BRAF(V600E) Test for Suspicious Lateral Lymph Nodes in Papillary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: This study evaluates the BRAF(V600E) test with fine-needle aspiration cytology (FNAC) for lateral lymph node (LN) metastasis in papillary thyroid carcinoma (PTC). METHODS: Ninety-one patients, including 95 lateral LNs with possible PTC metastasis, were consecutively entered into the study. We analyzed the accuracy of results for the BRAF(V600E) test and FNAC for lateral LN metastasis in PTC. RESULTS: Modified radical neck dissection was performed for 34 cases due to lateral LN metastasis. The sensitivity of FNAC was 88.2% , and the LN-BRAF(V600E) test 64.7%. The specificity and positive predictive value (PPV) were 100% for both tests. The negative predictive values (NPV) were FNAC, 93.8%, and LN-BRAF(V600E), 83.6%. For samples positive with either the BRAF(V600E) test or FNAC, the sensitivity was 94.1%, specificity 100%, PPV value 100%, and NPV 96.8%. CONCLUSION: This study suggests that the complementary LN-BRAF(V600E) test with FNAC is a supportive diagnostic method for PTC patients with indeterminate or non-diagnostic suspicious lateral LNs.

Chyle Leakage after Total Thyroidectomy and Central Neck Dissection: Report of Three Cases / 대한내분비외과학회지

Chyle leakage is a rare complication of surgery for thyroid cancer that generally develops after lateral neck dissection. Here, we describe chyle leakages experienced after central neck dissection (CND). A total of 615 patients with thyroid cancer were treated by total thyroidectomy with CND between Jan 2012 and Dec 2012 at our facility, and three (0.49%) developed chyle leakages. The amounts of leakage were all less than 100 ml/day. One patient was resolved with conservative management, while the others were treated with conservative treatment and fibrin glue injection in chylous lymphocele. Chyle leakage after CND is very uncommon, and most cases involve minor leakage. Fibrin glue could be a treatment option for chyle leakage following CND.

Early Results of Eversion Carotid Endarterectomy

PURPOSE: Eversion carotid endarterectomy (ECEA) has been used in western countries with acceptable early and late results. However, there has been no report of ECEA in Korea with regard to its safety and efficacy. The goal of the present study was to determine the early results of ECEA in Korea. METHODS: From October 2008 to December 2009, 19 ECEAs were performed on 18 patients by one vascular surgeon. The patient data and radiology results were prospectively collected according to the hospital protocol. The frequency of early postoperative stroke, myocardial infarction and mortality were evaluated. In addition, the frequency of procedure-induced new brain lesions (NBL) detected by diffusion-weighted MRI (DW-MRI) within one day after the procedure and the post-procedural complications were evaluated. RESULTS: All ECEAs were performed under regional anesthesia; shunts were not necessary in any of the cases. Among a total of 19 ECEAs, there were no cases of early postoperative stroke, myocardial infarction or mortality. Other early postoperative complications included one case of temporary cerebral hyperperfusion syndrome and two hematomas that spontaneously resolved. No NBL was detected on the postoperative DW-MRI. The external carotid artery lesion was aggravated in five cases and was detected on CT angiography before discharge. CONCLUSION: The results of this study showed no strokes or NBLs after ECEA under regional anesthesia. ECEA may be used safely for the management of atherosclerotic severe carotid stenosis in Korean patients; however, further study for long-term complications of ECEA is necessary.

Separate Visceral Revascularization in Thoracoabdominal Aortic Aneurysm Repair: Report of 3 Cases

Thoracoabdominal aortic aneurysm (TAAA) involving the roots of the celiac, superior mesenteric and both renal arteries is a rare, but potentially lethal disease. The overall postoperative mortality rate is high even when the intact TAAA is electively repaired. Furthermore, the postoperative complications are often serious and they include acute renal failure, paraplegia, respiratory distress and intestinal ischemia. The inclusion technique using a visceral-aortic patch (VAP) is considered the gold standard method for visceral artery revascularization for the treatment of TAAA. However, the inclusion technique is not feasible for patients with Marfan syndrome or for those patients with inappropriate anatomy for VAP. In such cases, separate visceral revascularization is a useful alternative and this may decrease the visceral ischemic time. Herein we report on 3 cases of TAAA, and the patients all underwent successful separate visceral revascularization, including one patient with Marfan syndrome.

