Inter-Society Consensus II C/D grades (P < 0.001), lesion length ≥15cm (P < 0.001), chronic total occlusion (P = 0.004), and degree of stenosis ≥70% (P < 0.001). Protective factors for severe dissection were end-stage renal disease (P = 0.008), severe calcification >50% (P < 0.001), and the use of a scoring balloon (P = 0.001). In multivariate analysis, factors associated with severe dissection were lesion length ≥15cm (OR, 2.259; 95% CI: 1.417-4-3.601), occlusion or degree of stenosis ≥70% (OR, 1.931; 95% CI: 1.255-2.971), severe calcification (OR, 0.520; 95% CI: 0.338-0.800), and the use of a scoring balloon (OR, 0.467; 95% CI: 0.263-0.830). CONCLUSIONS: Lesion length ≥15cm and occlusion or stenosis ≥70% were identified as independent predictive factors of severe dissection in femoropopliteal artery balloon angioplasty. Conversely, severe calcification and the use of a scoring balloon appeared to be protective factors against severe dissection.

Scoring Balloon Reduces the Severity of Dissection and Stent Implantation Rate in Superficial Femoral Artery Angioplasty Compared to Plain Balloon.

PURPOSE: The knowledge regarding the benefits of the scoring balloon (SB) in comparison to the plain balloon (PB) is limited. This study aims to elucidate the difference in efficacy between SB and PB as pre-balloon in superficial femoral artery angioplasty. METHODS: We retrospectively analyzed angiographic images of 113 lesions in 98 patients treated with endovascular surgery. 37 lesions were prepared by SB and 76 lesions by PB. Lesions without significant residual stenosis nor a flow-limiting dissection were treated by drug-coated balloon and the others by drug-eluting stent. Severity of dissection was evaluated by Kobayashi dissection grade and NHLBI classification. The rate of stent implantation was compared between the 2 groups. Kaplan-Meier analysis estimated freedom from target lesion revascularization (TLR) rate at 12 months. RESULTS: Severe dissections (>1/3 of lumen) occurred less frequently in the SB group (SB 40.5% vs. PB 75.0%, P = 0.001). Overall stent implantation rate was lower in the SB group (SB 27.0% vs. PB 55.3%, P = 0.005). In subgroup analysis for the complex lesions, the SB group had lower rate of severe dissection(>1/3 of lumen) in patients with long lesions(>15 cm) (SB 51.7% vs. PB 76.9%, P = 0.020) and lesions of calcium grade ≥2 (SB 43.8% vs. PB 72.5%, P = 0.009). SB group had lower stent implantation rate in patients with long lesions (SB 34.5% vs. PB 59.6%, P = 0.030), lesions of calcium grade ≥2 (SB 31.3% vs. PB 56.9%, P = 0.023), and total occlusion (SB 30.8% vs. PB 80.0%, P = 0.002). There were no procedure-related complications in either group except 1 case of puncture-site hematoma. There was no significant difference in TLR rate between both groups at 12 months (P = 0.509). CONCLUSION: SB reduces the incidence of severe dissection (>1/3 of lumen) and rate of overall stent implantation in comparison with PB. The use of SB is a safe and effective method of lesion preparation in SFA angioplasty.

Clinical Correlates of Frontal Intermittent Rhythmic Delta Activity Without Structural Brain Lesion.

Frontal intermittent rhythmic delta activity (FIRDA), rhythmic slow wave pattern lasting several seconds over the anterior leads of electroencephalography (EEG), has been reported in a wide variety of clinical conditions. We investigated the clinical significance of FIRDA without structural brain lesions. We reviewed 7689 EEGs between October 2017 and September 2019 at a university hospital. Patients (age >18 years) who were confirmed to have "nonsignificant neuroimaging" were examined. Clinical data were retrospectively collected, and the estimated cause was carefully decided. We found 83 FIRDA among 7689 EEGs (1.08%). After patients with any structural lesion identified on neuroimaging were excluded, 37 FIRDAs were reviewed. There were 20 (51.35%) patients of metabolic encephalopathy. Six patients showed FIRDA due to neurodegenerative disease (16.21%). In addition, we found 6 (16.21%) of neurodegenerative disease and 5 (13.51%) of hypoxic encephalopathy (cardiac arrest). Four (16.21%) patients were related to systemic infection (10.81%), whereas 2 were related to encephalitis (5.40%). We demonstrated several potential etiologies, including metabolic encephalopathy, neurodegenerative disease, hypoxic encephalopathy, and infections, which should be considered in the case of FIRDA without structural brain lesions.

