Influence of the Enhanced Recovery After Surgery Protocol on Postoperative Inflammation and Short-term Postoperative Surgical Outcomes After Colorectal Cancer Surgery

Purpose@#Many studies have shown that the enhanced recovery after surgery (ERAS) protocols improve postoperative surgical outcomes. The purpose of this study was to observe the effects on postoperative inflammatory markers and to explore the effects of a high degree of compliance and the use of epidural anesthesia on inflammation and surgical outcomes. @*Methods@#Four hundred patients underwent colorectal cancer surgery at 2 hospitals during 2 different periods, namely, from January 2006 to December 2009 and from January 2017 to July 2017. Data related to the patient’s clinicopathological features, inflammatory markers, percentage of compliance with elements of the ERAS protocol, and use of epidural anesthesia were collected from a prospectively maintained database. @*Results@#The complication rate and the length of hospital stay (LOS) were less in the ERAS group than in the conventional group (P = 0.005 and P ≤ 0.001, respectively). The postoperative white blood cell count and the duration required for leukocytes to normalize were reduced in patients following the ERAS protocol (P ≤ 0.001). Other inflammatory markers, such as lymphocyte count (P = 0.008), neutrophil/lymphocyte ratio (P = 0.032), and C-reactive protein level (P ≤ 0.001), were lower in the ERAS protocol group. High compliance ( ≥ 70%) was strongly associated with the complication rate and the LOS (P = 0.008 and P ≤ 0.001, respectively). @*Conclusion@#ERAS protocols decrease early postoperative inflammation and improves short-term postoperative recovery outcomes such as complication rate and the LOS. High compliance ( ≥ 70%) with the ERAS protocol elements accelerates the positive effects of ERAS on surgical outcomes; however, the effect on inflammation was very small.

The Effects of Preoperative Pain Education on the Decision to Discharge Patients Following Single-Incision Laparoscopic Appendectomy

Purpose@#Few studies have analyzed the effects of preoperative pain education on the postoperative decision to discharge. The purpose of this study was to determine the effects of pain education and management on the decision to discharge patients after single-incision laparoscopic appendectomy (SILA). @*Methods@#We analyzed 135 patients who had undergone SILA for acute appendicitis between March 2017 and April 2018 in a single medical center. Of these, 72 patients (53.3%) had received preoperative pain education (group 1), and 63 (46.7%) had not (group 2). We compared perioperative outcomes and complications between the groups. @*Results@#Baseline characteristics of sex, age, body mass index, American Society of Anesthesiologist score, and systemic inflammation factors (neutrophil-lymphocyte ratio, C-reactive protein level) did not differ significantly between the groups. There were no postoperative complications for patients in either group. Perioperative consequences and pathologic findings were not significantly different between the groups; however, length of hospital was significantly shorter in group 1. @*Conclusion@#Preoperative pain education in relation to postoperative pain management influenced the decision to shorten the postoperative hospital length of stay after SILA.

The Effects of Preoperative Pain Education on the Decision to Discharge Patients Following Single-Incision Laparoscopic Appendectomy

Purpose@#Few studies have analyzed the effects of preoperative pain education on the postoperative decision to discharge. The purpose of this study was to determine the effects of pain education and management on the decision to discharge patients after single-incision laparoscopic appendectomy (SILA). @*Methods@#We analyzed 135 patients who had undergone SILA for acute appendicitis between March 2017 and April 2018 in a single medical center. Of these, 72 patients (53.3%) had received preoperative pain education (group 1), and 63 (46.7%) had not (group 2). We compared perioperative outcomes and complications between the groups. @*Results@#Baseline characteristics of sex, age, body mass index, American Society of Anesthesiologist score, and systemic inflammation factors (neutrophil-lymphocyte ratio, C-reactive protein level) did not differ significantly between the groups. There were no postoperative complications for patients in either group. Perioperative consequences and pathologic findings were not significantly different between the groups; however, length of hospital was significantly shorter in group 1. @*Conclusion@#Preoperative pain education in relation to postoperative pain management influenced the decision to shorten the postoperative hospital length of stay after SILA.

