Clinical Characteristics of Primary Epiploic Appendagitis

PURPOSE: Primary epiploic appendagitis (PEA) is a rare cause of an acute abdomen. It can be clinically misdiagnosed as either diverticulitis or appendicitis on clinical examination because the clinical symptoms and signs of PEA are non-specific. The present study was performed to describe the clinical characteristics of PEA and to assess the differences between PEA and diverticulitis. METHODS: We reviewed the clinical records and radiologic findings of 31 consecutive patients with PEA and compared them with those of patients with diverticulitis without complications. RESULTS: In most cases, abdominal pain was localized to the right (13 cases, 41.9%) or left (13 cases, 41.9%) lower quadrants. Gastrointestinal symptoms such as nausea and vomiting were infrequent, and localized tenderness without peritoneal irritation was common. All patients were afebrile, and only 4 patients (12.9%) showed leukocytosis. In all cases except one, a pericolic fatty mass with a hyperattenuated ring was observed on computed tomography. Patients with left PEA were younger than those with diverticulitis (41.4 +/- 11.9 vs. 69.7 +/- 13.3, P < 0.001), and the mean body mass index was higher in patients with left PEA (26.4 +/- 2.9 vs. 22.6 +/- 3.4, P = 0.01). Whereas one patient (6.7%) with left PEA showed leukocytosis, the incidence of leukocytosis in patients with diverticulitis was 80% (8/10) (P < 0.001). CONCLUSION: In patients with an acute abdomen showing localized tenderness without associated symptoms or leukocytosis, a high index of suspicion for PEA is necessary. For correct diagnosis and proper management, it would useful for surgeons to be aware of the computed tomographic findings and the natural course of the disease.

Clinical Outcomes and Risk Factors of Traumatic Pancreatic Injuries

PURPOSE: Even though traumatic pancreatic injuries occur in only 0.2% to 4% of all abdominal injuries, the morbidity and the mortality rates associated with pancreatic injuries remain high. The aim of this study was to evaluate the clinical outcomes of traumatic pancreatic injuries and to identify predictors of mortality and morbidity. METHODS: We retrospectively reviewed the medical records of 26 consecutive patients with a pancreatic injury who underwent a laparotomy from January 2000 to December 2010. The data collected included demographic data, the mechanism of injury, the initial vital signs, the grade of pancreatic injury, the injury severity score (ISS), the revised trauma score (RTS), the Glasgow Coma Scale (GCS), the number of abbreviated injury scales (AIS), the number of associated injuries, the initial laboratory findings, the amount of blood transfusion, the type of operation, the mortality, the morbidity, and others. RESULTS: The overall mortality rate in our series was 23.0%, and the morbidity rate was 76.9%. Twenty patients (76.9%) had associated injuries to either intra-abdominal organs or extra-abdominal organs. Two patients (7.7%) underwent external drainage, and 18 patients (69.3%) underwent a distal pancreatectomy. Pancreaticoduodenectomies were performed in 6 patients (23.0%). Three patients underwent a re-laparotomy due to anastomosis leakage or postoperative bleeding, and all patients died. The univariate analysis revealed 11 factors (amount of transfusion, AAST grade, re-laparotomy, associated duodenal injury, base excess, APACHE II score, type of operation, operation time, RTS, associated colon injury, GCS) to be significantly associated with mortality (p<0.05). CONCLUSION: Whenever a surgeon manages a patient with traumatic pancreatic injury, the surgeon needs to consider the predictive risk factors. And, if possible, the patient should undergo a proper and meticulous, less invasive surgical procedure.

Comparison of clinical outcomes and hospital cost between open appendectomy and laparoscopic appendectomy / 대한외과학회지

