Analysis of PAX8 immunohistochemistry in lung cancers: a meta-analysis

Background@#In this meta-analysis, we aimed to evaluate the PAX8 immunohistochemical expressions in primary lung cancers and metastatic cancers to the lung. @*Methods@#We identified and reviewed relevant articles from the PubMed databases. Ultimately, 18 articles were included in this meta-analysis. PAX8 expression rates were analyzed and compared between primary and metastatic lung cancers. @*Results@#The PAX8 expression rate in primary lung cancers was 0.042 (95% confidence interval [CI], 0.025 to 0.071). PAX8 expression rates of small cell (0.129; 95% CI, 0.022 to 0.496) and non-small cell carcinomas of the lung (0.037; 95% CI, 0.022 to 0.061) were significantly different (p=.049 in a meta-regression test). However, the PAX8 expression rates of adenocarcinoma (0.013; 95% CI, 0.006 to 0.031) and squamous cell carcinoma (0.040; 95% CI, 0.016 to 0.097) were not significantly different. PAX8 expression rates of metastatic carcinomas to the lung varied, ranging from 1.8% to 94.9%. Metastatic carcinomas from the lung to other organs had a PAX8 expression rate of 6.3%. The PAX8 expression rates of metastatic carcinomas from the female genital organs, kidneys, and thyroid gland to the lung were higher than those of other metastatic carcinomas. @*Conclusions@#Primary lung cancers had a low PAX8 expression rate regardless of tumor subtype. However, the PAX8 expression rates of metastatic carcinomas from the female genital organs, kidneys, and thyroid were significantly higher than those of primary lung cancers.

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy for Treatment of Calcium Channel Blockers, Angiotensin II Receptor Blockers, and Metformin Overdose

An overdose of antihypertensive agents, such calcium channel blockers (CCBs) and angiotensin II receptor blocker (ARBs), and the antihyperglycemic agent, metformin, leads to hypotension and lactic acidosis, respectively. A 40-year-old hypertensive and diabetic man with hyperlipidemia and a weight of 110 kg presented to the emergency room with vomiting, dizziness, and hypotension following an attempted drug overdose suicide with combined CCBs, ARBs, 3-hydroxy-3-methylglutaryl-coemzyme A reductase inhibitors, and metformins. A conventional medical treatment initially administered proved ineffective. The treatment was then changed to simultaneous extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT), which was effective. This shows that simultaneous ECMO and CRRT can be an effective treatment protocol in cases of ineffective conventional medical therapy for hypotension and lactic acidosis due to an overdose of antihypertensive agents and metformin, respectively.

Analysis of Risk Factors for Conversion from Off-Pump to On-Pump Coronary Artery Bypass Graft

BACKGROUND: Off-pump coronary artery bypass (OPCAB) is performed worldwide, but significant risks are associated with conversion to on-pump surgery. Therefore, we evaluated the composite outcomes between an OPCAB group and a conversion group. METHODS: From January 2008 to December 2012, 100 consecutive patients underwent OPCAB at Hallym University Sacred Heart Hospital, of whom 84 underwent OPCAB without adverse events (OPCAB group), and 16 were converted to on-pump surgery (conversion group). Early morbidity, early and long-term mortality, and major adverse cardiac and cerebrovascular events (MACCEs) were the primary and long-term composite endpoints. RESULTS: The mean follow-up period was 55±26 months, with 93% of the patients completing follow-up. The composite outcomes in the OPCAB and conversion groups were as follows: early morbidity, 2.3% versus 12.5%; early mortality, 4.7% versus 0%; long-term mortality, 14.3% versus 25.0%; and MACCEs, 14.3% versus 18.8%, respectively. No composite endpoints showed statistically significant differences. Preoperative acute myocardial infarction (AMI) was identified as an independent risk factor for conversion (p=0.025). CONCLUSION: The conversion group showed no statistically significant differences in early mortality and morbidity, MACCEs, or long-term mortality compared with the OPCAB group. The preoperative diagnosis of AMI was associated with an increased number of conversions to on-pump surgery.