Effect of Adjuvant Chemotherapy on Stage II Colon Cancer: Analysis of Korean National Data / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Debates exist regarding the effectiveness of adjuvant chemotherapy for stage II colon cancer. This study aimed to investigate the current status of adjuvant chemotherapy and its impact on survival for Korean stage II colon cancer patients by analyzing the National Quality Assessment data. MATERIALS AND METHODS: A total of 7,880 patientswho underwent curative resection for stage II colon adenocarcinoma between January 2011 andDecember 2014 in Koreawere selected randomly as evaluation subjects for the quality assessment. The factors that influenced overall survival were identified. The high-risk group was defined as having at least one of the following: perforation/obstruction, lymph node harvest less than 12, lymphovascular/perineural invasion, positive resection margin, poor differentiation, or pathologic T4 stage. RESULTS: The median follow-up period was 38 months (range, 1 to 63 months). Chemotherapy was a favorable prognostic factor for either the high- (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.38 to 0.59; p < 0.001) or low-risk group (HR, 0.74; 95% CI, 0.61 to 0.89; p=0.002) in multivariate analysis. This was also the case in patients over 70 years of age. The hazard ratio was significantly increased as the number of involved risk factors was increased in patients who didn’t receive chemotherapy. Adding oxaliplatin showed no difference in survival (HR, 1.36; 95% CI, 0.91 to 2.03; p=0.132). CONCLUSION: Adjuvant chemotherapy can be recommended for stage II colon cancer patients, but the addition of oxaliplatin to the regimen must be selective.

Liver Inflammatory Pseudotumor Mimicking Cholangiocarcinoma / 대한췌담도학회지

Inflammatory pseudotumor of the liver is a benign disease which is histologically characterized by plasma cell infiltration and reactive fibrotic inflammation. Differentiating this disease from malignant tumor is not easy. The authors report a case of inflammatory pseudotumor mimicked as intrahepatic cholangiocarcinoma. A 74-year-old man visited the emergency department complaining of jaundice and myalgia which have lasted for 1 to 2 weeks. After computed tomography (CT) scan and magnetic resonance imaging of the liver, he was initially diagnosed with intrahepatic cholangiocarcinoma, but was ultimately found to be inflammatory pseudotumor after pathologic examination of the liver tissue. His symptoms improved after a course of antibiotic therapy and conservative treatment, and the lesion disappeared on follow-up CT scan.

Conversion from Selective to Comprehensive Neck Dissection: Is It Necessary for Occult Nodal Metastasis? 5-Year Observational Study

OBJECTIVES: To compare the therapeutic results between selective neck dissection (SND) and conversion modified radical neck dissection (MRND) for the occult nodal metastasis cases in head and neck squamous cell carcinoma. METHODS: Forty-four cases with occult nodal metastasis were enrolled in this observational cohort study. For twenty-nine cases, SNDs were done and for fifteen cases, as metastatic nodes were found in the operative field, conversion from selective to MRNDs type II were done. Baseline data on primary site, T and N stage, extent of SND, extracapsular spread of occult metastatic node and type of postoperative adjuvant therapy were obtained. We compared locoregional control rate, overall survival rate and disease specific survival rate between two groups. RESULTS: Among the 29 patients who underwent SND, only one patient had a nodal recurrence which occurred in the contralateral undissected neck. On the other hand, among the 15 patients who underwent conversion MRND, two patients had nodal recurrences which occurred in previously undissected neck. According to the Kaplan Meier survival curve, there was no statistically significant difference for locoregional control rate, overall survival rate and disease specific survival rate between two groups (P=0.2719, P=0.7596, and P=0.2405, respectively). CONCLUSION: SND is enough to treat occult nodal metastasis in head and neck squamous cell carcinoma and it is not necessary to convert from SND to comprehensive neck dissection.

