Laparoscopic internal fixation is a viable alternative option for continuous ambulatory peritoneal dialysis catheter insertion / 대한외과학회지

PURPOSE: One of the major drawbacks of peritoneal dialysis (PD) is catheter migration and dysfunction. Preventing catheter migration is one of the main concerns. We compared laparoscopic internal fixation method with open surgical method for catheter migration rates. METHODS: From January 2008 to August 2009, PD catheters were inserted by laparoscopic fixation (LF) method in 22 patients and by open surgery (OS) in 32 patients. Clinical data were reviewed retrospectively. The frequency of migration, peritonitis, and other complications were compared. Catheter and patient survival rates were also compared. RESULTS: The mean age and sex ratio were not different between groups. Mean follow-up duration was 29.1 months in LF group and 26.1 months in OS group. More patients in LF group (27.3%) had history of laparotomy than in OS group (3.1%) (P = 0.01). The mean operation time was significantly longer in LF group (101.6 +/- 30.4 minutes) than in OS group (72.4 +/- 26.03 minutes) (P = 0.00). The cumulative incidence of catheter migration was 65.6% in OS group and 13.6% in LF group (P = 0.00). Migration-free catheter survival was higher in LF group (P = 0.001). There were no differences in complication rates between groups. Overall catheter survival was similar (P = 0.93). Patient survival rate at 2 years was not different (P = 0.13). CONCLUSION: Laparoscopic internal fixation of continuous ambulatory peritoneal dialysis catheter significantly reduces migration rates without any addition of complications. Also, laparoscopic technique did not incur patient morbidity or mortality despite the requirement for general endotracheal anesthesia and longer operation time. Therefore, internal fixation can be afforded safely in patients with previous abdominal surgery as either a salvage or preventive measure in patients with repeated catheter migration.

Symptomatic Renal Artery Aneurysm Dealt with Aneurysmectomy and Patch Closure / 대한혈관외과학회지

Renal artery aneurysm (RAA) is a rare disease, and the precise incidence has not been very well known. It appears that with the increasing use of diagnostic ultrasound, computed tomography and arteriography, RAA are being identified more frequently than in the past. Rupture of RAA is associated with 10% mortality and the chance of nephrectomy is very high. Although, most of renal artery aneurysms are treated by endovascular technique, surgery is often necessary for aneurysms associated with bifurcation area or large braches. Here, we report a case of saccular renal artery aneurysm which was managed by open surgery.

Initial Experience of Hybrid Vascular Operation / 대한혈관외과학회지

PURPOSE: Despite advances in the techniques and development of new devices, endovascular (EV) procedures are not the panacea for peripheral vascular diseases. This is partly because substantial cases are too complicated to manage with only EV procedures and partly because of the relatively large size of devices. We reviewed our experience of hybrid vascular procedures and report here on their outcomes. METHODS: Between August 2008 and March 2010, thirteen cases of hybrid vascular operation were performed. A retrospective review of electronic medical records was performed. The primary outcome measures were technical outcomes and patency rates. RESULTS: The mean follow-up duration was 17.7 months. Treatment indications were as follows: critical ischemia (n=6), claudication (n=3), abdominal aortic aneurysm with leg ischemia (n=3), and unstable aortic atheroma with recurrent embolism (n=1). All operations were performed under local anesthesia in an angiography suite. A single surgeon and a single interventional radiologist performed all the major procedures together. Technical and clinical success rates were 92.3%. All limbs were salvaged in patients with critical ischemia. The primary patency rate of the 13 cases was 83.3% at 1 year. There was no in-hospital mortality. CONCLUSION: hybrid vascular operation is useful for patients with a complex vascular condition. The role of hybrid vascular operation should be established with regards to not only the cost benefit but also the long-term outcomes.

A Clinical Analysis of Abdominal Stab Wounds

PURPOSE: A classic approach to abdominal stab wounds has been a routine laparotomy for the purpose of diagnosis or treatment. However, management protocols for abdominal stab wounds are still contentious in most trauma centers. We examined the relationship between the character of the stab wound and the injured intraabdominal organs by retrospectively analyzing the medical records of patients with abdominal stab wounds admitted to Gil hospital, and the findings for our patients are then confronted with a review of the literature. We aimed to propose proper management protocols to approach abdominal stab wounds. METHODS: The medical records of all 80 patients sustaining abdominal stab wounds, admitted at the Department of Surgery, Gil Hospital, Gachon Medical School, from January 2004 to December 2008 were retrospectively reviewed. All the abdominal stab wounds were collated based on the site and the character of the injury, investigations performed on admission, results of investigations, operations performed and findings at the time of the operation. RESULTS: The most prevalent age group was patients in their forties and the average age of the patients was 41 years for both genders. The stab wounds were most commonly located at the periumbilical area (16.9%), followed by the epigastric area (15.6%), and 18.2% of the patients had multiple wounds. The most commonly eviscerated organ was the omentum (9 out of 16 cases); 61.7% of non-eviscerated patients underwent a therapeutic laparotomy while 81.3% of eviscerated patients underwent a therapeutic laparotomy. The small bowel was the most commonly injured organ (22.7%, 17 out of 75 injuries). The review revealed a relatively common diaphragmatic injury in abdominal stab wound patients (8 cases, 10.5%). The average hospital stay was 11 days. CONCLUSION: This review revealed commonly eviscerated and injured intraabdominal organs in abdominal stab wound patients and their relationship with a therapeutic laparotomy. Although the management is still controversial, the authors suggest indications for an immediate laparotomy and a protocol for managing abdominal stab wounds. Hemodynamic instability and peritoneal irritation signs are definite indicators for an immediate laparotomy, but the review revealed intraabdominal organ evisceration alone not to be a statistically significant factor. In addition, the authors suggest that abnormal CT findings can be valuable for making a decision on management of hemodynamically stable stab wound patients. Further study may clarify a role for a more selective approach to operative intervention and for a more extensive use of selective observation.