PURPOSE: Laparoscopic appendectomy has been recognized to have many advantages such as greater cosmetic results, less postoperative pain and shorter hospital stays. On the other hand, the cost of laparoscopic procedures is still more expensive than that of open procedures in Korea. The aim of this study is to compare clinical outcomes and hospital costs between open appendectomy and laparoscopic appendectomy. METHODS: Between January 1, 2010 and December 31, 2010, 471 patients were diagnosed with acute appendicitis. Of these, 418 patients met the inclusion criteria and were divided into two groups of open appendectomy (OA) group and laparoscopic appendectomy (LA) group. We analyzed the clinical data and hospital costs. RESULTS: The mean operation time for laparoscopic appendectomy (72.17 minutes) was significantly longer than that of open appendectomy (46.26 minutes) (P = 0.0004). The mean amounts of intravenous analgesics for OA group (2.00 times) was greater than that of LA group (1.86 times) (P < 0.0001). The complication rate was similar between the two groups (OA, 6.99% vs. LA, 10.87%; P = 0.3662). The mean length of postoperative hospital stay was shorter in LA group (OA, 4.55 days vs. LA, 3.60 days; P = 0.0002). The mean total cost covered by the National Health Insurance was more expensive in LA group (OA, 1,259,842 won [Korean monetary unit] vs. LA, 1,664,367 won; P = 0.0057). CONCLUSION: Clinical outcomes of laparoscopic appendectomy were superior to that of open appendectomy even though the cost of laparoscopic appendectomy was more expensive than that of open appendectomy. Whenever surgeons manage a patient with appendicitis, laparoscopic appendectomy should be considered as the procedure of choice.

Comparison of clinical outcomes and hospital cost between open appendectomy and laparoscopic appendectomy / 대한외과학회지

PURPOSE: Laparoscopic appendectomy has been recognized to have many advantages such as greater cosmetic results, less postoperative pain and shorter hospital stays. On the other hand, the cost of laparoscopic procedures is still more expensive than that of open procedures in Korea. The aim of this study is to compare clinical outcomes and hospital costs between open appendectomy and laparoscopic appendectomy. METHODS: Between January 1, 2010 and December 31, 2010, 471 patients were diagnosed with acute appendicitis. Of these, 418 patients met the inclusion criteria and were divided into two groups of open appendectomy (OA) group and laparoscopic appendectomy (LA) group. We analyzed the clinical data and hospital costs. RESULTS: The mean operation time for laparoscopic appendectomy (72.17 minutes) was significantly longer than that of open appendectomy (46.26 minutes) (P = 0.0004). The mean amounts of intravenous analgesics for OA group (2.00 times) was greater than that of LA group (1.86 times) (P < 0.0001). The complication rate was similar between the two groups (OA, 6.99% vs. LA, 10.87%; P = 0.3662). The mean length of postoperative hospital stay was shorter in LA group (OA, 4.55 days vs. LA, 3.60 days; P = 0.0002). The mean total cost covered by the National Health Insurance was more expensive in LA group (OA, 1,259,842 won [Korean monetary unit] vs. LA, 1,664,367 won; P = 0.0057). CONCLUSION: Clinical outcomes of laparoscopic appendectomy were superior to that of open appendectomy even though the cost of laparoscopic appendectomy was more expensive than that of open appendectomy. Whenever surgeons manage a patient with appendicitis, laparoscopic appendectomy should be considered as the procedure of choice.

Clinical Review of Pneumatosis Intestinalis

PURPOSE: Pneumatosis intestinalis (PI) is increasingly being detected in recent years with the more frequent use of computerized tomography (CT). The present study was performed to evaluate the clinico-radiologic characteristic presentation of PI and to determine the prognostic factors for mortality. METHODS: Fifteen patients who were diagnosed with PI on CT between June 2000 and May 2010 were retrospectively reviewed. Age, sex, location of PI, presence of portal vein gas, time to diagnosis, American Society of Anesthesiologists (ASA) classification, Acute Physiology And Chronic Health Evaluation II (APACHE II), acidosis, shock, and other associated findings were analyzed for their association with outcome. RESULTS: Fifteen patients (7 males and 8 females, average age, 60.3 years) were diagnosed with PI. Mortality rate was 47% (7 patients). The mortality rate in patients with septic shock, APACHE II score (18), acidosis (pH<7.36) were all 100%, 87%, 100%, respectively (P<0.05). Age, sex, location of PI, portal vein gas, time to diagnosis, ASA classification, associated findings did not show statistical difference. CONCLUSION: Shock, APACHE II score (18) and acidosis were associated with high mortality in patients with PI. So, more intensive management and interest are recommended in patients with shock, APACHE II score (18), and acidosis due to PI.

