Role of surgery in gastrointestinal bleeding

With the help of the evolution of endoscopic and angiographic intervention, nonsurgical techniques became the procedures of choice for the diagnosis and treatment of gastrointestinal (GI) bleeding and role of surgery have been decreased. However, surgical operations are still necessary for controlling bleeding lesions when these maneuvers fail and conventional operations continue to be life-saving in many instances. Laparoscopic surgeries have an advantage of less postoperative pain and wound problem, quicker recovery, and shorter hospital stay and been widely used for GI bleeding. An elective laparoscopic resection of the intestine for appropriate indications may be an ideal application of this technique, while emergent use should be tempered by skillful surgeons because most patients are relatively unstable and time-limited. Newly developed technologies will continue to facilitate collaboration and cooperation between gastroenterologists, radiologists, and surgeons by encouraging working in multispecialty teams. This review will address the surgical approach associated with various treatments for GI bleeding according to many kinds of GI bleeding diseases.

Changes in Providers' Behavior after the Reviewer Unification of Auto Insurance Medical Benefit Claims / 보건행정학회지

BACKGROUND: This study aims to analyze the behavioral changes of healthcare providers and influencing factors after the reviewer unification of auto insurance medical benefit claims by an independent review agency. METHODS: The comparison data were collected from the second half of 2013 and the same period of 2014. The key indicators are the number of admission days, the number of outpatient visits, inpatient ratio, inpatient medical expenses, and outpatient medical expenses. RESULTS: Four indicators (number of admission days, number of outpatient visits, inpatient ratio, and outpatient medical expenses) showed statistically significant drops, while one indicator (inpatient medical expenses) showed no significant change. CONCLUSION: The reviewer unification of auto insurance medical benefit claims by an independent review agency showed significant reduction in cost and patient days.

Legislative Issues in Disclosing Financial Conflicts of Interest to Participants in Biomedical Research: Effectiveness and Methodology

This research focuses on the analysis regarding disclosure of financial conflicts of interest (FCOI) after Gelsinger v. University of Pennsylvania (Penn). The main legal issue was that the participants did not have enough opportunity to make an autonomous decision about participating in the research because he was not informed about the researchers' and the institution's substantial FCOI. The disclosure system was adopted by the Code of Federal Regulations. Under the regulation, researchers and institutions need to report FCOI over $5,000 to the institution, and the internal review boards have to report to the federal authority if needed. In case of human research, the disclosure to Food and Drug Administration is mandatory. FCOI disclosure system would help participants to make an autonomous decision, and increase trust to the research process and researchers. Moreover, the system would let researchers keep fiduciary duty while (possibly) lowering legal liability in case of a lawsuit. There were discussions about the disclosure methodology in the United States. However, there have not been a lot of discussions in Korea even after the “Humidifier Disinfectant” case. Therefore, new legislations need to be considered. First, the system requires disclosure funded by not only government but also private institutions. Second, like California Supreme Court, the subject would be reviewed under the reasonable person standard by participants, including patents, equity, and stock. Third, the disclosure needs to include simple or brief explanation to the FCOI to be better understood by the participants. Fourth, the disclosure should be in the informed consent process.

Analysis of the Factors that Affect the Mortality Rate in Severe Acute Pancreatitis / 대한소화기학회지

BACKGROUND/AIMS: Severe acute pancreatitis occurs in about 20% of the patients with acute pancreatitis and can be associated with multiorgan failure and local complications. In patients with predicted severe acute pancreatitis, overall mortality rates are about 15-30%. The aim of this study was to determine the factors correlated with mortality in patients with severe acute pancreatitis. METHODS: We reviewed five hundread and seventy two consecutive cases of acute pancreatitis from January, 2000 to December, 2005. Of them, 109 patients who fulfilled the criteria of Atlanta classification for severe acute pancreatitis were enrolled. Data were collected by chart reviews including age, gender, etiology, body mass index (BMI), modified Glasgow score, APACHE II score, APACHE III score, Balthazar CT index, and other laboratory parameters performed within 48 hours after the initial admission. RESULTS: Severe acute pancreatitis was most commonly caused by alcohol. Overall mortality rate was 20.2% in severe acute pancreatitis and 10 (45%) deaths occurred within the first week. Multiple logistic regression analysis identified serum creatinine, corrected calcium concentrations, and CT index as predictors of mortality in patients with severe acute pancreatitis. The risk score (R) was calculated by combining 3 prognostic values with regression coefficients; R=2.512 log(e) (creatinine mg/dL)+1.729 log(e) (CT index)-4.780 log(e) (corrected calcium mg/dL). The AUC for this score was 0.877 and a cutoff level of 0 was determined to predict the mortality with 83.3% sensitivity and 89.5% specificity. CONCLUSIONS: The newly designed risk score comprising 3 parameters can be used as the significant early predictor for hospital mortality in severe acute pancreatitis.