Extravascular Migration of a Fractured Inferior Vena Cava Filter Strut

A 20-year-old man presented with a femur fracture and epidural hemorrhage (EDH) following a fall. One month after fracture surgery, swelling developed in both legs, and he was diagnosed as having a deep-vein thrombosis and pulmonary embolism. A retrievable inferior vena cava filter (IVCF) was inserted, because EDH is a contraindication to anticoagulants. Four months later, he complained of abdominal pain, and a computed tomography scan showed a fractured IVCF strut. After percutaneous removal failed 3 times, the IVCF was surgically removed by orthopedists using a portable image intensifier without cardiopulmonary bypass.

Hemoglobin Level to Facilitate Off-Pump Coronary Artery Bypass without Transfusion

BACKGROUND: Conservation of blood during cardiac surgery is important because of the shortage of donor blood, risks associated with transfusion, and the costs of allogeneic blood products. This retrospective study explored the feasibility of off-pump coronary artery bypass (OPCAB) without transfusion. METHODS: One hundred and two consecutive patients underwent OPCAB from January 2007 to June 2012 at Hallym University Sacred Heart Hospital. Excluding 10 chronic renal failures patients, 102 patients were enrolled. Their characteristics, clinical data, and laboratory data were analyzed. We investigated the success rate of OPCAB without transfusion according to preoperative hemoglobin (Hb), and the cutoff point of the Hb level and the risk factors for transfusion. We implemented multidisciplinary blood-saving protocols. RESULTS: The overall operative mortality and the success rate of OPCAB without transfusion were 2.9% (3/102) and 73.5% (75/102). The success rates in patients with Hb70 years, diagnosis of acute myocardial infarction, preoperative Hb and creatinine levels, and operation time. The events precipitating the need for transfusion were low Hb level in 9 patients and hypotension or excessive bleeding in 18 patients. CONCLUSION: The preoperative Hb level of >11 facilitates OPCAB without transfusion. These results suggest that transfusion-free OPCAB can be performed by modifying the risk factors and correctable causes of transfusion and improving various blood salvage methods.

Cardiac Resynchronization Therapy Using a Dual Chamber Pacemaker in Patients with Severe Left Ventricular Dysfunction and a Left Bundle Branch Block

Through the use of a dual chamber (DDD) pacemaker, we achieved a cardiac resynchronization effect in a 51-year-old female patient who was transferred to our hospital from another hospital for an operation for three-vessel coronary artery disease. Her electrocardiogram showed a left bundle branch block (LBBB) and a prolonged QRS interval of 166 milliseconds. Severe left ventricle (LV) dysfunction was diagnosed via echocardiography. Coronary artery bypass grafting (CABG) was then performed. In order to accelerate left atrial activation and reduce the conduction defect, DDD pacing using right atrial and left and right ventricular pacing wires was initiated postoperatively. The cardiac output was measured immediately, and one and twelve hours after arrival in the intensive care unit. The cardiac output changed from 2.8, 2.4, and 3.6 L/min without pacing to 3.5, 3.4, and 3.5 L/min on initiation of pacing. The biventricular synchronization using DDD pacing was turned off 18 hours after surgery. She was transferred to a general ward with a cardiac output of 3.9 L/min. In patients with coronary artery disease, severe LV dysfunction, and LBBB, cardiac resynchronization therapy can be achieved through DDD pacing after CABG.

A Hybrid Procedure for Atrial Fibrillation Using Total Thoracoscopic Ablation and Post-Procedural Electrophysiological Confirmation of Ablation Lines

Atrial fibrillation (AF) is the most common chronic arrhythmia in the world, and it is associated with an increased long-term risk of stroke, heart failure, and all-cause mortality. To overcome the limitations of transvenous radiofrequency (RF) ablation for AF, total thoracoscopic ablation (TTA) has evolved as a new technique. TTA has several advantages over transvenous RF ablation and is known to produce better outcomes, especially in patients with persistent AF. Herein, we report 2 cases of successful TTA followed by an electrophysiological study confirming satisfactory ablation lines; the first such procedure reported in Korea.