Prognostic Factors for Complication and Mortality of Colonic Perforation

PURPOSE: The present study was performed to assess the outcomes in patients with colonic perforation and to determine the prognostic factors for mortality. METHODS: The cases of 42 patients who underwent surgery for colonic perforation between March 1999 and September 2008 were retrospectively reviewed. Age, sex, American Society of Anesthesiologists (ASA) classification, presence of preoperative shock, duration of symptoms, cause of perforation, location of perforation, degree of peritonitis, and the Mannheim Peritonitis Index (MPI) score were analyzed for their association with early outcome by using univariate and multivariate analyses. RESULTS: Diverticulitis (46%, 19 patients) and colorectal cancer (36%, 15 patients) were the most common causes of noniatrogenic colonic perforation, and the sigmoid colon was the most common site of perforation (60%, 25 patients). The postoperative mortality was 21.4% (9 patients). The mortality in patients with preoperative shock, with a MPI score of more than 25, and with Hinchey stage III or IV peritonitis were 70.0%, 57.1%, and 53.3%, respectively (P<0.001). No statistical difference was observed in postoperative mortality with regard to age, sex, ASA classification, duration of symptoms, cause of perforation, and location of perforation. According to the multivariate analysis, preoperative shock proved to be the only significant prognostic factor for mortality (P=0.027) (odds ratio: 19.8, 95% confidence interval: 1.4-276.9). CONCLUSION: Preoperative shock, a MPI score of more than 25, and Hinchey stage III or IV peritonitis were associated with high postoperative mortality in patients with colonic perforation. Especially, more intensive management and interest are required for patient s with preoperative shock due to colonic perforation.

Clinical Analysis of 473 Cases of Inguinal Hernia in Adult Patients

PURPOSE: This article compares the results of various methods of inguinal hernia repair in adults. METHODS: We retrospectively reviewed the medical records of 473 patients over 20 years of age who received an inguinal hernia repair procedure between January 2000 and June 2007. We analyzed the patients' clinical factors and outcomes, dividing them into five groups according to method of repair: Bassini group, Lichtenstein group, mesh plug group, Prolene Hernia System (PHS) group, and laparoscopic group. RESULTS: The mean number of used analgesics was significantly smaller in the PHS group than in other groups (P<0.05, PHS group: 0.46, Bassini group: 1.55, Lichtenstein group: 1.20, mesh plug group: 0.82, laparoscopic group: 1.44). The mean operation time was significantly shorter in the PHS group than in the other groups (P<0.05, PHS group: 45.18 min, Bassini group: 59.85 min, Lichtenstein group: 68.20 min, mesh plug group: 66.73 min, laparoscopic group: 83.33 min). Finally, the mean postoperative hospital staywas significantly shorter in the PHS group than in the other groups (P<0.05, PHS group: 2.93 day, Bassini group: 4.96 day, Lichtenstein group: 4.17 day, mesh plug group: 4.01 day, laparoscopic group: 5.11 day). Out of five groups, there was onecase of postoperative recurrence in the Bassini group. CONCLUSION: Mesh PHS operation is a more preferred method of inguinal hernia repair in adults because it offers a lower postoperative pain, shorter operation time, shorter postoperative hospital stay.

Colonic Obstruction Caused by Sigmoid Volvulus Combined with a Transomental Hernia: A Case Report

The case of sigmoid volvulus combined with a transomental hernia is reported. A 70-year-old man was admitted to our hospital with mild abdominal pain and distension. Although no signs of peritoneal irritation were apparent, a plain abdominal X-ray showed a markedly dilated loop of the sigmoid colon, and CT revealed a whirl pattern of the sigmoid mesentery. These findings suggested sigmoid volvulus. Colonoscopic reduction was attempted as an initial nonoperative treatment, and an urgent laparotomy was performed after the reduction failed. The sigmoid loop was herniated through the great omentum, with torsion in the clockwise direction. The colon was manually untwisted in the counter-clockwise direction, and the sigmoid loop was released by dividing the great omentum. During this one-stage operation, intraoperative colonic irrigation, sigmoid resection, and primary anastomosis were performed. The postoperative course was uneventful. Although sigmoid volvulus combined with a transomental hernia is rare, urgent surgical intervention is essential on failure of endoscopic reduction.