A Clinical Review in 1,108 Cases of Suspected Appendicitis: with Focusing on the Characteristics of Reproductive Age Women

PURPOSE: Appendicitis is the most common abdominal surgical emergency. The diagnosis of appendicitis can be difficult, occasionally taxing the diagnostic skills of even the most experienced surgeon, and especially for diagnosing reproductive women. This study was designed to evaluate the various pathologies of the appendix and the other intraabdominal organs in patients who were preoperatively diagnosed with acute appendicitis, and we wanted to analyze the difference of the perioperative results between the reproductive women and the other patients. METHODS: The study was a retrospective analysis of 1,108 appendectomies that were performed from September 2003 to August 2006. The data were analyzed for the following parameters: the age-related and sex-related incidence of acute appendicitis, the rates of negative appendectomy, negative operation and appendicular perforation, and the incidence of other encountered pathologies. In addition, we present the clinical results of the reproductive women. RESULTS: The diagnostic accuracy for acute appendicitis was 87.2%. The negative appendectomy rate was 11.6% and it was significantly higher (20.8%) in the reproductive women than in the male patients of the same age (P=0.001). On the clinical analyses of the reproductive aged appendicitis group showed they a shorter pain duration and a higher WBC count, and more frequent epigastric discomfort, nausea, vomiting and RLQ tenderness (P< 0.05). CONCLUSION: We noted a high rate of negative appendectomy among reproductive female patients, so more care should be taken to diagnose these patients.

Variations in Nurse Staffing in Adult and Neonatal Intensive Care Units / 간호학회지

PURPOSE: This study was done to analyze variations in unit staffing and recommend policies to improve nursing staffing levels in intensive care units (ICUs). METHOD: A cross-sectional study design was used, employing survey data from the Health Insurance Review Agency conducted from June-July, 2003. Unitstaffing was measured using two indicators; bed-to-nurse (B/N) ratio (number of beds per nurse), and patient-to-nurse (P/N)ratio (number of average daily patients per nurse). Staffing levels were compared according to hospital and ICU characteristics. RESULT: A total of 414 institutions were operating 569 adult and 86 neonatal ICUs. Tertiary hospitals (n=42) had the lowest mean B/N (0.82) and P/N (0.76) ratios in adult ICUs, followed by general hospitals (B/N: 1.34, P/N: 0.97). Those ratios indicated that a nurse took care of 3 to 5 patients per shift. Neonatal ICUs had worse staffing and had greater variations in staffing ratios than adult ICUs. About 17% of adult and 26% of neonatal ICUs were staffed only by adjunct nurses who had responsibility for a general ward as well as the ICU. CONCLUSION: Stratification of nurse staffing levels and differentiation of ICU utilization fees based on staffing grades are recommended as a policy tool to improve nurse staffing in ICUs.

Intestinal Obstruction Due to a Torsional Huge Meckel's Diverticulum

Meckel's diverticulum is an uncommon cause of acute abdominal pain and small bowel obstruction in adults. We present a case of a 28-yr-old man with acute pain for whom the diagnosis of Meckel's diverticulum was not suspected until exploratory laparotomy was performed. The procedure revealed a huge gangrenous Meckel's diverticum that was torsioned, and it gave rise to ileal obstruction.

A Case of Fulminant Hepatitis from Hepatitis A in a Child / 소아과

Fulminant hepatitis from hepatitis A in children is rare and has a low survival rate. We report a case of fulminant hepatitis from hepatitis A in a 12-year-old girl. The patient was admitted because of a three day history of fever, epigastric pain and vomiting. On her second hospital day, she had insomnia, anxiety, dysthesia, continuous fever, vomiting and nausea. In laboratory findings, decreased white blood cell and platelet count, markedly elevated serum aminotransferase levels, elevated serum bilirubin levels, prolonged prothrombin time and partial thromboplastin time were seen. Factor VIII appeared normal range. The histopathologic findings were necrosis in hepatic lobules, periportal necrosis, portal lymphocytic infiltration and fibrous portal expansion. We treated the patient with supportive care. After treatment, clinical manifestations and laboratory findings were improved.

