Missing Right Coronary Artery in a Patient with Acute Inferior ST Segment Elevation Myocardial Infarction: A Case of Extremely Rare Variation of Coronary Anatomy

We recently encountered an interesting case of acute inferior ST segment elevation myocardial infarction (STEMI). This patient had a rare anatomic variation, single coronary artery. The right coronary artery originate from the left circumflex proper artery, not from aorta, was totally obstructed with thrombi. Though it took more time to figure out the patient's coronary anatomy and the culprit lesion, we successfully performed primary percutaneous coronary intervention within the guideline-recommended time period. We performed left coronary angiography at the beginning. This strategy could be helpful in determining the culprit lesion and preventing unnecessary procedural delay in acute inferior STEMI.

Clinical Characteristics and Surgical Safety in Patients with Acute Appendicitis Aged over 80

PURPOSE: The aim of this study was to evaluate the clinical characteristics and treatment outcomes, including surgical safety, in patients over 80 years of age who underwent an appendectomy. METHODS: This study involved 160 elderly patients who underwent an appendectomy for acute appendicitis: 28 patients over 80 years old and 132 patients between 65 and 79 years old. RESULTS: The rate of positive rebound tenderness was significantly higher in the over 80 group (P = 0.002). Comparisons of comorbidity, diagnostic tool and delay in surgical treatment between the two groups were not statistically different. American Society of Anesthesiologists score was significantly higher in the over 80 group than in the 65 to 79 group (2.4 +/- 0.5 vs. 1.6 +/- 0.5; P < 0.00005). Comparisons of operative times and use of drainage between the two groups were not statistically different. In the pathologic findings, periappendiceal abscess was more frequent in the over 80 group (P = 0.011). No significant differences existed between the two groups when comparing the results of gas out and the time to liquid diet, but the postoperative hospital stay was significantly longer in the over 80 group (P = 0.001). Among the postoperative complications, pulmonary complication was significantly higher in the over 80 group (P = 0.005). However, operative mortality was zero in each group. CONCLUSION: In case of suspicious appendicitis in elderly patients, efforts should be made to use aggressive diagnostic intervention, do appropriate surgery and prevent pulmonary complications especially in patients over 80 years of age.

Clinical Characteristics and Surgical Safety in Patients Older than 80 Years with Inguinal Hernia

BACKGROUND: Inguinal hernia repair is a common surgical intervention in the elderly. The aim of this study was to describe the clinical characteristics and treatment outcomes in patients over 80 years of age undergoing inguinal hernia repairs. METHODS: We retrospectively reviewed the medical records of 150 patients older than 65 years of age who had undergone an inguinal hernia repair between January 2006 and December 2010. Dividing our subjects by age into two groups, 65 to 79 years and 80 years and older, we compared their clinical features and surgical outcomes. RESULTS: There were 122 patients (81.3%) in the 65 to 79 years group and 28 (18.7%) in the over 80 years group. Average body mass index was 22.8 kg/m2 in the 65 to 79 group and 21.8 kg/m2 in the over 80 group. Comorbidities were present in 63.9% of the cases in the 65 to 79 group and 67.9% in the over 80 group. American Association of Anaesthetists score was significantly higher in the over 80 group (1.6+/-0.3 vs. 1.9+/-0.3, p=0.046). Comparisons of operative time for each operative method were statistically not different. Postoperative hospital stay and analgesic use also showed no significant differences between the groups. Among the postoperative complications, wound hematoma was most prevalent in both groups but was not statistically different. There was no surgery-related mortality in either group. CONCLUSION: Our results indicate that inguinal hernia repair can be done safely in those older than 80 years, unless there is high surgical risk per se.

Laparoscopic Versus Open Appendectomy for Appendicitis in Elderly Patients

PURPOSE: The appendectomy is the most common emergent surgical procedure in elderly patients. The increasing number of elderly persons has been accompanied by an increase in the number of cases of acute appendicitis in the elderly. In order to understand the clinical significance of a laparoscopic appendectomy for elderly patients with appendicitis, we investigated the results of a laparoscopic appendectomy for treating patients over 60 years of age with appendicitis and compared them with the results for an open technique. METHODS: We studied retrospectively patients over 60 years of age who underwent an appendectomy with either a laparoscopic (LA) or open (OA) technique for appendicitis between July 2007 and December 2009. There were 30 patients in the LA group and 47 patients in the OA group. The demographic data, operative time, length of the hospital stay, bowel movement, pain control, cost, complications and pre-existing disease were assessed. RESULTS: There were no significant differences between the LA and the OA groups with respect to pre-existing diseases, gender, age, American Society of Anesthesiologists (ASA) score and the number of cases of complicated appendicitis, operative time, length of hospital stay, and times of analgesics use. However, the proportion of early gas out (within POD #2) was significantly greater in the LA group (80% vs. 57%, P < 0.05), and postoperative complications were significantly lower in the LA group (7% vs. 32%, P < 0.01). The costs for the two groups were not significantly different. CONCLUSION: A laparoscopic appendectomy is a safe and effective procedure in elderly patients and is not associated with any increase in morbidity. It can be recommended for routine use in treating elderly patients with appendicitis.