Surgical Experience of Ascending Aorta and Aortic Valve Replacement in Patient with Calcified Aorta

BACKGROUND: The conventional method of aortic cross-clamping is very difficult and increases the risk of cerebral infarct due to embolism of the calcified aorta in these patients. Accordingly, we analyzed our experience with 11 cases of ascending aorta and aortic valve replacement with hypothermic circulatory arrest. MATERIALS AND METHODS: From January 2002 to December 2009, 11 patients had ascending aorta and aortic valve replacement with hypothermic arrest at our hospital. We performed a retrospective study. RESULTS: There were 5 males and 6 females, with a mean age of 68 years (range, 44 to 82 years). Eight patients had aortic stenosis, and 3 patients had aortic regurgitation. An aortic cannula was inserted into the right axillary artery in 3 patients and ascending aorta in 6 patients. Two patients with aortic regurgitation had a remote access perfusion catheter inserted though the right femoral artery. The mean cardiopulmonary bypass time was 180 minutes (range, 110 to 306 minutes) and mean hypothermic circulatory arrest time was 30 minutes (range, 20 to 48 minutes). The mean rectal temperature during hypothermic circulatory arrest was 21degrees C (range, 19degrees C to 23degrees C). No patient had any new onset of cerebral infarct or cardiovascular accident after surgery. There was no hospital mortality. Early complications occurred in 1 patient who needed reoperation due to postoperative bleeding. Late complications occurred in 1 patient who underwent a Bentall operation due to prosthetic valve endocarditis. The mean follow-up duration was 32 months (range, 1 month to 8 years) and 1 patient died suddenly due to unknown causes after 5 years. CONCLUSION: Patients with a calcified aorta can be safely treated with a technique based on aorta and aortic valve replacement under hypothermic circulatory arrest.

Endovenous Laser Treatment (EVLT) with High Ligation of an Incompetent Small Saphenous Vein / 대한흉부외과학회지

BACKGROUND: Endovenous laser treatment (EVLT) has recently been introduced as a less invasive technique for treating an incompetent small saphenous vein and many good results have been reported. The purpose of this study is to assess the efficacy and safety of EVLT combined with high ligation in patients with an incompetent small saphenous vein. MATERIAL AND METHOD: The study included 60 patients (66 limbs) who were treated with EVLT combined with high ligation of an incompetent small saphenous vein between January 2006 and May 2009. The preoperative clinical findings, the postoperative results and the postoperative ultrasonography follow up results at 1 and 3 months were reviewed. RESULT: Postoperative complications were observed in 17 patients (15 limbs, 28.3%) and postoperative paresthesia occurred in 5 limbs (7.6%), but there was no deep vein thrombosis. Ultrasonography follow up at 3 month was performed in 93.9% of the limbs (62/66). The vein occlusion rate at 1 and 3 months were found to be 91.9% (57/62) and 90.3% (56/62), respectively. CONCLUSION: We performed EVLT combined with high ligation and ambulatory phlebectomy in patients with an incompetent small saphenous vein, and this all revealed relatively satisfactory results with a low complication rate, but it showed a relatively low cure rate even though we also performed EVLT combined with high ligation altogether. We need to determine whether EVLT combined with a high ligation procedure will improve the venous occlusion rate. We also need to investigate how we can minimize the occurrence of nerve injury.