Clinical Application of Sution-type Cigarette Drain for Hepatopancreatoabiliary Surgery

Commercially available intra-abdominal drains such as Penrose drain or closed suction drain have some demerits in either functional reliability of prolonged duration or easiness of bedside management. To cope with these demerits, we devised a Suction-type Cigarette Drain (SCD) and evaluated its usefulness. We made multiple side-holes at a silastic Penrose drain and a silastic tube. These two tubes were integrated as like a conventional cigarette drain. The outside portion of SCD was tightly tied to prevent air leak and the inner drainage tube was connected to a suction bag. SCD was applied to 26 cases of various hepatopancreatobiliary operations including pancreatoduodenectomy (n=10), distal pancreatectomy (n=4), hepatic posterior segmentectomy (n=3), partial cholecystectomy (n=7), and emergent laparotomy after liver transplantation (n=2). There was no significant fluid collection around the SCD in follow-up computed tomogram of all patients. All SCD remained functioning well at the time of removal (mean 13 days). There was no skin irritation, with the exception of 1 patient. Our experience supports that SCD is highly reliable and acceptably convenient for clinical use. We think that this type of intra-abdominal drainage deserves applying to various hepatopancreatobiliary operations.

Isolated Caudate Lobectomy with Bile Duct Resection Performed in a Patient with Type IV Hilar Bile Duct Cancer

The prognosis of hilar bile duct cancer has been improved by extensive curative resection, but limited functional reserve of the liver occasionally does not permit such a major hepatectomy. We report a type IV hilar bile duct cancer case undergone isolated caudate lobectomy as a limited but curative resection, in whom the indocyanine green retention test at 15 minutes revealed 23.9% despite long-term biliary decompression and the whole liver was rather atrophic. Complete removal of the Spiegel lobe, paracaval portion, and caudate process combined with hilar bile duct resection made 3 right and 4 left intrahepatic duct openings, which were reconstructed as a whole at each side of transection plane after ductoplasty. The patient recovered uneventfully. Although surgical technique for isolated caudate lobectomy must be more difficult comparing with other anatomical hepatectomy, but it can be a ultimate technique of limited curative resection for advanced hilar bile duct cancer patients with decreased hepatic reserve. Comprehension to the anatomy of the caudate lobe is a prerequisite for its resection, thus we discussed it in detail.

Gastric Aspirate Examination as an Index for Detection of Early Onset Neonatal Sepsis

PURPOSE: Our study was undertaken to evaluate the efficacy of gastric aspirate examination (GAE) in the early identification of early onset sepsis. METHODS: A retrospective chart review was done for a total 291 neonates who were admitted with high risk for early onset sepsis to Nowon Eulji Hospital neonatal intensive care unit between Jan. 1999 and Jan. 2003. Contents of gastric aspirate via nasogastric tube were analyzed with wet smear, gram stain and culture. Positive blood culuture was our definitive criterion for sepsis. GAE was considered positive when five or more leukocytes per high power field were counted on wet smear or when any bacteria were present on gram stain or when any organism grew on culture. RESULTS: Positive results in gastric aspirate examination are 57 patients (19.6%) in wet smear, 28 patients (9.6%) in gram stain, 30 patients (10.3%) in culture and positive result in blood is 27 patients (9.3%). There are no statistically correlation between gastric aspirate examinations and early onset sepsis. CONCLUSION: We concluded that gastric aspirate examinations are of limited value in predicting the diagnosis of early onset sepsis in neonate.

Popliteal Entrapment Syndrome

Popliteal artery entrapment syndrome, capable of causing intermittent claudication or even critical ischemia of the lower leg, is a rare disease that usually affects young men. This syndrome arises due to an abnormally medially displaced popliteal artery which has been entrapped and/or occluded by the medial head of the gastrocnemius muscle, especially in knee hyperextension posture. This report summarizes our experience with popliteal entrapment syndrome in 6 limbs of 5 patients treated during a 3-year period. Popliteal entrapment syndrome is more prevalent than previously appreciated. On the basis of our experience, early surgical intervention is recommended in all cases of entrapment at the time of diagnosis to avoid occlusion as a result of continued arterial wall degeneration.

A Case of Complete Hydatidiform Mole with Coexisting Surviving Fetus / 대한산부인과학회잡지

No abstract available.