Rectal Foreign Body (Glass Cup) Extracted by Laparotomy

Anorectal trauma associated with retained rectal foreign body is an infrequent clinical problem, but presents a challenge to physicians taking care of patients with this problem. We report a case of rectal foreign body (glass cup) extracted by laparotomy. A 49-year-old male with a history of alcoholism presented to the emergency room four days after inserting a glass cup into his rectum. He complained of vague anal pain and failure to pass flatus or stool for four days. He had attempted to extract the glass cup using various methods (digital, instrumental manipulation, enema), none of which was successful. Computed tomography revealed a glass cup lodged in the rectum, without complication. The patient was brought to the operating room, administered spinal anesthesia, and placed in lithotomy position after failure of extraction in the emergency room. Although the object was palpable, it could not be extracted either manually or by the use of forceps. We decided to perform an emergent laparotomy under general anesthesia. After the abdomen was opened, an attempt was made to milk the object toward the distal rectum. However, this proved to be impossible secondary to severe rectal mucosal edema. The glass cup was eventually extracted through performing a colotomy at the rectosigmoid junction, with primary repair. The patient's postoperative course was uneventful, and he was discharged on the eighth postoperative day.

Skeletal Muscle Metastasis from Colorectal Cancer: Report of a Case

Metastases from colorectal cancer can occur by either lymphatic or hematogenous spread, and the sites most commonly involved are the liver and lung. Although skeletal muscle comprises a considerable portion of body mass and receives abundant blood supply, it is one of the most unusual sites of metastasis from any malignancies. We report a case of skeletal muscle metastasis from colorectal cancer. An 83-year-old female patient presented with a painful mass in the right posterior thigh. She had already undergone low anterior resection and right lobectomy of liver for rectal cancer with liver metastasis (T2N1M1) about 4 years ago. Although a follow-up computed tomography scan showed a metastatic solitary pulmonary nodule in the left lobe 2 years after the primary operation, she refused further aggressive treatment. Magnetic resonance imaging showed a localized mass in the semimembranosus muscle of the right thigh, and fine-needle aspiration cytology demonstrated clusters of atypical cells compatible with adenocarcinoma. The patient underwent excision of the painful mass located in the right semimembranosus muscle. Histologically, the thigh mass proved to be adenocarcinoma identical to the primary lesion. The patient died of heart failure on the 2nd postoperative day.

Clinical Analysis of Appendicitis in the Elderly Over 60 Years of Age

PURPOSE: As average life expectancies are prolonged, the elderly population is steadily increasing. The increasing number of elderly persons has been accompanied by cases of acute appendicitis in the elderly. In order to understand the clinical significance and to improve the treatment of elderly patients with appendicitis. we analyzed patients over 60 years of age with appendicitis. METHODS: We retrospectively reviewed the medical records of 268 patients over 60 years of age who were pathologically diagnosed with appendicitis. We analyzed the patients' clinicopathologic factors and outcomes, dividing them into 3 age groups: 60~69, 70~79, 80 and over. RESULTS: Of the 268 patients, there were 109 male and 159 female. The sex ratio was 1:1.46. The numbers of patients in each group were 169 (63.1%) in the 60-69 group, 73 (27.2%) in the 70~79 group, and 26 (9.7%) in the over 80 group. There was no difference in the leukocyte count and the time delay in surgical treatment between the groups. In the older groups, compared to the younger groups, there were more frequent paramedian and median incisions in the operation (P=0.02), a longer duration of postoperative admission (P=0.001) and starvation after the operation (P<0.001). In the pathologic findings, the gangrenous and abscess stages of appendicitis were more frequent in the older groups than in the younger groups (P<0.001). CONCLUSIONS: Early aggressive diagnostic intervention, such as ultrasound and CT, is essential in managing appendicitis in elderly patients who complain of vague abdominal pain.