The Comparison of Medical and Surgical Treatment for Gallbladder Dyskinesia

PURPOSE: The purpose of this study was to compare outcomes for surgical treatment with those for medical treatment of GB dyskinesia. METHODS: Retrospective analysis of medical records and telephone interviews of 67 patients diagnosed with GB dyskinesia was done at Pohang St. Mary's Hospital between January 2004 and December 2009. Group 1 (n=18) patients received laparoscopic cholecystectomy. Group 2 (n=49) patients received medical treatment. GB dyskinesia was the diagnosis if the patient had typical biliary colic symptoms without GB stones or other GI disease, and if the ejection fraction was less than 35% on Tc-99m-DISIDA scans. RESULTS: The average age of patients diagnosed with GB dyskinesia was 45.8 years old. The sex ratio was 15:52 (male:female). The average symptom duration was 25.4 days. All had RUQ and, or epigastric pain. There were no significant between group differences in age, sex ratio, symptom duration, symptoms, follow up period, and ejection fraction. In group 1, patient symptoms improved after treatment in 16 cases (88.9%); in group 2, patient symptoms improved in 19 cases (38.8%). Surgical treatment was significantly more effective than medical treatment. The reasons for choosing medical treatment were predominantly the preference of the doctors. CONCLUSION: Surgical treatment is a more effective treatment for GB dyskinesia than medical treatment. Therefore, laparoscopic cholecystectomy should be considered as the 1st line treatment of choice for GB dyskinesia.

The Expression of Matrix Metalloproteinases and Tissue Inhibitors of Metalloproteinases in the Wall of Great Saphenous Vein in Patients with Varicose Veins

PURPOSE: Although varicose veins are very common in adults, the mechanism of the disease has not been established. Degradation of the extracellular matrix is regulated by various matrix metallopreteinases (MMPs) and their inhibitors tissue inhibitor of metallaproteinase (TIMPs). This study was performed to analyse the relationship between venous wall degeneration and expression of these matrix proteinases. METHODS: Twelve great saphenous vein (GSV) segments from 7 patients without varicose veins (control) and 86 GSV segments from 18 patients (22 limbs) with varicose veins (C2,4,5EPASPR) were used for this study. Light microscopic examination was used in the evaluation of vein wall degeneration, immunohistochemistry and Western blotting for the expression of MMPs (MMP-1, MMP-2, MMP-9 and MMP-13) and TIMPs (TIMP-1 and TIMP-2), and zymography for gelatinolytic activity of MMP-2 and MMP-9 were performed. RESULTS: MMP-9 was more strongly expressed in the vein wall of both control and patient groups, especially in the endothelial cells and medial muscle layers and TIMP-2 followed. The expression of MMP-9 was closely related to the degree of venous wall degeneration. Activated MMP-2 and MMP-9 were observed in both groups and expressed more in the proximal GSV of the patients. In the Western blotting, the expression of MMP-9 and TIMP-1 were significantly higher than other MMPs and TIMP-2 in the patients with varicose veins. CONCLUSION: MMP-9 is much more expressed in the wall of degenerative veins. This matrix-degrading enzyme may play an important role in the degeneration of venous wall followed by its remodeling.

The Matrix Metalloproteinase Expression in Early Arterialized Saphenous Vein Grafts

The venous wall remodeling of a vein graft that's used in arterial bypass is the results of extensive degeneration of the extracellular matrix, and this is induced by hypertensive hemodynamic stimulation, and matrix metalloproteinases (MMPs) contribute to this partially adverse change. This study investigated the expression of MMPs in the early phase of an arterialized vein graft. Three paired great saphenous vein (GSV) segments of a pre- and post-arterialized vein graft were obtained from 3 patients with atherosclerotic arterial occlusive disease. Light microscopic examination, immunohistochemistry and zymography were performed. There is no difference between the pre- and post-arterialized GSV segments for the morphological changes of the venous walls and also on the immunohistochemistry for MMPs and TIMPs. The activities of MMP-2 and -9 were significantly increased in 2 of 3 patients. In the early arterialized phase of the vein graft, the morphological change and expression of MMPs and TIMPs were not prominent; however, MMP-2 and -9 may have some roles in venous wall remodeling.