Clinical Significance of Perineal Descent in Pelvic Outlet Obstruction Diagnosed by using Defecography

PURPOSE: The aim of this study was to evaluate the clinical significance of perineal descent (PD) in pelvic outlet obstruction patients diagnosed by using defecography. METHODS: One hundred thirty-six patients with pelvic outlet obstruction (POO; median age 49 years) had more than one biofeedback session after defecography. Demographic finding, clinical bowel symptoms and anorectal physiological studies were compared for PD at rest and PD with dynamic changes. RESULTS: Age (r = 0.33; P < 0.001), rectocele diameter (r = 0.31; P < 0.01), symptoms of incontinence (P < 0.05) and number of vaginal deliveries (r = 0.46; P < 0.001) were correlated with increased fixed PD. However, the female gender (P < 0.005), rectal intussusceptions (P < 0.05), negative non-relaxing puborectalis syndrome (P < 0.00005) and rectocele (P < 0.0005) were correlated with increased dynamic PD. Duration of symptoms, number of bowel movements, history of pelvic surgery and difficult defecation were not related with PD. There was no significant correlation between fixed and dynamic PD and success of biofeedback therapy. CONCLUSION: Age, vaginal delivery and diameter of the rectocele are associated with increased fixed PD. Female gender, rectal intussusceptions and a rectocele are correlated with increased dynamic PD. Biofeedback is an effective option for POO regardless of severity of PD.

Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Pelvic Outlet Obstruction

PURPOSE: The aim of this study was to identify the prognostic factors associated with poor outcome of biofeedback therapy. METHODS: One hundred thirty-seven (137) constipated patients with pelvic outlet obstruction (median age 49 years) had more than one biofeedback session after defecography. Follow-up data (mean follow-up: 14 months; range: 2~37 months) were obtained in 114 patients. Any differences in demographics, clinical symptoms, and parameters of an anorectal physiological study were evaluated between the success group and the failure group. RESULTS: At follow-up, 80 (70 percent) patients felt improvement in symptoms, but 34 (30 percent) patients did not. Pre-biofeedback presence of symptoms of difficult defecation predict poor outcome (88 vs. 69 percent for failure vs. success, P<0.05). The positive and the negative predictive values of difficult defecation for poor outcome were 35 percent and 86 percent, respectively. A negative mean pressure change on pre-biofeedback anal manometry was related to a poor outcome (65 vs. 26 percent for failure vs. success, P<0.001). The positive and the negative predictive values of negative mean pressure change for poor outcome were 51 percent and 83 percent, respectively. A negative electrical current change on pre-biofeedback anal electromyography was related to a poor outcome (23 vs. 9 percent for failure vs. success, P<0.05). The positive and the negative predictive values of negative electrical-current change for poor outcome were 53 percent and 74 percent, respectively. CONCLUSIONS: Difficult defecation, negative mean pressure change in pre-biofeedback anal manometry, and negative electrical current change in pre-biofeedback anal electromyography were predictors associated with poor outcome of biofeedback therapy for constipated patients with pelvic outlet obstruction.

Effect of Electrical Stimulation and Biofeedback Therapy for Constipated Patients with Impaired Rectal Sensation

PURPOSE: Biofeedback therapy is widely used for the management of constipation associated with pelvic outlet obstruction. Some patients have shown poor outcome after biofeedback alone. A subgroup of patients complains of absence of desire to defecate. The main pathophysiology of constipation may be impaired rectal sensation or compliance. This study evaluated the effect of electrical stimulation and biofeedback therapy (EST-BF) for this subgroup of constipated patients with impaired rectal sensation. METHODS: Of the 37 patients diagnosed with pelvic outlet obstruction by using cinedefecography, 9 patients (M:F=2:7, age=22~77 years, median=57 years) who had impaired rectal sensation (rectal desire threshold > or =100 ml) on anorectal manometry were selected. These patients were treated with EST-BF therapy 2~6 (median: 5) sessions, Kontinece, Multichannel system, HMT, Inc, Seoul, Korea). Treatment consisted of 20 minutes of variant-mode electrical stimulation and 20 minutes of EMG biofeedback therapy per week administered by a specialized colorectal surgeon. All patients were evaluated by using a standardized questionnaire and a threshold for rectal sensation based on balloon distention before and after treatment. RESULTS: At post EST-BF, six (67%) patients had experienced an improvement in symptoms, including five (56%) patients with complete symptom relief. Significant improvement in rectal sensation, especially the rectal defecation desire threshold (pre-EST-BF vs. post- EST-BF: 181.0+/-38.7 vs. 88.3+/-29.1) was achieved. CONCLUSIONS: EST- BF may be an effective option for use in the treatment of functional constipation with impaired rectal sensation.