Abdominal Traumatic Handlebar Hernia

Traumatic abdominal wall hernia (TAWH) is an unusual type of hernia that may follow direct blunt trauma to the abdomen. Moreover, TAWH that is caused by bicycle handlebars is a rare finding. Despite an overall increase in the incidence of blunt abdominal trauma, the cases of TAWH remain rare, probably due to the elasticity of the abdominal wall for resisting the shear forces generated by a traumatic impact. Although the first case was described by Selby in 1906, very few cases of TAWH have been reported in the literature. Also, "Handlebar hernia" was described by Dimyan et al. in 1980. These injuries are localized hernias resulting from local blunt trauma to the abdominal wall from an object with insufficient force to penetrate the skin, yet this trauman is able to disrupt the deeper tissues of the muscle and fascia. The significance of such hernias is underestimated, and although they can be not immediately life-threatening, they can be fatal if associated with such complications as incarceration and strangulation. We describe here a case of traumatic handlebar hernia in a 55-year old man who presented with left lower quadrant pain that was caused by a motorcycle accident.

A Case of Mesenchymal Chondrosarcoma In Pancreas

Mesenchymal chondrosarcomas are very rare tumors, and they are more aggressive in comparison to the conventional type tumors. They can occur in any location containing mesenchymal cells, but most of them arise in the lower extremities, the leptomeninges and the eye orbits. Other sites are very uncommon and they represent approximately 1% of all chondrosarcomas; these rare tumor locations carry a poor prognosis. In this report, we present a case of extraskeletal mesenchymal chondrosarcoma of the pancreas. We could find only one case of extraskeletal mesenchymal chondrosarcoma with pancreatic metastasis from thigh in our PubMed-line search. We describe here a case of primary originating mesenchymal chondrosarcoma of the pancreas in a 40-year old man who presented with abdominal pain, and this is the first report of the pancreas as the primary origin of mesenchymal chondrosarcoma.

A Case of Metastatic Thyroid-Papillary Carcinoma to the Breast / 한국유방암학회지

We report a case of metastatic thyroid-papillary carcinoma of the breast. A 42-year-old woman was admitted to our hospital due to palpable masses on both breasts. Past history revealed that she had three individual thyroid operations due to thyroid papillary carcinoma. The first was a left lobectomy 6 years ago, the second was a subtotal thyroidectomy 2 years ago, and the third was a excision of the neck mass due to last year's recurrence. The patient underwent mass excisions on both breasts under the impression of a benign tumor. Pathologic findings of the masses showed similar histologic findings of the thyroid papillary carcinoma and immunohistochemical stainings demonstrated that the tumors originated from the thyroid.

Expression of Vascular Endothelial Growth Factor (VEGF) and p53 in Colorectal Cancer

PURPOSE: Neovascularization has been shown to be essential for the growth of solid tumors. Vascular endothelial growth factor (VEGF) is one of the most important mediators of angiogenesis, and recent studies have demonstrated that the p53 tumor suppressor gene plays an important role in controlling tumor angiogenesis. We examined the expression of VEGF and p53 as a function of microvessel density to evaluate its clinical significance in colorectal cancer and to investigate the correlation of VEGF and p53. METHODS: The study material included 20 patients who survived more than 5 years postoperatively without distant metastasis (non-metastasis group) and 21 patients who had synchronous (10 patients) and metachronous (11 patients) metastasis (metastasis group). Immunohistochemical staining for VEGF, p53 protein and factor VIII-related antigen was done. RESULTS: The expression rate of VEGF was 20% in non-metastatic tumors and 71% in metastatic tumors (p<0.05). The VEGF expression was not correlated with microvessel density. Otherwise, the microvessel density were 32.9 9.1 in non-metastatic tumors and 40.1 12.0 in metastatic tumors (p<0.05). VEGF expression was correlated with p53 over expression. CONCLUSION: VEGF expression might be a useful prognostic factor for metastasis in colorectal cancer. Also, our findings suggest the presence of a p53-VEGF pathway in colorectal cancer.

Resection of Colorectal Liver Metastases / 한국간담췌외과학회지

BACKGROUNDING/AIMS: It has been nearly established that liver resection for colorectal metastases is a relatively safe procedure with survival benefit to patients. This study was performed to evaluate if the liver resection for colorectal metastases is effective method and to determine the appropriate therapeutic modality. METHODS: Between January 1995 and January 1999, sixteen patients who had liver resectin for metastatic colorectal carcinoma at our hospital were analyzed retrospectively. RESULTS: Wedge resection was performed in 7 patients, segmentectomy in 3 patients, and lobectomy in 6 patients. The median survival time was 26 months and cumulative 1 and 4-year survival rate were 83.1% and 34.6%, respectively. Extent of hepatic resection had marginally influenced the survival(p=0.0514). No prognostic factor was related significantly to survival. Recurrence in remaining liver following the anatomical liver resection was significantly low compared with wedge resection( 12.5% vs. 71.5%, p=0.035). CONCLUSION: Liver resection is an effective and safe treatment for colorectal liver metastases. The anatomical liver resection decreased recurrence rate in the remnant liver. The curative resection with an adequate surgical margin will improve outcome.