Surgical Treatment of Spontaneous Meningocele of the Temporal Bone Causing a Pulsatile Tinnitus / 대한이비인후과학회지

A meningocele is a protrusion of meninges through a defect in the skull base. It is a rare but potentially life-threatening condition requiring surgery. It can present with conductive hearing loss, persistent middle ear effusion, cerebrospinal fluid otorrhea, recurrent meningitis, and epilepsy. We report a patient who presented with a three-year history of intermittent pulsatile tinnitus in her left ear. She had clear middle ear effusion and radiological evaluations suggesting an attic cholesteatoma. She underwent a tympanomastoidectomy and we discovered a meningocele in the epitympanum and a bony defect of the tegmen tympani. We easily restored the meningocele using a microelevator and bolstered the bone with temporalis fascia, conchal cartilage and musculoperiosteal flap. There was no evidence of cerebrospinal fluid leakage and the patient's tinnitus disappeared six months after the operation.

Usefulness of the Attic Reconstruction Using the Tragal Cartilage and Perichondrium for Prevention of a Retraction Pocket

BACKGROUND AND OBJECTIVES: Bone defect of the attic wall is a critical cause of the postoperative retraction pocket after canal wall up mastoidectomy. So, proper treatment of the attic defect is important and attic reconstruction is an acceptable procedure but it is controversial when the attic is reconstructed or not. The aim of this study is to analyze the usefulness of the attic reconstruction using tragal cartilage and perichondrium for prevention of retraction pocket and propose the indication to perform the attic reconstruction. SUBJECTS AND METHODS: We retrospectively reviewed the medical records of 46 consecutive patients who underwent tympanomastoidectomy and attic reconstruction using tragal cartilage between January 2005 and January 2009. The follow-up period varied from 12 to 65 months, with the average period of 34 months. We analyzed postoperative status of the scutum and the tympanic membrane, and development of the residual or recurrent cholesteatomas and evaluate development of the retraction pocket according to the preoperative size of the bony defect of the scutum and status of the ossicular chain. RESULTS: Retraction pocket was developed in the 13% of the operations and most of the cases had large attic destruction more than 3 mm and destructed ossicular chain. CONCLUSIONS: Attic reconstruction using tragal cartilage is a simple method to repair the bony defect of the external ear canal and effective in preventing postoperative retraction pocket if the size of destructed scutum is less than 3 mm.

The predictive factors for injury severity and pregnancy outcomes after traffic accidents during pregnancy / 대한산부인과학회지

OBJECTIVE: To estimate the predictive factors associated with traffic injury severity and pregnancy outcomes in traffic accidents during pregnancy. METHODS: We performed a retrospective case review study to assess 109 pregnant women who were injured by traffic accidents and were admitted to Gangneung Asan Hospital and KyungHee University Hospital from September 1996 to January 2009. The clinical data of maternal age, parity, gestational age, symptoms of the patients that happened after accidents, accident location, seat position in vehicle, maternal injury severity which was quantified with injury severity score (ISS), pregnancy outcomes, and subchorionic hematoma were reviewed with the medical records or the telephone interviews. Adverse pregnant outcomes included abortion, preterm delivery and fetal death in uterus. Multiple logistic regression analysis was performed to evaluate the predictive factors for injury severity and pregnancy outcomes after traffic accidents. RESULTS: Pedestrian injury and first trimester were significantly associated with severity of maternal injury. Multivariate analysis revealed that abdominal pain was independently predictive factor for the severity of maternal injury. The second trimester, pedestrian injury, right front seat of vehicle, severity of maternal injury and subchorionic hematoma were significantly associated with adverse pregnancy outcomes. Multivariate analysis revealed that severity of maternal injury and subchorionic hematoma were independently predictive factors for adverse pregnancy outcomes. CONCLUSION: According to predictive factors for pregnancy outcomes, the severity of maternal injury estimated with ISS score and subchorionic hematoma seems to be helpful indicators in the management of traffic accident injuries during pregnancy.

A case of advanced hepatocellular carcinoma with portal vein tumor invasion controlled by percutaneous ethanol injection therapy / 대한간학회지

Portal vein invasion is a grave prognostic indicator in the setting of hepatocellular carcinoma (HCC). There is currently no effective method for preventing the invasion of HCC into the main portal vein. We report here a case of advanced HCC with portal vein tumor thrombosis that was effectively treated with percutaneous ethanol injection (PEI), having previously enabled subsequent successive transarterial chemoembolization (TACE). A 60-year-old male patient was diagnosed with a huge HCC, based on computed tomography and angiographic findings. Despite two sessions of TACE, the tumor invaded the right portal vein. PEI was performed on the malignant portal vein thrombosis, and three sessions thereof reduced the extent of tumor thrombi in the portal vein. Successive TACEs were performed to treat the HCC in the hepatic parenchyma. The patient was still living 19 months after the first PEI with no evidence of tumor recurrence, and his liver function remained well preserved.