Wound outcomes and factors associated with wound healing after first-time femoropopliteal artery intervention in patients with ischemic tissue loss.

BACKGROUND/OBJECTIVE: This study's goal is to describe wound outcomes at 2 years following intervention for atherosclerotic femoropopliteal lesions in patients with ischemic tissue loss. METHODS: A retrospective review of 135 first-time endovascular procedures for chronic femoropopliteal atherosclerotic lesions related to ischemic tissue loss was performed. The final wound outcomes were categorized according to the initial wound healing, recurrence and the need of major/minor amputation. RESULTS: At 2-years of follow up, 76 limbs (56.3%) showed complete wound healing without recurrence, however, wound development occurred at other sites on the same foot following complete primary healing in 11 limbs (8.1%). Tolerable wounds persisted or wounds recurred at the same site in 30 limbs (22.2%), and 18 limbs (13.3%) needed major amputations. Independent factors that prevented wound healing without recurrence at 2 years were renal insufficiency (HR = 0.225, 95% C.I. = 0.091-0.556, p = 0.001), ankle pressure < 50 mmHg or flat forefoot PVR (HR = 0.328, 95% C.I. = 0.124-0.867, p = 0.025) and functional performance < 4 metabolic equivalents (MET) (HR = 0.150, 95% C.I. = 0.063-0.360, p < 0.001). CONCLUSION: Wound outcome classifications showed detailed information regarding clinical outcomes in patients with ischemic tissue loss. Renal insufficiency, ischemia grade 3 and poor functional performance were independent risk factors that prevented wound healing.

Effect of Opt-out System for Organ Donation After Brain Death on Ethical Legitimacy and Potential Efficacy in a Mathematical Model.

OBJECTIVES: We aimed to compare the possible outcomes of the current (opt-in) system and an opt-out system for organ donation in South Korea using a mathematical model. MATERIALS AND METHODS: A structured questionnaire was used to investigate the decision on organ donation and family consent after brain death under the current system and an opt-out system. The survey was conducted in August 2018 by means of a voluntary survey of 100 opposite-sex married couples. RESULTS: Sixty-three percent of participants wished to self-donate their organs after brain death: 69.5% were positive and 30.5% were negative regarding the implementation of the opt-out system. Among 200 participants, the total number of possible donors increased from 110 (55.0%) in the current system to 139 (69.5%) in the opt-out system. Positive autonomy was defined as obtainment of consent from the donor and the spouse, and negative autonomy was defined as concordaence of refusal between the donor and the spouse. Comparisons between the systems showed that the rate of autonomy increased from 57.0% in the current system to 61.5% in the opt-out system. Although the achievement of positive autonomy increased from 59.5% in the current system to 74.6% in the opt-out system, the achievement of negative autonomy decreased from 52.7% in the current system to 39.2% in the opt-out system. CONCLUSIONS: An opt-out system can increase the number of organ donors; however, achievement of negative autonomy can decrease.

The Effect of Severe Femoropopliteal Arterial Calcification on the Treatment Outcome of Femoropopliteal Intervention in Patients with Ischemic Tissue Loss.

PURPOSE: We investigated the effect of severe calcification of the femoropopliteal artery on intervention outcomes in patients with ischemic tissue loss. MATERIALS AND METHODS: A retrospective review of the first endovascular treatment of the femoropopliteal artery for ischemic tissue loss between May 2010 and February 2018 was performed. The calcification of femoropopliteal lesions was estimated by the Compliance 360° score, and lesions with a score of 4 were defined as severe calcification lesions. RESULTS: Overall, 135 first femoropopliteal endovascular procedures on 135 limbs from 112 patients were included in this study. Among the 135 limbs that received treatement of the femoropopliteal arteries, 74 limbs had Trans-Atlantic Inter Society Consensus (TASC) A or B lesions and 61 limbs had TASC C or D lesions. Among 61 cases of TASC C or D lesions, 21 limbs (34.4%) had severe calcification; there was no statistically significant difference in limb salvage (P=0.75), and amputation-free survival (P=0.11) based on the degree of calcification. However, the survival rate in TASC C or D lesions was significantly different between the two groups (non-severe calcification group vs severe calcification group at 1-year, 2-years, and 3-years: 88.6%, 79.7%, and 61.0% vs 70.0%, 56.0%, and 28.0%, respectively, P=0.01). In multivariate analysis of influencing factors for poor survival in TASC C or D using the Cox proportional hazards model, severe calcification (hazard ratio, 2.362; 95% confidence interval, 1.035-5.391; P=0.041) was a statistically significant risk factor. CONCLUSION: Severe femoropopliteal artery calcification was associated with poor survival, especially in TASC C or D lesions.