Primary Aortocaval Fistua Associated with Abdominal Aortic Aneurysm

Primary aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA), occurring in only 4% of ruptured cases and less than 1% of all AAAs. The hemodynamic changes resulting from the major shunt caused by the ACF include a sudden increase in inferior vena caval pressure and volume with renal venous hypertension and a decrease in total peripheral resistance. So, if untreated, it leads to irreversible high output heart failure. Preoperative diagnosis is crucial, as adequate preparation should be made for massive bleeding expected at operation. Successful treatment depends on management of perioperative hemodynamics, control of bleeding from fistula and prevention of thromboembolism. We report two cases of successfully treated spontaneous ACF with a review of the literature.

The Expression of Matrix Metalloproteinase according to Hydrostatic Pressure in Varicose Veins

PURPOSE: The expression of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinase (TIMPs) caused by hydrostatic pressure stress is important in the development of varicose veins (VVs). This study was performed to analyse the expression of various MMPs and TIMPs according to the hydrostatic stress and the anatomical level of human great saphenous vein (GSV). METHODS: Forty-nine vein samples were obtained from 10 patients with VVs (control group), and 34 samples from 7 VV patients after 1-hour hydrostatic stress just before surgery (stress group) at each anatomical site (proximal, Hunter, Dodd, and Boyd perforators) of GSV. Light microscopic examination and immunohistochemistry for MMP-1, -2, -9, -13 and TIMP-1, -2 were performed. RESULTS: Intimal hyperplasia, fragmentation and loss of elastic fibers, infiltration of collagen fibers, and disorganization of medial muscle layers were evident in most vein samples. The degree of vein wall degeneration was not different between the 2 groups, and the anatomical sites of GSV. By immunohistochemistry, the expression of MMPs and TIMPs was not significantly different according to the group and the site. The expression of MMP-9 was more intense than that of other MMPs and TIMPs in all samples. MMP-9 was well localized to endothelial cells, medial muscle layers, and adventitial vasa vasorum. CONCLUSION: There are no distinct differences in the varicose vein samples after short-term postural blood stasis compared to the resting group. MMP-9 may be the key enzyme of the venous wall remodeling.

Spontaneous Isolated Dissection of the Celiac Artery: a Case Report

Visceral artery dissection is uncommon in the absence of concurrent dissection of the aorta, iatrogenic injury from instrumentation or trauma. Spontaneous isolated visceral artery dissection is considered to be rare and most of the reported cases have been associated with the superior mesenteric artery. In addition, only a small number of cases of isolated celiac artery dissection can be found in the literature. The natural history of a celiac artery dissection is unpredictable due to the rarity of this disease, but spontaneous resolution, definite occlusion and/or aneurysm formation may occur. However, the optimal management is still controversial due to the rare nature of the disease. Here we report on a case of spontaneous isolated celiac artery dissection that improved with conservative management.

Abdominal Aortic Aneurysm Repair in Patient with a Renal Allograft: A Case Report

Renal transplant recipients requiring aortic reconstruction due to abdominal aortic aneurysm (AAA) pose a unique clinical problem. The concern during surgery is causing ischemic injury to the renal allograft. A variety of strategies for protection of the renal allograft during AAA intervention have been described including a temporary shunt, cold renal perfusion, extracorporeal bypass, general hypothermia, and endovascular stent-grafting. In addition, some investigators have reported no remarkable complications of the renal allograft without any specific measures. We treated a case of AAA in a patient with a renal allograft using a temporary aortofemoral shunt with good result. Since this technique is safe and effective, it should be considered in similar patients with AAA and previously placed renal allografts.

Brachial-ulnar Artery Bypass for Treating Ischemic Steal Syndrome: Report of A Case

Ischemic steal syndrome is an uncommon, but horrible complication of vascular access surgery, and this malady is manifested by paresthesia, weakness, pallor, pain, ulceration and tissue loss in the severe cases. Because peripheral ischemic steal syndrome can develop by any or a combination of the several mechanisms (retrograde flow, arterial stenosis, very-high fistula flow, distal arteriopathy), the treatment should be based on a detail history, physical examination and appropriate evaluations that include a complete angiogram. We report here on a 50-year-old woman with ischemic finger ulcers after she underwent hemodialysis access surgery, and she was successfully treated by a brachial-ulnar bypass with using a saphenous vein graft.