Outcome and Predictors of Success of Biofeedback for Descending Perineum Syndrome

Purpose: To determine the outcome and identify predictors of success of biofeedback for descending perineum syndrome (DPS). Methods: 103 patients diagnosed with DPS by defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were also analyzed. Results: At post- biofeedback, 81 patients felt improvement in symptoms, including 29 with complete symptom relief. At follow-up (median: 13 months, n=82), 58 patients felt improvement in symptoms, including 12 with complete symptom relief. There was a significant reduction in difficult defecation (from 78 to 34, 37%, from pre-biofeedback to post-biofeedback, and at follow-up respectively; P<0.001), incomplete defecation (from 88 to 44, 41%; P<0.001), hard stool (from 63 to 25, 0%; P<0.01), small caliber stool (from 63 to 0,0%; P<0.001, P<0.005), fecal incontinence (from 10 to 1,1%; P<0,01), anal pain (from 21 to 2, 6%; P<0.001, P<0.05), laxative use (from 30 to 11, 6%; P<0.001), enema use (from 16 to 0, 1%; P<0.001) and digitation (from 11 to 1%, from pre-biofeedback to at follow-up; P<0.05). Normal spontaneous bowel movement was increased from 47% pre-biofeedback to 79% post-biofeedback (P<0.001), 86% at follow-up (P<0.001). Difficult defecation predict poor outcome (96 vs. 66%; failure vs. success, P<0.01). Positive mean pressure change predict good outcome (69 vs. 35%; success vs. failure, P<0.05). Conclusions: Biofeedback is an effective option for DPS.

Massive Bleeding from Multiple Jejunal Diverticulosis

Jejunoileal diverticulosis is formed by herniation of mucosa and submucosa through the muscular layer of the bowel wall. The condition usually consists of multiple diverticula at the mesenteric border, in contrast to the true congenital Meckel's diverticulum. Small bowel diverticulum is a rare disease that can give rise to unexpected problems such as malabsorption, perforation, diverticulitis, obstruction and bleeding. Since the reported complication rate is low, uncomplicated small bowel diverticula are generally recommended to be left untreated. Bleeding from a diverticulum is often sudden and massive. We report herein a case of a 43-yearold women who presented with massive bleeding from multiple jejunal diverticula. She had been admitted to hospital one day previously with the chief complaint of severe whole abdominal pain which was aggravated progressively. On physical examination, she showed an acute, ill appearance. The abdomen was slightly distended and tender with rebound tenderness. On the abdomen CT, the jejunal wall was thickened and the mesenteric lymph nodes were enlarged. An emergency laparotomy was performed. Multiple jejunal diverticula, distributed from 20 to 100 cm distal to the ligament of Treitz, were found, along with massive bleeding from diverticulosis. A segment of the jejunum containing all diverticula was resected and end to end anastomosis was performed. Due to the relative rarity of these lesions and their complications, diagnosis is often difficult and delayed. Awareness of their tendency to cause nonspecific abdominal symptoms and serious complications may lead to earlier diagnosis and timely treatment.

Primary Neurilemmoma of the Thyroid Gland

Neurilemmoma, like other non-epithelial tumors, seldom occurs in the thyroid gland. We present a case of a 61-year-old woman with a neurilemmoma of her left thyroid lobe. She was clinically and biochemically euthyroid, and underwent a left thyroid lobectomy without complications. The tumor was an encapsulated solid mass, 34x23x1 5mm in size and was diagnosed as neurilemmoma. Neurilemmoma of the thyroid gland tends to develop in the right lobe, but this case was in the left.