The effect of a mandatory choice systemfor organ donation after brain death onethical legitimacy and potential efficacyin a mathematical model.

Background: The "mandatory choice" system is an organ donation system that forces individuals to clearly express their choice about organ donation. Although this system is widely practiced in western countries, it has not yet been implemented in many Asian countries. This study aimed to compare the possible outcomes of a mandatory choice system and the current system in Korea. Methods: A mathematical model was used to predict outcomes under each system. A structured questionnaire assuming two systems (current opt-in and mandatory choice) was developed to investigate participants' decisions on organ donation and the family's consent after brain death in each system. Participants who enrolled in this survey were 100 couples (200 people). Results: The total number of donors decreased slightly from 102 (51.0%) in the current opt-in system to 93 (46.5%) in the mandatory choice system. The rate of achieving autonomy was increased from 62.5% (125/200) in the current system to 68.0% (136/200) in the mandatory choice system. The achievement of negative autonomy was relatively higher in the mandatory choice system (73.6% [67/91] vs. 63.2% [55/87]). Conclusions: The mandatory choice system can supplement the weak ethical point of the current system by increasing the achievement of autonomy.

The Mass Infection of COVID-19 in Daegu City of Korea: Vascular Surgeons' Perspective.

Since February 18, 2020, the number of patients with COVID-19 has increased rapidly after the infection was initially confirmed in Daegu. Daegu city subsequently became the largest epicenter of the coronavirus outside China. In the early days of the outbreak of mass infection, Daegu citizens were in various difficult circumstances. Vascular surgery in Daegu was also affected as much as other medical field. Most of elective schedule were canceled, and the vascular surgeons cooperated to utilize the limited medical resources in Daegu region. Fortunately, the citizens of Daegu city could overcome the first crisis because of matured citizenship, sufficient medical resources and the timely-supplied surplus bed for patient isolation. Now all humanity today is interdependent and we are all one community in the pandemic. To overcome pandemic, it is necessary to respect and share experiences in various places at the beginning of the crisis.

Survey for the Opinion of Medical Students and Medical Staff on a Financial Incentive System for Deceased Organ Donation in an Asian Country.

BACKGROUND: Financial incentives for deceased organ donation are associated with many controversial ethical issues. This study examines the perspectives of medical students and staff members on financial incentives for the families of brain-dead organ donors. METHODOLOGY: A structured survey form was used between December 7, 2017 and January 28, 2018 to elicit opinions on financial incentives for the families of brain-dead organ donors. Forty-three medical staff members and 81 medical students participated in the survey voluntarily. The opinions on the financial incentive system and the relationship between willingness to give information about organ donation to families and a financial incentive system were assessed. RESULTS: The majority of the participants (81.4%) had positive thoughts on organ donation. More than half of the participants (60.5%) thought that the financial incentive system did not erode the ethical purity of organ donation. As charge doctors, most respondents (84.6%) were willing to give information about organ donation to family members in the presence of financial incentives. However, the percentage decreased significantly to 60.5% when financial incentive was no longer factored into consideration (P < .001). LIMITATION: The study population is small, and the participants are not representative of the general population. CONCLUSION: The opinions of medical students and medical staff on financial incentives for deceased organ donation were generally positive. Financial incentives proved to be a potential influencing factor as an option of organ donation to be given to families.

Arterial Aneurysmal Degeneration With Venous Varicosity Following Ligation of an Arteriovenous Fistula in a Kidney Transplant Recipient.