The Long-term Results and Causes of Death after Abdominal Aortic Aneurysm Repair

PURPOSE: The purpose of this study was to analyze the causes of late death and the long-term survival of patients following abdominal aortic aneurysm (AAA) repair. METHODS: From 1993 to 2005, 146 (98 intact and 48 ruptured) consecutive AAA patients underwent open repair. The perioperative data was supplemented with a retrospective review of the medical records and the use of the database of the National Statistical Office to calculate the survival rates and the causes of death. RESULTS: There was one operative death (1%) in the intact AAA group and 12 (25%) in the ruptured AAA group. After exclusion of the operative deaths, the survival rates of the intact AAA patients were 94.5% at 1 year, 77.0% at 5 years and 33.2% at 10 years; these findings demonstrated a significant longer survival for the intact AAA patients than for patients with ruptured AAA (86.1% at 1 year, 56.7% at 5 years and 0% at 10 years, respectively). The causes of late death included cardiovascular disease in 52.8% (coronary artery disease in 22.6%, cerebrovascular disease in 20.8%, other arterial aneurysms in 5.7% and graft-related death in 3.8%), malignancies in 11.3% and pulmonary disease in 11.3%. The multivariate analysis showed that the long-term survival rates were influenced by the rupture status, the history of cerebrovascular disease and hypertension. CONCLUSION: This study showed that the long-term survival after intact AAA repair was better than that for ruptured AAA repair even if we exclude the operative deaths. The most common cause of late death was cardiovascular disease. Our findings suggest that the patients with preoperative cerebrovascular disease and hypertension require additional care.

Surgical Repair of an Abdominal Aortic Aneurysm in Association with a Horseshoe Kidney: A Case Report

Horseshoe kidney (HSK) is an unusual congenital anomaly showing fusion of both kidneys anterior to the aorta. Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with HSK may be technically demanding because of the complex anomaly of the kidney and of its collecting system and arteries. We report a 76-year-old man with an AAA associated with HSK. The preoperative CT angiography showed a HSK and an AAA measuring 6.4 cm in diameter. In addition, there was an aberrant isthmus renal artery arising from the aneurysm. The aneurysm was exposed via a transperitoneal approach and the AAA repair was performed successfully without division of the isthmus of the HSK. The aberrant renal artery and inferior mesenteric artery were successfully re-implanted to the graft. The renal function showed no impairment postoperatively.

Primary Popliteal Venous Aneurysm: A Case Report

Primary venous aneurysms are rare and are not clinically important in most cases. However, popliteal venous aneurysms can have serious complications, including pulmonary embolism and death, caused by thrombus formation inside of the aneurysm. Surgical repair of the aneurysm is generally recommended in symptomatic patients with thrombus or a combined pulmonary embolism. By contrast, the treatment of an asymptomatic popliteal venous aneurysm is controversial. We present the case of a primary popliteal venous aneurysm in a 63-year-old woman who had local extremity symptoms. The saccular 5.5 x 4.6 x 3.6 cm aneurysm was successfully repaired with an open tangential aneurysmectomy and lateral reconstruction.

Lower Extremity Bypasses in Patients with Dialysis-dependent End-stage Renal Disease

PURPOSE: The combination of critical limb ischemia and dialysis-dependent end-stage renal disease (DD-ESRD) represents a challenging clinical problem. The present study was undertaken to examine our experience with this combined malady at our hospital and to determine if performing lower extremity bypass in these patients is justified. METHOD: From June 2001 to May 2006, 12 arterial reconstructions were performed in 9 patients (mean age: 64.7+/-6.7 years) suffering with DD-ESRD and diabetes mellitus. The risk factors that were association with surgical morbidity and mortality, limb loss and graft patency were retrospectively reviewed. RESULT: The in-hospital mortality rate was 18.2%. There was no graft occlusion during the follow-up periods. The limb salvage rate was 82.5% at 1 year. There were 2 major limb amputations despite that the bypass grafts were patent. The 1-year and 3-year cumulative survival rates were 63.6% and 33.9%, respectively. CONCLUSION: After performing lower extremity arterial reconstruction, the limb salvage rates were acceptable in patients with critical ischemia and DD-ESRD, but the survival rates were poor. Failure to salvage the limb in these patients was due to infectious wound problems rather than to graft thrombosis.