Clinical Characteristics of Chronic Pancreatitis according to the History of Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: Chronic pancreatitis (CP) is characterized clinically by a broad spectrum of variable features depending on many factors such as etiology, stage of the disease, and the presence of local complications. The aims of this study were to investigate the clinical aspect of CP and to analyze the characteristics according to the history of pancreatitis. METHODS: Eighty nine medical records from the patients who were diagnosed as CP at Korea University Ansan Hospital from January 1997 through December 2007 were reviewed retrospectively. After patients were divided into two groups according to the previous history of pancreatitis: the group I (n=34, no history of pancreatitis) and II (n=43, history of pancreatitis more than once), the clinical characteristics of two groups were compared. RESULTS: The mean age was 50+/-13.2 years and the male to female ratio was 5:1. Alcohol was the cause of CP in 71.9%, and 23.6% had no evident cause. Age (53.4+/-15.5 vs. 46.2+/-11.5, p=0.021), etiology (idiopathic 41.2% vs. 11.6%, p=0.004), and the presence of abdominal pain (73.5% vs. 100%, p=0.030) were significantly different between group I and II. However, in comparison of other factors that reflected the advanced stage of CP such as presence of pancreatic calcification, complications, and Cambridge grade on ERCP, there was no significant difference. CONCLUSIONS: Since CP which present, as the first manifestation shows much an advanced stage, the method for early diagnosis of CP is particularly needed.

A Case of Cerebellopontine Angle Osteoma Causing Sudden Hearing Loss with Vertigo / 대한평형의학회지

Osteomas arising from the internal auditory canal (IAC) and locating in the cerebellopontine angle (CPA) are rare. These tumors may cause compression of the IAC with varying degree of hearing loss, vertigo, and tinnitus but sometimes asymptomatic. Here we present a 60-year-old female patient presented with a hearing loss of sudden onset in her right ear and recurrent dizziness of whirling type. Magnetic resonance imaging and computed tomography revealed CPA osteoma arising from the porus of the IAC. Osteomas should be considered as differential diagnosis in patients with sudden hearing loss and vertigo.

Abdominal Obesity as a Risk Factor for the Development of Erosive Esophagitis in Subjects with a Normal Esophago-Gastric Junction

BACKGROUND/AIMS: Obesity is reported to be associated with erosive esophagitis (EE). However, the temporal association of obesity and abdominal obesity with EE is unclear. We conducted this study to investigate the temporal association of obesity, especially abdominal obesity with EE. METHODS: Among 1,182 subjects who underwent health screening examinations including upper endoscopy in both 2003 and 2006, a total 1,029 subjects with a normal esophagogastric junction on upper endoscopy in 2003 were enrolled. All subjects completed questionnaires and anthropometric measurements were obtained twice by trained personnels. The patients with newly developed EE were compared to the subjects without newly developed EE. RESULTS: Among 1,029 subjects, 42 (4.1%) were newly diagnosed with EE and 82 (8.0%) with hiatal hernia. The mean body mass index (BMI) in both examinations was significantly different between the two groups based on the development of erosive esophagitis (p90 cm vs <80 cm). CONCLUSIONS: Our study showed that abdominal circumference is an independent risk factor for EE, demonstrating a temporal relationship between abdominal obesity and EE.