A Clinical Review of Breast Cancer

BACKGROUND : The incidence of breast cancer has steadily increased through the years. The establishment of the cause of breast cancer plays an important role for the diagnosis, management and prevention of breast cancer. METHODS : We analysed 241 cases of breast cancer that were treated during the 13 years from January 1985 to December 1997 at the Department of General Surgery, Inje University Paik Hospital, Seoul. RESULTS : The peak incidence of breast cancer was in the 5th decade (100 cases, 41.5%). The most common age of menarche ranged from 14 to 20 years (89.9%). The most common age of first full-term delivery ranged from 25 to 29 years (54.5%). The normal group was the most frequent body mass index (156 cases, 65.8%). The most common chief complaint was a painless palpable breast mass (166 cases, 68.9%). Most patients (181 cases, 75.1%) visited the hospital within 6 months of developing symptoms. The upper outer quadrant was the most frequent location for breast cancer (146 cases, 60.6%). The most common type of operative technique was a modified radical mastectomy (225 cases, 93.4%). The most common size of the breast mass ranged from 2 to 5 cm (151 cases, 62.7%). A pathologically positive axillary lymph node was present in 122 cases (52.4%). The predominant type of pathological classi fication was invasive ductal carcinoma (215 cases, 90.7%). According to the TNM system, the most common stage was stage II (161 cases, 66.8%). The five-year survival rates for the patients in stages I, II, III were 96.7%, 82.2%, 68.9%, respectively. CONCLUSIONS : We conclude that women with mass or mass-related symptoms needed more careful evaluation and aggressive approaches for discovering breast cancer.

Retroperitoneal Sarcoma

Soft-tissue sarcomas account for 1% of all solid tumors. Of these, less than 15% will occur in the retroperitoneum. Late diagnosis and large tumor size make retroperitoneal sarcomas difficult to resect. Resection with wide margins in all directions is rarely possible owing to proximity to vital structures. Radiation therapy is limited in dosage and, as with chemotherapy, has only been successful in a limited number of cases. These problems result in a poor prognosis. A series of patients with retroperitoneal sarcoma was reviewed with a focus on issues of surgical management and prognostic factors. A retrospective analysis of 12 patients with retroperitoneal sarcomas who had undergone operations at the Department of Surgery, Inje University Paik Hospital, Seoul, from 1980 through 1996 was performed. The mean age of the 10 adult patients was 51 years; the male-to-female ratio was 2:1. Eighty-three percent of the patients presented with an abdominal mass. The mean diameter of the tumors was 18.3 cm. Leimyosarcomas(33%) and liposarcomas(25%) comprised the majority of the histologic types. The tumor grades were I, II, and III in 3 cases each. Resection of the tumor was possible in 75%(9/12) of the cases, although 17% of the resections were incomplete. Resection of adjacent organs was required in 66% of the cases. The resectability rose from 60% in 80s to 86% in 90s, with no statistical significance, possibly due to the small number of cases in this series. There was no postoperative morbidity or mortality. Actuarial 1-, 3-, and 5-year survival rates after resection were 75%, 60%, and 30%, respectively. Four of the 7(57%) patients who underwent complete resections had recurrence 3 to 33 months after surgery; this was notable for grade II or III tumors only. Two patients with grade I tumors are alive 65 and 102 months respectively after complete resection and show no evidence of the disease. One patient who underwent an incomplete resection of the tumor died 50 months after the operation. Only the tumor grade was a significant prognostic factor(p=0.0207). In conclusion, a wide en-bloc resection of a retroperitoneal sarcoma with a clear margin in all directions is a prerequisite for long-term survival. Aggressive follow-up for the first 3 years after a complete resection of a high-grade tumor is justified.