Successful Closure of Fasciotomy Wound by Application of Topical Negative Pressure

Fasciotomy wounds are a major contributor to prolonged hospital stay and can lead to amputation. Although it is generally recommended to close the fasciotomy wound as early as possible, it is usually challenging. Primary closure is more favorable because it commences more functional and esthetic results with less morbidity. But primary closure is difficult to achieve due to skin edema, retraction and necrosis. Topical negative pressure care (TNP) has been used in other areas of wound care, such as mediastinitis and burn wounds. TNP has recently gained popularity and has shown promising outcomes. Topical negative pressure systems are commercially available but very expensive. We designed a modified negative pressure system with wall-suction and applied it to a complicated fasciotomy wound. We herein report our experience with a review of related literatures.

Phased Reduction of Cyclosporine Combined with Mycophenolate Mofetil in Renal Transplant Recipients: Three-year Results of a Prospective Study

PURPOSE: Although cyclosporine (CsA) improves short-term renal graft outcomes, many paradigms reduce or withdraw this drug because of its nephrotoxicity. However, inadequate immunosuppression with azathioprine led to little success. We conducted a prospective study to define the prolonged effect of CsA reduction in stable renal transplant recipients with mycophenolate mofetil (MMF). METHODS: Thirty-nine primary renal transplant recipients were divided into two cohorts, the AZA (N=13) and the MMF cohort (N=26). Both cohorts were allowed to reduce the CsA dose up to 50% of baseline within 3 to 4 months of conversion to AZA or MMF. Graft function, clinical parameters, and adverse events were monitored for up to 3 years. RESULTS: Ccr gradually deteriorated in the AZA cohort, but was stable in the MMF cohort. There was no episode of acute rejection or graft loss observed in either cohort. CONCLUSION: The CsA dose can be reduced in combination with MMF treatment in stable renal transplant recipients after 2 years of transplantation, resulting in beneficial effects on Ccr, lipid profiles, and blood pressure.

Development and Clinical Implication of Post- transplant Diabetes Mellitus / 대한이식학회지

PURPOSE: It has been known that the incidence of post-transplant diabetes mellitus (PTDM) is variable according to the immunosuppressant used. The goals of this study are to uncover the factors associated with the development of PTDM and to clarify the fate of PTDM. METHODS: The medical records of 267 patients who underwent renal transplant between 1996 and December 2002 at Seoul National University Hospital were retrospectively reviewed. Patients were divided into three groups: cyclosporine group (CsA, n=179), high tacrolimus group (HFK, mean trough level during post-transplant 2 week>15 ng/m, n=33) and low tacrolimus group (LFK, mean trough level during post- transplant 2 week40year), family history of diabetes and obesity (BMI>25) were the risk factors for PTDM development. Incidences of associated clinical events, such as acute rejection, cerebrovascular accident, myocardial infarction, or infection were not different between PTDM and non-PTDM group. PTDM was resolved in 13 out of 46 patients (28.3%). Only 7 out of 33 patients (21.2%) in whom PTDM persisted lost their graft. CONCLUSION: PTDM incidence was higher in HFK group. So, LFK protocol is considered to be safe and beneficial, at least in terms of PTDM. Tacrolimus as immunosuppressant, recipient, family history of DM and obesity were the risk factors of PTDM development. PTDM was reversible in 28.3% of patients. PTDM had little impact on clinical outcomes during mid-term period.

Intestinal Obstruction Caused by Spontaneous Transomental Internal Hernia

A transomental hernia is a rare type of internal hernia. Only one case of this type of hernia has been reported in Korea whereas several cases have been described in other countries. This is the second case of a mechanical obstruction caused by a transomental internal hernia in Korea. We report this case with a brief review of the relevant literature.