von Willebrand Disease in Childhood Chronic ITP / 대한혈액학회지

BACKGROUND: This study was performed to diagnose von Willebrand disease (vWD) in children with chronic immune thrombocytopenic purpura (ITP). METHODS: Seventeen cases of chronic ITP were included in this study. Screening tests and specific tests were performed. These tests were also performed on their families when the patient was diagnosed vWD. Their past histories and family histories for bleeding tendencies were also reviewed. RESULTS: Five cases were diagnosed with vWD: One had a low level of vWF:RCo and factor VIII with a normal level of vWF:Ag, and others had a low level of vWF:RCo and vWF:Ag with a normal level of factor VIII. Among these, two cases showed abnormal screening test results, with prolongation of the aPTT or BT. The vWF multimer test could be performed in three cases, and two cases had a normal pattern and one had a abnormal pattern. Among the five vWD children, the past histories and family histories of a bleeding tendency could be obtained for four vWD patients and three families showed a bleeding tendency. But all the families were found to be normal on the first screening and the specific tests. CONCLUSION: von Willebrand disease was combined in 5 cases (29.4%) among the 17 chronic ITP children. More evaluations, such as the vWF multimer test and the ristocetin-induced platelet aggregation (RIPA) test are needed to confirm the subtype. A follow-up test of the same type should be repeated on family members who have a history of bleeding, but they have normal test results for the diagnosis or exclusion of vWD.

Correlation between Cephalhematomas and Intracranial Hematomas

PURPOSE: Cephalhematomas rarely lead to serious complications, such as skull fractures and intracranial hematomas, so CT and/or MRI scans are indicated only in cases in which depressed fractures are suspected or neurologic symptoms develop. Nevertheless, we have experienced several cases of cephalhematomas associated with intracranial hematomas in the absence of remarkable neurologic symptoms. The aim of this study was to evaluate the correlation between cephalhematomas and intracranial hematomas and determine the need for neuroimaging in infants with cephalhematomas. METHODS: Infants who were admitted to the NICU with cephalhematomas and underwent neuroimaging (CT and/or MRI) between January 2002 and July 2006 were evaluated. Neuroimaging was done when the symptoms suggested the development of an intracranial hematoma. RESULTS: Among 54 infants with cephalhematomas, 18 infants underwent neuroimaging. Six of 18 infants (33.3%) had intracranial hematomas, 4 infants had epidural hematomas, and 2 infants had subdural hematomas. Four of these 6 infants had neurologic symptoms or depressed skull fractures; 2 infants had no neurologic symptoms or depressed skull fractures. The neuroimaging was done to evaluate the cause of an excessive elevation of serum bilirubin and unexplained anemia. There were no remarkable differences between the infants with and without intracranial hematomas with respect to gestational age, birth weight, head circumference, diameter of the cephalhematoma, neurologic symptoms, and other clinical signs and symptoms. CONCLUSION: Based on this study, intracranial hematomas are common complications of cephalhematomas, thus more careful inspection and neuroimaging may be needed in cases of cephalhematomas in newborns.

An analysis of the risk factors for metabolic syndrome affecting stress urinary incontinence in korean middle-aged and older women / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to identify the relationship between metabolic syndrome and stress urinary incontinence. METHODS: Based form 362 case, the risk factors including the parameters of metabolic syndrome for stress urinary incontinence (SUI) were analyzed retrospectively: body mass index (BMI), hypertension, insulin resistance, triglyceride, HDL-cholesterol. RESULTS: The risk for metabolic syndrome were associated positively with SUI. Women with the risks for metabolic syndrome had 2.503 times of the odds for SUI compared without the risks for metabolic syndrome (95% CI 1.28-4.87, p<0.001). The independent risk factors for SUI were BMI (OR 3.574 ; 95% CI 0.09-0.31, p<0.001) and insulin resistance (OR 2.563 ; 95% CI 0.04-0.31, p=0.011) by multivariate analysis. CONCLUSION: Our results suggested that metabolic syndrome was the important factor of the stress urnary incontinence. And we confirmed the need for the treatment of metabolic disturbance and the prevention of metabolic syndrome aimed at correcting hormonal-metabolic disturbance in middle-aged and older women with SUI.

A Case of Systemic Amyloidosis with Pancreatic Involvement Mimicking Autoimmune Pancreatitis / 대한소화기학회지

Systemic amyloidosis is a disorder characterized by extracellular deposition of amyloid in various organs and tissues including the kidney, heart, and liver. However, pancreatic involvement is rare, and has not been reported in Korea. Systemic amyloisosis involving pancreas needs to be differentiated from several pancreatic diseases because of diffuse pancreatic enlargement and partial stricture or obstruction of main pancreatic duct. Recently, we experienced a 60-year old man who was suspected as autoimmune pancreatitis or infiltrative disorders on imaging studies, and finally diagnosed as systemic amyloidosis involving pancreas and liver on biopsy examination. We report the case with review of the relevant literatures.