Left Atrial Rupture with Stable Vital Signs: A case report / 대한흉부외과학회지

Cardiac rupture after blunt chest trauma is a relatively uncommon diagnosis, and it is associated with a very high mortality rate. A 41-years-old man crashed his car into a guardrail and he was then transported to hospital. Although unstable vital signs are the most common symptoms of cardiac injury, this patient had stable vital signs. The chest CT scan showed pericardial effusion, and echocardiography did not clearly reveal cardiac tamponade, but the right atrium was slightly collapsed. Cardiac injury was suspected, and surgery was commenced for obtaining the diagnosis and treatment. A 2 cm laceration at the junction of the left atrium and the left inferior pulmonary vein was discovered and this was repaired with 4~0 Polypropylne monofilament sutures. We report here on the successful management of a patient with left atrial rupture following blunt chest trauma.

Risk Factors and Prognostic Influences of Burn Wound Infection

PURPOSE: Among persons sustaining severe burns, burn wound infection may develop into devastating sepsis. The purpose of this study is to validate the risk factors for burn wound infection in order to increase the effectiveness of the early treament of those patients at high risk for burn wound infection. METHODS: We retrospectively evaluated 155 hospitalized burn patients with an affected burn area greater than 20% extent and who underwent wound culture because of clinically suspected wound infection from March 1997 to December 2000. RESULTS: When patient age, cause of burn, total burn surface area (TBSA), full thickness burn area (FTBA), anatomical distribution of burn, dehydration at admission treated as independent variables, TBSA and FTBA were seen to significantly influence the burn wound infection rate (p<0.05). When the length of hospital stay, interval from burn to skin graft, outcome of burn were taken as independent variables, the length of hospital stay and outcome of burn were significantly influenced by burn wound infection (p<0.05). CONCLUSION: The high risk group for wound infection comprises patients with extensive TBSA or FTBA and should be selected early to undergo intensive treatment as follows ; meticulous wound monitoring and aseptic maneuver, early eschar excision and early skin graft, adequate nutritional support, isolation against hospital-acquired infection, judicious antibiotic management based on antimicrobial susceptibility testing and control of emergent antibiotic-resistant bacteria.

A Comparison of Open and Laparoscopic Cholecystectomy for Patients with Liver Cirrhosis / 한국간담췌외과학회지

BACKGROUNDS/AIMS: Cholelithiasis is a prevalent diseases worldwide and it is known that its incidence is twice as common in cirrhotic patients compared with noncirrhotic patients. Liver cirrhosis is a critical factor contributing to morbidity and mortality in biliary tract surgery, as patient with cirrhosis are at particular risk of developing bleeding, infection and intractable ascites. Recently laparoscopic cholecystectomy has become the procedure of choice for cholelithiasis in the general population. This retrospective study was conducted to assess the effective treatment by comparing the results of open cholecystectomy versus laparoscopic cholecytectomy in cirrhotic patients. METHODS: Between January 1991 and December 1998, 53 patients with liver cirrhosis underwent cholecystectomy for cholelithiasis in the department of surgery at asan medical center. The patients were classified into two groups: one consisting of 18 patients who underwent open cholecystectomy and another consisting of 35 patients who underwent laparoscopic cholecystectomy. All cases that converse to an open cholecystectomy from a laparoscopic cholecystectomy were excluded from this analysis. RESULTS: No statistical difference was observed in the duration of surgery(OC: 110.6+/-32.6 vs. LC: 82.1 +/-26.7 min, p>0.05). Laparoscopic cholecystectomy was followed by a significantly smaller intraoperative blood loss(OC: 730.5+/-384.6 vs. LC: 324+/-168 ml, p<0.05), a earlier resumption of a normal diet(OC: 4.3+/-1.3 vs. LC: 1.3+/-0.4 days, p<0.05), and a shorter hospital stay(OC: 13.8+/-6.1 vs. LC: 4.7 +/-2.1 days, p<0.05) in comparison to open cholecystectomy. Postoperative complications in laparoscopic cholecystectomy group was significantly less(OC: 9 vs. LC: 4, p<0.05). There was no operative mortality in both group. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in compensated cirrhotic patients and may be the procedure of choice whenever cholecystectomy is indicated in a cirrhotic patient because it may be associated with more advantages.