Late occurrence of arterial aneurysms following ligation of a hemodialysis arteriovenous fistula (AVF) is rare. Here, we report the case of 51-year-old male patient with an AVF in which arterial aneurysms developed. The patient had undergone left arm radiocephalic (RC) AVF creation for hemodialysis in 2000. He had received a living related donor kidney transplantation from his father in the same year. His RC AVF was ligated in 2009. However, his arm continued to gradually grow in size even after ligation and he visited a hospital for acute pain and erythema around the left elbow in 2017. Since his renal allograft function had been deteriorating, duplex ultrasonography was performed. It revealed 2 giant aneurysms in the distal brachial artery and proximal radial artery with diameters of 3.0 and 2.8 cm, respectively. The superficial veins of the left upper arm showed varicosity and had multifocal thrombi. Microfistula between the artery and vein was revealed by contrast-enhanced ultrasonography and the contrast agent microbubbles flowed from the artery toward the superficial veins. The aneurysms were resected and the arteries were reconstructed with great saphenous vein. There were no perioperative complications and the patient was discharged on postoperative day 3. No complications in the arm or bypass conduit have occurred at 6 months after the surgery.

Effects of phased education on attitudes toward organ donation and willingness to donate after brain death in an Asian country.

BACKGROUND/OBJECTIVE: This study aims to investigate the effects of phased education on attitudes toward organ donation and willingness to donate after brain death. METHODS: A survey was conducted using a questionnaire to examine attitudes toward organ donation of the families of patients admitted to a surgical intensive care unit (SICU) between March 1, 2014 and September 30, 2016. RESULTS: Ninety-two people voluntarily participated in this survey. Before reviewing the educational material, 75.0% had a positive attitude toward organ donation, 60.9% were willing to donate their own organs, and 38.0% were willing to donate a family member's organs. After reviewing the educational material, these figures increased to 92.4%, 80.4%, and 56.5%, respectively. Before receiving an education, there was a significant difference in consistency between people's attitudes and willingness to donate their own organs, versus donating a family member's organs (79.3% vs 54.3%, p < 0.001). With phased education, these percentages increased from 79.3% to 85.9% with regard to donating one's own organs, and from 54.3% to 64.1% with regard to donating a family member's organs. CONCLUSION: Phased education was effective overall, but it had a limited effect on changing the willingness to donate a family member's organs. It increased the consistency between people's attitudes toward organ donation and willingness to donate their own, or a family member's organs.

Factors affecting outcomes after endovascular treatment for femoropopliteal atherosclerotic lesions.

BACKGROUND/OBJECTIVE: This study aimed to investigate the outcomes of femoropopliteal interventions in relation to various influencing factors. METHODS: A retrospective review of 243 endovascular procedures for femoropopliteal atherosclerotic lesions on 243 limbs of 197 patients was performed. RESULTS: In patients with claudication, the TLR free rates at 1-, 3-, and 5-year intervals were 89.1%, 82.2%, and 78.9%, respectively. Amputation-free survival rates in the claudicants at 1-, 3-, and 5-year intervals were 95.3%, 81.1%, and 65.2%, respectively. Freedom from ischemia at 1-, 3-, and 5-year follow-ups was 77.8%, 69.0%, and 61.3%, respectively. In patients with critical limb ischemia, the TLR free rates at 1-, 3-, and 5-year intervals were 91.3%, 87.4%, and 65.4%, respectively, amputation free survival rates were 72.5%, 44.2%, and 36.8%, respectively, and their freedom from ischemia was 64.6%, 63.4%, and 49.7%, respectively. In the multivariate analysis of influencing factors related to freedom from ischemia, renal insufficiency (hazard ratio [HR] 1.623; 95% confidence interval [CI] 0.999-2.636; p = 0.050), TASC C/D lesion (HR 1.903; 95% CI 1.151-3.148; p = 0.012), and poor tibial runoff (HR 1.770; 95% CI 1.037-3.023; p = 0.036) were statistically significant risk factors. TASC C/D lesion and poor tibial runoff were significant risk factors for recurrent or persistent ischemia in claudication (p = 0.015) and in critical limb ischemia (p = 0.05), respectively. CONCLUSION: Endovascular treatment for femoropopliteal atherosclerotic lesions showed acceptable intermediate-term and long-term outcomes. Renal insufficiency, TASC C/D lesions, and poor tibial runoff adversely affected freedom from ischemia.