Collagen-induced Activation of MMPs ( Membrane -type Matrix Metalloproteinase and Matrix Metalloproteinase-2) in ovarian cancer cell lines in Vitro / 대한산부인과학회잡지

OBJECTIVE: Metastatic dissemination of epithelial ovarian carcinoma is thought to be mediated via tumor cell exfoliation into the peritoneal cavity, followed adhesion to and invasion through the mesothelium which overlies the contents of the peritoneal cavity. MMP-2 is secreted as a zymogen, the activation of which has been associated with metastatic progression in human ovarian cancer cell lines. METHODS: We have utilized short-term cultures to analyze the effect of specific extracellular matrix proteins, type I collagen. RESULTS: Culturing Caov-4 ovarian cell line on type I collagen led to a significant increase in conversion of the MMP-2,72kD to the MMP-2,66kD, and MT-MMP expression. MT-MMP expression correlates with expression and activation of MMP-2 during malignant progression. Altered MT-MMP expression in ovarian cell lines might contribute to MMP-2 activation, which facilitates invasion of these tumors. CONCLUSION: In summary, we found increased expression of MT-MMP that correlated with increased level of activated MMP-2 and cellular counts in chemoinvasion assay in Caov-3 cell line. But no significant increases in Skov-4 cell line on type I collagen. Conclusion: These data suggest that type I collagen induces MMP-2 activation in part by up-regulation of MT-MMP expression but has a more complicated mode of action involving additional processes.

Prevalence and clinical significance of abnormal p53 gene in patients with ampullary adenocarcinoma / 대한내과학회지

BACKGROUND: Although abnormalities of p53 gene and their relation to clinicopathologic parameters have been identified in some human malignancies, there is little published data on their prevalence and clinical significance in ampullary adenocarcinoma (AAC). The aim of this study is to determine the prevalence of p53 abnormalities in AAC and to evaluate their relation to clinicopathologic features. METHOD:35 formaline-fixed paraffin-embedded tissues of AAC were examined for detection of p53 abnormalities by both single-strand conformation polymorphism (SSCP) analysis of polymerase chain reaction- amplified DNA fragments corresponding to exons 5-8 and immunohistochemistry (IHC) using monoclonal antibody to p53 protein (Novocastra, DO7), and the association between the p53 abnormalities and clinicopathologic parameters was analyzed. RESULT: In 22.9% of AAC, p53 gene muation was demonstrated by SSCP analysis, mainly at PCR-amplified exon 8 and exon 7. The p53 protein overexpression by IHC was 48.6% of AAC. Six SSCP and IHC-positive (17.2%) cases and 16 normal (45.7%) cases showed concordant results between the methods, although 13 cases (37.1%) showed discordance, including 11 IHC-positive (31.4%) and 2 SSCP-positive (5.7%) cases. Overall, the prevalence of p53 abnormalities was 54.3%. No significant associations between the p53 abnormalities and clinicopathological parameters such as clinical manifestations, histologic differentiation, and tumor stage were observed. CONCLUSION: The p53 abnormalities detected in 55% of AAC are not associated with prognostic factor, suggesting that abnormal p53 gene may play a role in the development of AAC, but not in its invasiveness.

Telomerase Activity in Gestational Trophoblastic Disease / 대한산부인과학회잡지

The purpose of this study was to evaluate the significance of telomerase activity in gestational trophoblastic disease and the association of telomerase activity in complete hydatidiform mole and subsequent development of persistent gestational trophoblastic tumor. By using the standard telomerase repeat assay, we examined telomerase activity in 2 normal placentas, 31 complete hydatidiform moles, 7 invasive moles, 5 choriocarcinoma tissues and choriocarcinoma cell line (JEG-3). Telomerase activity was detected in 13 of 15 (86.7%) complete hydatidiform mole patients who eventually had chemotherapy for the treatment of persistent gestational trophoblastic tumor. All of the 9 patients with metastatic disease (FIGO Stage III) had telomerase activity in their initial molar tissue. In contrast, telomerase activity was evident in only two of 16 (12.5%) complete hydatidiform mole patients with spontaneous remission. While telomerase activity was not detected in normal placentas, high level of telomerase activity was detected in all of 7 invasive moles, 5 choriocarcinoma tissues and choriocarcinoma cell line (JEG-3). The presence of telomerase activity in a complete hydatidiform mole is associated with the development of persistent gestational trophoblastic tumor, such as invasive mole and choriocarcinoma.

A Case of Concurrent Esophageal and Doudenal Double Primary Cancer / 대한소화기내시경학회지

The occurrence of double primary cancer of the esopbagus and duodenum is considered very rare. Moreover, it is difficult to manage this type of double cancer because esophageal cancer has a biologic tendency to early metastasis. We report a case of double primary cancer, which we have synchronously confirmed esophageal squamous cell carcinoma and duodenal adenocarcinoma with gastrofiberscopic biopsy, and then treated them by gastrojejunostomy and systemic chemotherapy.