Long-Term Results of a Hepatopancreatoduodenectomy for Biliary-Tract Cancer

PURPOSE: The majority of carcinomas of the biliary tract are often diagnosed at an advanced stage, despite improved diagnostic capabilities. Aggressive surgery is generally recommended in an attempt to cure the advanced disease because only complete resection of the tumor can provide a chance to improve the survival rate. Thus, the purpose of this research was to assess the effectiveness of a hepatopancreato duodenectomy (HPD) in patients with both advanced gallbladder cancer directly invading adjacent organs and diffuse bile-duct cancer by analyzing the long term results of an HPD. METHODS: Forty patients underwent an HPD at Asan Medical Center from December 1993 to May 1999, and their cases were retrospectively reviewed. Gallbladder cancers was present in 14 of the patients and bile-duct cancers in 24 cases; the other 2 cases were benign. Cancers were classified by using the criteria of the American Joint Commission on Cancer (AJCC). Survival curves were calculated by using the Kaplan-Meier method. The median follow-up was 35 months. RESULTS: Hepatectomies varied from a right trisegmentectomy to an S4aS5 subsegmentectomy. There were 19 (47.5%) major postoperative complications, including intraabdominal bleeding, intestinal obstruction, liver abscess, and others. Of the 14 patients experiencing tumor recurrence, 7 (50%) cases involved the remnant liver. There were 4 (10%) perioperative mortalities. The 5 (22.7%) patients who with stage IVa and IVb cancer (22 cases) survived more than 3 years are all still alive and without tumor recurrence. The 1-and 3-year cumulative survival rates for gallbladder cancer were 83.3% and 48.5%, respectively, and those for bile-duct cancer were 83.3% and 49.7%. The differences in survival between the groups was not statistically significant, excluding perioperative deaths. The median survival was 13.7 months. CONCLUSION: An HPD is indicated for either advanced gallbladdercancer or diffuse bile-duct cancer because complete resection through this surgical procedure can provide a chance to improve survival. It is necessary to decrease perioperative mortality and morbidity by complete preoperative evaluation, meticulous operative manipulation, and intensive postoperative care.

Anterior Segment Congestion of a Right Liver Lobe Graft in Living Donor Liver Transplantation and its Strategy to Prevent Congestion / 대한이식학회지

PURPOSE: A left lobe graft from a small donor will not meet the metabolic demands of a larger recipient in adult-to-adult living donor liver transplantation (LDLT). One solution to this problem is to use a right lobe graft. However, the necessity of the middle hepatic vein (MHV) drainage from the anterior segment of a right lobe graft was not yet clearly described in the literatures. METHODS: From July 1997 to February 1998, five right lobe grafts without having a MHV drainage were implanted in 5 recipients with 2 HBV-cirrhosis, 2 fulminant hepatic failure and 1 secondary biliary cirrhosis. The graft weight ranged from 650 gm to 1000 gm, and their volume ranged from 48% to 83% of the ideal liver mass of the recipients. RESULTS: Two grafts showed severe congestion of the anterior segment immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction in each patient postoperatively. Eventually, one patient died of sepsis on posttransplant 20th day demonstrating progressive hepatic dysfunction. CONCLUSION: A right lobe graft without having MHV drainage might result in severe congestion of the anterior segment, which was able to lead to the patient's death in an extreme situation. Preservation of the anterior segment venous drainage in the right lobe graft is possible by two harvesting method: an extended right lobe (ERL) graft in which MHV is included in the graft and a modified right lobe (MRL) graft in which venous tributaries of the anterior sement were reconstructed via interposition vein grafts into the recipient's hepatic venous system. Theoretically, in a view point of donor safety, a MRL graft is more advantageous than an ERL graft because MHV is left in the donor liver. Here, we report our experiences of 27 MRL grafts in adult-to-adult LDLTs.