Ultrasound-Guided Direct Needle Engagement for Flush-Occluded Superficial Femoral Artery.

Flush ostial occlusion of the superficial femoral artery (SFA) is challenging for endovascular treatment. Neither ipsilateral nor contralateral access is easy. The drawback of ipsilateral common femoral artery (CFA) access is that the CFA is too short for catheter manipulation and sheath engagement. Contralateral retrograde CFA access could have merit, but it has the drawback of poor pushability and torquability in the manipulation of devices. The most challenging part of flush ostial occlusion is the difficulty of wire engagement into the SFA orifice. We describe a case of successful treatment of a flush-occluded long SFA lesion using ultrasound-guided direct ipsilateral ostial access.

Impact of Tibial Runoff on Outcomes of Endovascular Treatment for Femoropopliteal Atherosclerotic Lesions.

OBJECTIVES: The aim of this study is to investigate the impact of tibial runoff on outcomes of femoropopliteal interventions for atherosclerotic lesions. METHODS: A retrospective review of 243 endovascular procedures for femoropopliteal atherosclerotic lesions on 243 limbs of 197 patients was performed. RESULTS: The distribution rates of good tibial runoff (runoff score <7) and poor tibial runoff (runoff score ≥7) were 37.0% and 63.0%, respectively. In the poor tibial runoff group, the patients were older ( P = .019), and the proportion of male was lower ( P = .014). There was a significantly higher proportion of rest pain or tissue loss ( P < .001), and the prevalence of stroke ( P = .031) and renal insufficiency ( P = .005) was significantly higher in the poor runoff group. After femoropopliteal intervention, the amputation-free survival ( P = .03) and freedom from ischemia ( P = .003) were significantly lower in the poor runoff group. The interventions targeting below-the-knee (BTK) lesions performed concomitantly for critical limb ischemia or tissue loss with poor tibial runoff did not show a significant advantage in terms of freedom from ischemia; however, minor trends of longer lasting freedom from ischemia were observed when BTK intervention was combined. CONCLUSION: The patients with poor runoff showed significantly lower amputation-free survival and freedom from ischemia. In poor tibial runoff limbs with critical limb ischemia or tissue loss, BTK intervention did not demonstrate additional significant beneficial outcomes; however, there was a minor trend of longer lasting freedom from ischemia after concomitant BTK intervention.

Survey Regarding Attitude of Family About Organ Donation After Brain Death in Korea.

BACKGROUND This study examined the attitude of patients' relatives in South Korea toward organ donation after brain death. MATERIAL AND METHODS A structured questionnaire was used to obtain the information on the attitude toward organ donation for relatives of patients who were admitted to the surgical intensive care unit (SICU) between March 1, 2014 and September 30, 2016. In total, 92 persons participated voluntarily. The investigation included general opinion about organ donation; and additional categorical analysis was performed. RESULTS In this study, 75% of participants agreed that they had positive thoughts on organ donation; however, fewer participants (60.9%) showed a positive attitude towards donating their own body, while only a third of participants (38.1%) agreed that they would donate relatives' body. We could confirm specifically concerns about excessive physical damage during organ recovery (34.7%) and ignorance or disrespect by hospital staff (15.2%), as well as consideration of being sacrificed for the benefit of others (26.0%). The participants who agreed to donate relatives' body showed significantly different responses in each categories of the questionnaire compared to the participants who disagreed or were undecided. CONCLUSIONS Despite positive perceptions concerning organ donation after brain death, there were nonetheless several prejudices and misunderstandings to overcome. The findings of this study can be used to establish evidence-based strategies.

Results of Infrainguinal Bypass with a Composite Graft Combining Polytetrafluoroethylene and Vein Graft in Absence of Appropriate Saphenous Vein Graft.