Long-term Outcomes of Post-transplant Diabetes Mellitus in Renal Transplant Recipients / 대한이식학회지

PURPOSE: Post-transplant diabetes mellitus (PTDM) is believed to cause serious complications. PTDM might be one of the important risk factors of cardiovascular death after renal transplantation. Because the consequence of PTDM is expected to take long time, long-term follow-up is necessary. We performed this study not only to define the prevalence and risk factors of PTDM but also to define the long-term clinical impact of PTDM. METHODS: Among 508 patients who had received renal transplantation at Seoul National University Hospital between July 1969 and December 1995, 431 patients were included. Patients were grouped into PTDM and non-DM groups. The clinical characteristics were compared between two groups. RESULTS: Mean follow-up duration was 121.9 months (2~346 months). PTDM was developed in 68 (15.8%) patients. Recipient age at transplantation (P=0.004), family history of DM (P=0.000) and obesity (P= 0.000) were significant risk factors in multivariate analysis. Complications of PTDM such as cerebrovascular disease (CVD, P=0.040), ischemic heart disease (IHD, P=0.040), and infection (p=0.044) were significantly more frequent in PTDM group. The frequency of chronic allograft nephropathy (CAN) was not different between two groups. Although graft survival rate was not affected by PTDM, patient survival rate was significantly lower in PTDM group (P=0.002). CONCLUSION: PTDM increased complication rates such as CVD, IHD and infection. PTDM seemed not to affect graft survival, but to worsen the patient survival rate.

The Pattern & Change of Venous Reflux in Primary Varicose Vein

PURPOSE: Venous reflux in primary varicose vein arises from the saphenofemoral junction (SFJ), and the saphenopopliteal junction (SPJ) and it can arise from the non-junctional great saphenous vein (GSV) tributaries and, the non-saphenous veins. Superficial venous surgery (SVS) is associated with a significant improvement in the lower leg venous hemodynamics. We performed a retrospective study to examine the prevalence of the reflux pattern in the primary varicose veins and, to observe any change of non-junctional GSV reflux. METHOD: From May 2004 to July 2005, 481 patients (766 limbs) were diagnosed with venous incompetence by performing a duplex ultrasound examination. A follow-up duplex ultrasound examination was performed for a group of non-junctional GSV reflux patients and for a group of patient having both superficial vein reflux and deep vein reflux. RESULT: The prevalence of SFJ reflux, SPJ reflux, below the knee GSV reflux with competent SFJ and, non saphenous vein reflux was 82%, 13%, 10% and, 4.5% respectively. In the patients with SVS who had deep vein reflux (DVR), DVR was absent in only on two patients (6%). Eight patients (9.1%) of the 88 primary varicose vein patients had asymptomatic left iliac vein obstruction detected by performing an ascending venogram during radiofrequency ablation (RFA). On the duplex findings after SVS, the reflux pattern of left deep venous system was not different from the right deep venous system. CONCLUSION: Varicose veins may occur in any vein, even if junctional reflux is predominant. Careful duplex ultrasound evaluation will delineate the changing pattern of venous reflux with/without SVS. Although superficial venous surgery must fit the patient's map, the results might be variable. Prospective studies are needed to analyze the dynamics of venous reflux after SVS.

A Primary Leiomyosarcoma of the Inferior Vena Cava

Leiomyosarcoma of the inferior vena cava (IVC) is an uncommon tumor and usually shows poor prognosis. Complete surgical resection is the only proven therapy and the effect of adjuvant therapy on the patient's survival has still not been demonstrated. We recently, experienced a case of IVC leiomyosarcoma that had been surgically resected and the tumor was noted to have spread to the liver on follow up. Metastatic tumor was removed by hepatectomy without any further evidence of necurrence. We report here on this case of the IVC leiomyosarcoma along with conducting a review of the relevant literatures.

MMF-related Colitis Carrying GVHD-like Pathologic Feature in Renal Transplant Recipient / 대한이식학회지

BACKGROUND: Graft-Versus-Host Disease (GVHD) is known to be associated with bone marrow transplantion. It is very rare in solid organ transplantation, especially in renal transplantation. There were only a few reported cases of GVHD in pancreas, liver transplant recipients or transfusion associated GVHD in immunocompromised patients. CASE: A 36 years-old man received renal transplantation from his mother on May 20th, 1996. Cyclosporine A, azathioprine & prednisolone were used as immunosuppressants. There was no episode of acute rejection after transplantation. After transplantation, he suffered from cytomegalovirus (CMV) cystitis, bile duct stones. He had never been transfused blood products since transplantation. Thereafter, his post-transplantation course was quite favorable until December 20th, 2003, when troublesome diarrhea and weight loss developed. At that time, he was taking 1.25 g/day of MMF (25 mg/kg/day). Hospital course: The MMF dose was reduced to 500mg bid (312 mg/m2/dose or 20 mg/kg/day) under the suspicion of CMV colitis. The results of serologic test and culture for CMV were all negative. The colonoscopic biopsy revealed pathologic features such as crypt drop-out, crypt abscess, crypt atrophy, single cell apoptosis and goblet cell depletion just like in GVHD. He had no necrotic skin lesion and his liver function test was in normal range. However, his complete blood count showed pancytopenic features. The MMF was discontinued immediately after the pathologic results were reported. His diarrhea and other clinical sym-ptoms were disappeared, and the pancytopenic features recovered gradually after discontinuation of MMF. He also gained 2.6 kg weight and discharged with good graft function.