Ileocolonoscopic and Histologic Studies in Ankylosing Spondylitis / 대한류마티스학회지

OBJECTIVE: To investigate the frequency of gut inflammation in the ankylosing spondylitis and the role of gut lesion in the pathogenesis of the ankylosing spondylitis. METHODS: Ileocolonoscopy and biopsy were performed in 24 patients with. ankylosing spondylitis. RESULTS: 1) Endoscopic lesions were observed in 7 patients(29.2%) of 24 patients and more often in the terminal ileum(6/7) than in the colon(I/7). Among 7 patients with endoscopic lesions, 5 patients were presented as juvenile chronic arthritis. 2) Histologic signs of gut inflammation were detected in 14 patients(58. 3%). Actue lesions were seen in 2 patients (8. 3%) and chronic lesions were seen in 12 patients (50%). 3) In 12 patients without the involvement of peripheral joints, acute lesion was not seen(0%), and chronic lesions were seen in 6 patients(50%). In 12 patients with the involvement of peripheral joints, acute lesions were seen in 2 patients (16.7%), and chronic lesions were seen in 6 patients(50%). Gut inflammations were more frequent in patients with the involvement of peripheral joints than in those without the involvement of peripheral joints. 4) In 12 patients without the administration of sulfasalazine, acute lesion was not seen(0%), and chronic lesions were seen in 7 patients(58.7%) In 12 patients with the administration of sulfasalazine, acute lesions were seen in 2 patients (16.7%), and chronic lesions were seen in 5 patients(41.6%). The frequency of gut lesions in patients without the administration of sulfasalazine was not different from that in patients with the administration. of sulfasalazine (p<0.05). CONCLUSION: Gut inflammation was frequently found in patients with ankylosing spondylitis. Chronic gut inflammation could play a role in the pathogenesis of the ankylosing spondylitis.

The Clinical Features of Skin Tags and the Association Between Skin Tags and Colonic Polyps / 대한피부과학회지

BACKGROUND: Skin tags are benign fleshy or darker colored papillomatous dermal tumors locatei mostly in the neck, axill or groin. Recent reports on a possible association between skin tags and colonic polyps, however, caused interest in these henign tumors of the dermis, especially wite regarding to their frequercy. OBJECTIVE: The purpose rate this study was to explore the clinical profiles of skin tags, the effect of obesity on the frequeny of skin tags and the association between skin tags and obesity in the normal population. We also tried to evaluate the usefulness of skin tags as a general marker for the presence of colonic piyps. METHODS: The first, 524 unselected patients were examined. The patient material comprised of 240 males and 284 females. Each patient was inspected with regard to skin tags by a clermatolgist. 334 patients were classified into obese groups and nonobese groups and then we evaluated the relationship between skin tags and the degree of obesity. The second, ninety consecutive patients referred for coloniscopic evaluation were examined to determine the association between skin tags and colonic polps. RESULTS: We found 22.9% of the males and 22.5% of the females to be skin tag carriers in the general population. We also noticed a steady increase of the frequency according to age eccept for the third decads. Of the skin tags found 51% were in the axillar region, 40% around the neck and 8% in the inguinal region. In the study for the relationship between skin tags and obesity, 44.9% of the obise patients and 23% of the nonobese patients were skin tag carriers(relative risk=1.95, p<0.05). In the study for the association between skin tags and colonic polyps in patients undergoing colonoscopic examination, 18 of patients with skin tags(45%) hnd colonic polyps and 11 of patients without skin tags(22%) had colonic polyps(relative risk=2.05, p<0.05). CONCLUSION: This study identified an obese group that are at risk of the developing skin tags. Consideration of skin tags as a marker for colonic polyps is likely to prove helpful.

A Case of Multiple small cell carcinoma in Esophagus and Cardia / 대한소화기내시경학회지

Small cell carcinoma does originate from APUD cells of any parts of the body. Usually the cases discovered in the lung and have poor prognosis. In esophagus only about 100 cases are reported world widely after McKneown reports in 1952 and only 2 cases were reported in Korea. There was a cese of small cell carcinoma developed multiple lesions in esophagus but no reports said that small cell carcinoma developed syncronously in esophagus and other organs. We are to report a case that showed a multiple lesions in esophagus and cardia. The patient 60 yeata old man, has suffered from the substernal discomfort and significant weight loss for one month.