PURPOSE: Use of a composite graft combining a polytetrafluoroethylene graft with an autogenous vein is an option for limb salvage in the absence of an adequate single segment vein graft. We aimed to investigate the results of infrainguinal bypass with a composite graft. MATERIALS AND METHODS: We retrospectively reviewed 11 infrainguinal arterial bypasses on 11 limbs which underwent surgery from March 2012 to November 2016. RESULTS: Critical limb ischemia was common (63.6%) indication of bypass surgery and most (90.9%) of the patients had history of failed previous treatment including endovascular treatment (36.4%) and bypass surgery (72.7%). At the 2 years after graft implantations, primary patency and amputation-free survival of below-knee bypasses using composite graft were 73% and 76%, respectively. CONCLUSION: Infrainguinal arterial bypasses with composite graft had an acceptable patency. In patients without other alternative conduits for revascularization, bypass with a composite graft can be an option.

Factors Associated with a Family's Delay of Decision for Organ Donation After Brain Death.

BACKGROUND This study aimed to explore the factors associated with a family's delay of decision for organ donation after brain death, and to investigate the effect of such a delay on organ donation. MATERIAL AND METHODS Medical records and data on counseling about organ donation with the families of 107 brain-dead potential donors between September 2012 and March 2016 at a single tertiary medical center were retrospectively reviewed. RESULTS The final consent rate was 58% (62/107), and successful donation was performed in 40% (43/107). Ninety-two families (86%) made a decision within 48 hours, whereas 15 (14%) required more than 48 hours for a final decision. In univariate and multivariate analyses, the independent factors associated with a decision delay were mean arterial pressure ≤60 mm Hg and coma therapy. In the early decision group (<48 hours), the consent and successful donation rates were 55% (51/92) and 39% (36/92), respectively, whereas in the delayed decision group (≥48 hours), these rates were 73% (11/15) and 47% (7/15), respectively. The consent and successful donation rates were not inferior in the delayed decision group. CONCLUSIONS These findings justify continuous efforts to maintain organ viability and to extend counseling to encourage donation even if the family cannot decide immediately.

Delayed appendectomy versus early appendectomy in the treatment of acute appendicitis: a retrospective study.

BACKGROUND: The controversy still exists about the timing of operation for appendicitis. The aim of this study was to compare the outcomes between early appendectomy and delayed appendectomy and assess the feasibility of delayed operation. METHODS: The medical records of patients with acute appendicitis who received operation between January 1, 2011 and December 31, 2011, were retrospectively reviewed. Outcome measures were white blood cell (WBC) count at postoperative first day, time to soft diet, complication rate, surgical site infection (SSI) rate, length of hospital stay, and readmission within 30 days. RESULTS: During the study period, a total of 478 patients underwent appendectomies, and 145 patients were excluded, leaving 333 who met inclusion criteria. Based on the time from arrival at hospital to incision, they were divided into two groups: 177 (53.2%) in group A and 156 (46.8%) in group B. There were no significant differences in preoperative demographics and clinical data between two groups. The mean WBC count at postoperative first day of group B were lower than that of group A (p = 0.0039). There were no significant differences in time to soft diet, length of postoperative hospital stay, complication rate, and readmission rate between two groups. SSI including intra-abdominal abscess was also shown no significant difference (Group A, 1.7% and Group B, 3.9%; p = 0.3143). CONCLUSIONS: This study revealed that delayed appendectomy was safe and feasible for adult patient although the clinical outcomes of delayed appendectomy were not superior to those of early appendectomy. We suggest that surgeons would decide the appropriate timing of appendectomy with consideration other situations such as available hospital resources.

The prognosis and treatment outcomes of patients with recurrent hepatocellular carcinoma after liver transplantation.

Liver transplantation (LT) is performed in patients with hepatocellular carcinoma (HCC), but recurrent HCC after LT remains a problem. We retrospectively reviewed the data from 63 patients with recurrent HCC who underwent LT at a single institution between September 1996 and March 2011 to determine the prognosis of patients with recurrent HCC after LT. A survival analysis was performed with the preoperative data, histological findings, patterns of recurrence, and treatment methods. Univariate and multivariate analyses were performed to determine the factors associated with early (<1 yr) cancer-related death. The independent prognostic factors, according to the multivariate analysis, were recurrence within six months (hazards ratio [HR] = 4.557, p = 0.021) and initial multiple-organ involvement (HR = 5.494, p = 0.015). The survival rates of patients differed according to the treatment type. The combined treatment with local and systemic treatment resulted in increased survival even in patients with HCC recurrences involving multiple organs.