Therapeutic Efficacy of Adefovir Dipivoxil in Korean Children and Adolescents with Chronic Hepatitis B who have Developed Lamivudine Resistance / 대한소아소화기영양학회지

PURPOSE: To estimate the long-term therapeutic efficacy and safety of adefovir dipivoxil in children and adolescents with chronic hepatitis B who have developed lamivudine resistance. METHODS: Sixteen patients (12 boys and 4 girls; ages 4.3~20.9 years; mean age 14.2 years) with chronic hepatitis B infection resistant to lamivudine therapy received adefovir (0.3 mg/kg/day, maximal dose 10 mg) orally for at least 9 months between March 2004 and April 2008. Each patient was followed up for a mean period of 27 months (range 9~49 months) until April 2008 at Kyungpook National University Hospital in Korea. Therapeutic responses to adefovir were evaluated at 12, 24, 36, and 48 months from the initiation of therapy using the Kaplan-Meier method. Response measurements included ALT normalization, HBV DNA negativization, 2 log(10) IU/mL decrement of HBeAg titer, HBeAg loss, and HBeAg/Ab seroconversion rate. RESULTS: Three (18.8%) of the 16 patients treated with adefovir showed HBeAg/Ab seroconversion. Kaplan-Meier estimates of cumulative ALT normalization were 12.5% (12 months), 43.8% (24 months), 63.5% (36 months), and 92.7% (48 months), respectively. Cumulative HBV DNA negativization was 6.7%, 30.0%, 45.6%, and 78.2% at 12, 24, 36, and 48 months, respectively. Cumulative 2 log(10) copies/mL decrement of HBeAg titer was 12.5%, 43.8%, 56.3%, and 86.9% at 12, 24, 36, and 48 months, respectively. Cumulative HBeAg loss and HBeAg/Ab seroconversion were 6.7% (12 months) and 22.2% (24 months), respectively. CONCLUSION: The long-term therapeutic efficacy of adefovir dipivoxil was favorable in children and adolescents with chronic hepatitis B who had developed lamivudine resistance. The long-term use of adefovir should be safe in children.

Recurrent Acute Pancreatitis Associated with Sphincter of Oddi Dysfunction in a Child / 대한소아소화기영양학회지

Recent studies suggest that sphincter of Oddi dysfunction (SOD) is one of the possible causes of unexplained recurrent acute pancreatitis in children. A 14-year-old boy who had suffered from idiopathic recurrent acute pancreatitis was diagnosed with SOD. Abdominal ultrasonography, computerized tomography, and magnetic resonance cholangiopancreatography revealed no evidence of stone, tumor, or pancreatic ductal anomaly. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincter of Oddi manometry (SOM) revealed elevated basal pressure and tachyoddia consistent with SOD. Hence, an endoscopic pancreatic sphincterotomy was performed. We report a case of recurrent acute pancreatitis associated with SOD in a child. ERCP and SOM may be considered in patients with multiple unexplained attacks of pancreatic pain and negative abdominal imaging.

Recurrent Acute Pancreatitis Associated with Sphincter of Oddi Dysfunction in a Child / 대한소아소화기영양학회지

Recent studies suggest that sphincter of Oddi dysfunction (SOD) is one of the possible causes of unexplained recurrent acute pancreatitis in children. A 14-year-old boy who had suffered from idiopathic recurrent acute pancreatitis was diagnosed with SOD. Abdominal ultrasonography, computerized tomography, and magnetic resonance cholangiopancreatography revealed no evidence of stone, tumor, or pancreatic ductal anomaly. Endoscopic retrograde cholangiopancreatography (ERCP) and sphincter of Oddi manometry (SOM) revealed elevated basal pressure and tachyoddia consistent with SOD. Hence, an endoscopic pancreatic sphincterotomy was performed. We report a case of recurrent acute pancreatitis associated with SOD in a child. ERCP and SOM may be considered in patients with multiple unexplained attacks of pancreatic pain and negative abdominal imaging.