Lower Extremity Bypasses in Patients with Dialysis-dependent End-stage Renal Disease

PURPOSE: The combination of critical limb ischemia and dialysis-dependent end-stage renal disease (DD-ESRD) represents a challenging clinical problem. The present study was undertaken to examine our experience with this combined malady at our hospital and to determine if performing lower extremity bypass in these patients is justified. METHOD: From June 2001 to May 2006, 12 arterial reconstructions were performed in 9 patients (mean age: 64.7+/-6.7 years) suffering with DD-ESRD and diabetes mellitus. The risk factors that were association with surgical morbidity and mortality, limb loss and graft patency were retrospectively reviewed. RESULT: The in-hospital mortality rate was 18.2%. There was no graft occlusion during the follow-up periods. The limb salvage rate was 82.5% at 1 year. There were 2 major limb amputations despite that the bypass grafts were patent. The 1-year and 3-year cumulative survival rates were 63.6% and 33.9%, respectively. CONCLUSION: After performing lower extremity arterial reconstruction, the limb salvage rates were acceptable in patients with critical ischemia and DD-ESRD, but the survival rates were poor. Failure to salvage the limb in these patients was due to infectious wound problems rather than to graft thrombosis.

The Availability of Computed Tomography for the Patients with Deep Vein Thrombosis

PURPOSE: Computed-tomography (CT) is known as a useful modality to diagnose the occurrence and extent of deep vein thrombosis (DVT) and the existence of pulmonary embolism (PE). This article will focus on the availability of DVT-CT at Kyungpook National University Hospital. METHOD: From 1994 to 2006, 403 DVT patients were documented for the extent of thrombus and the existence of PE. DVT-CTs, according to our protocol, were obtained for 136 patients; there were 112 CT scans taken that were limited to the abdomen and lower extremity, and 47 patients underwent only chest CT to diagnose PE. Other modalities such as duplex scan and venography for DVT and lung scan for PE were also performed for 155 patients. RESULT: The patients in the CT group (248 patients) demonstrated that the extent of the thrombus was in the inferior vena cava (IVC) in 38 (16%), the iliac veins (IVs) in 98 (40%), the femoral veins (FVs) in 73 (29%), the popliteal veins (PVs) in 3 (1%), and the mesenteric veins in 24 (10%). For the group that underwent venography or duplex scanning (155 patients), the extent of thrombus was in the IVC in 4 (3%), the IVs in 47 (30%), the FVs in 73 (47%), and the PVs in 21 (14%). For the 136 patients who underwent DVT-CTs, 38 (28%) cases had PE. The DVT-CT and lung scan were in agreement for all the 12 cases who underwent both two tests. CONCLUSION: In the present study, DVT-CT accurately revealed the extent of DVT and it is a useful tool for making the diagnosis of PE.

The Availability of Computed Tomography for the Patients with Deep Vein Thrombosis

PURPOSE: Computed-tomography (CT) is known as a useful modality to diagnose the occurrence and extent of deep vein thrombosis (DVT) and the existence of pulmonary embolism (PE). This article will focus on the availability of DVT-CT at Kyungpook National University Hospital. METHOD: From 1994 to 2006, 403 DVT patients were documented for the extent of thrombus and the existence of PE. DVT-CTs, according to our protocol, were obtained for 136 patients; there were 112 CT scans taken that were limited to the abdomen and lower extremity, and 47 patients underwent only chest CT to diagnose PE. Other modalities such as duplex scan and venography for DVT and lung scan for PE were also performed for 155 patients. RESULT: The patients in the CT group (248 patients) demonstrated that the extent of the thrombus was in the inferior vena cava (IVC) in 38 (16%), the iliac veins (IVs) in 98 (40%), the femoral veins (FVs) in 73 (29%), the popliteal veins (PVs) in 3 (1%), and the mesenteric veins in 24 (10%). For the group that underwent venography or duplex scanning (155 patients), the extent of thrombus was in the IVC in 4 (3%), the IVs in 47 (30%), the FVs in 73 (47%), and the PVs in 21 (14%). For the 136 patients who underwent DVT-CTs, 38 (28%) cases had PE. The DVT-CT and lung scan were in agreement for all the 12 cases who underwent both two tests. CONCLUSION: In the present study, DVT-CT accurately revealed the extent of DVT and it is a useful tool for making the diagnosis of PE.

Bilateral Obturator Bypasses for Femoral Graft Infection: 1 Case Report

Infection of both native and prosthetic vessels are most frequently seen in the groin. The successful treatment of prosthetic graft infection requires excision of the affected graft, adequate debridement, and restoration of circulation. Restoration of arterial circulation can be accomplished by using in situ reconstruction with femoral vein, cryopreserved allografts, or antibiotic-impregnated synthetic grafts. The obturator and lateral femoral bypasses are the most frequently used extra-anatomic bypasses. We experienced one case of bilateral obturator bypasses for the femoral graft infection.