Impact of Anti-HCV(+) on Renal Transplantation

BACKGROUND: A high incidence of chronic liver disease is reported in end-stage renal failure patients due to hemodialysis and blood transfusion. An average of 20% of the patients who received renal hemodialysis are infected with hepatitis C virus, but the incidence of infection in these patients varies widely according to geographic location and the diagnostic methods used. Controversy exists regarding the impact of pretransplantation HCV infection on the outcome of renal transplantation. We measured the seroprevalence of the antibody to hepatitis C (anti-HCV) in renal transplant candidates and compared the prevalence of posttransplantation liver disease, graft, and patient survival among renal transplant recipients with and without anti-HCV at the time of the transplantation, and we attempted to define the possible factors affecting the clinical course following renal transplant in positive HCV patients. METHODS: Between June 1990 and December 1997, 634 patients underwent renal transplants at our institute. Viral infection with hepatitis were analyzed in these patients by using anti-HCV positivity using first, second, and third generation EIA, and RT-PCR. RESULTS: Twelve (12) of the 634 (1.9%) had positive anti-HCV before renal transplantation. During a mean follow-up of 29.4 months, viral mRNA was detected in the pretransplantation serum in 3 out of 8 (37.5%) positive anti-HCV patients. Among the 12 patients with positive anti-HCV, 2 (16.6%) showed early liver dysfunction, and 1 (8.3%) showed histologic progression to chronic hepatitis leading to hepatic failure and death. Graft loss occurred in 1 of the 12 (8.3%) patients with positive anti-HCV and in 62 of the 622 (9.8%) patients with negative anti-HCV. Three (3) out of the 12 (25%) patients with positive anti-HCV, and 121 of the 622 (19.6%) patients with negative anti-HCV had episodes of rejection. One (1) of the 12 (8.3%) patients with positive anti-HCV and 26 of the 622 (4.2%) patients with negative anti-HCV died after kidney transplantation. There were no statistical differences in patients or graft survival between the positive anti-HCV (+) and the negative anti-HCV patients. CONCLUSION: From these results, we can assume that the presence of anti-HCV without advance liver disease should not be a contraindication for kidney transplantation.

Results of Use of Hepatitis B Core Antibody-Positive Donors in Living Donor Liver Transplantation with Passive Immunoprophylaxis / 한국간담췌외과학회지

BACKGROUND: In Korea, the number of patients enrolled in liver transplantation registry exceeds the supply of cadaveric donor. This donor shortage leads to living donor liver transplantation(LDLT). Due to wide prevalence of hepatitis B in Korea, many healthy donors for LDLT shows hepatitis B surface antigen-negative[HBsAg(-)] and core antibody-positive [HBcAb(+)]. However, the risk of using graft livers from HBsAg(-) and HBcAb(+) donors has not been clearly defined. The aim of this study is to identify the safety of using HBcAb(+) donor and the effectiveness of passive immunoprophylaxis with hepatitis B immunoglobulin(HBIG) in non-hepatitis B virus induced cirrhotic recipients. METHODS: From December 1994 to July 1998, 59 patients underwent living donor liver transplantation at the Asan Medical Center. Among them, 35 cases were non-hepatitis B virus induced cirrhotic recipients. Of these 35 recipients, 14 patients received liver graft from HBsAg(-) and HBcAb(+) donors and prophylactic passive immunoprophylaxis with HBIG. RESULTS: Eleven cases remained HBsAg(-) with HBIG immunoprophylaxis. Three of 14 recipients who were HBsAg(-) converted to HBsAg(+) serologically after receiving HBcAb(+) donor liver. All of these 3 cases did not receive HBIG therapy. CONCLUSIONS: Passive immunoprophylaxis with HBIG may prevent non-hepatitis B induced cirrhotic recipients from converting to HBsAg(+) status by using HBcAb(+) donor. Our experience suggests that HBcAb(+) donors can be accepted as potential donors in living donor liver transplantation.