A case of combined deficiency of antithrombin III and protein C complicated by recurrent venous thrombosis / 대한내과학회지

Primary venous thrombosis caused by deficiency or qualitative abnormality of antithrombin III, protein C and protein S is usually inherited as an autosomal dominant trait. Usually, deep vein thrombosis or pulmonary thromboembolism is developed by such abnormalities, however, mesenteric vein thrombosis is rarely reported. A 27-year-old man with previous history of deep vein thrombosis underwent segmental resection of jejunum due to mesenteric vein thrombosis complicated by necrosis of jejunum. Postoperative investigation disclosed combined deficiency of antithrombin III and protein C. His son also showed deficiency of antithrombin III. Postoperatively, he is on life-long warfarin therapy without experiencing recurrence of venous thrombosis.

A Case Report: Recurrent Intravenous Leiomyomatosis / 대한산부인과학회잡지

Intravenous leiomyomatosis is an uncommon uterine tumor characterized by the growth of histologically benign smooth muscle initially into venous channels within the broad ligament, intrauterine, and iliac vein, and can extend to inferior vena cava, and right side of the heart. Intravenous leiomyomatosis is always grossly visible as worm-like plugs within the involved vessels. A 41-year-old woman presented with lower abdominal mass, and she had undergone total abdominal hysterectomy and left salpingoophorectomy for leiomyoma of uterus. On pathological examination it was diagnosed as intravenous leiomyomatosis. 16 month later, She was admitted with lower abdominal mass on retroperitoneal cavity. The patient was successfully treated by resection of recurred mass and right salpingoophorectomy. A case of recurrent intravenous leiomyomatosis is presented with a brief review of literatures.

Comparison of Laparoscopic and Open Appendectomies

BACKGROUND: Kurt Semm, a German gynecologist, was first to describe a laparoscopic appendectomy for an incidental appendectomy in gynecologic surgery. At that time, it was limited to an incidental appendectomy performed during gynecologic surgery. The development of laparoscopic instruments and more experience has allowed surgeons to perform laparoscopic surgery easier than before. Nowadays, laparoscopy allows surgeons to perform appendectomies in a safe and effective way, and it reduces the risk of performing unnecessary appendectomies. METHODS: We reviewed the records of 201 patients who had an appendectomy at our hospital from February 1997 to December 1997. A laparoscopic appendectomy was carried out in 51 cases, and an open appendectomy was carried out in the others. RESULTS: 1) There was not a significant difference between the two groups in regard to age and sex. The male-to-female ratios were 1.32:1 in laparoscopic appendectomy group and 1.17:1 in the open appendectomy group. The mean ages were 30.3 years in laparoscopic appendectomy group and 29.7 years in open appendectomy group. 2) There was not a significant difference in pathologic severity between the two groups. The majority had suppurative appendicitis in both groups. Postoperative complications were less frequent in the open appendectomy group. 3) The mean operative times were 55.6 minutes in the laparoscopic appendectomy group and 42 minutes in the open appendectomy group. 4) The mean hospital stays were 4.69 days in the laparoscopic appendectomy group and 6.96 days in the open appendectomy group. 5) The mean postoperative periods until normal activity were 8.79 days in the laparoscopic appendectomy group and 12.85 days in the open appendectomy group. 6) The postoperative use of analgesics was less frequent in the laparoscopic appendectomy group. 7) Conversion to an open laparotomy occurred in 3 cases. CONCLUSIONS: We think that a laparoscopic appendectomy is a safer, more effective, more cosmetic, and less invasive procedure than an open appendectomy.

Characterization of Changes in Cells and Extracellular Matrix Components during the Regenerative Processes in the Resected Rat Thyroid / 대한해부학회지

Thyroid gland is composed of follicles surrounded by basement membrane, which is known to be related to the regenerative processes in several organs. This study was performed to observe the morphological details and changes of the basement membrane components, which are the presumtive factors in thyroid regeneration, with time sequences after partial thyroidectomy and then the relations between the components and thyroid regeneration were confirmed. Thyroid galnds of adult male rats were examined before and 1, 2, 3, 4, 5, 7 and 10 days after bilateral partial[50-60%] thyroidectomy. The basememnt membranes of follicles were prominent with high eosinophilicity at later stage when H & E stained. But in PAS and EM staining, the basement membrane of the operated groups didn`t show any specific changes comparing with control group but the dense collagenous fibers at the interfollicular space outside the membrane. Immunostaining of proliferating cell nuclear antigen[PCNA], which reflects the growth fraction, showed 2.3% positivity of total follicular cells in control group. The PCNA positive ratio in experimental groups were 10.3%, 15.9%, 19.9%, 12.2%, 10.5%, 1.9%, 2.7% on postoperative 1, 2, 3, 4, 5, 7, 10 days respectively. In unilaterally thyroidectomized rats, the resected lobe revealed 18.2% of PCNA positive ratio 3 days after operation, while that in the unresected lobe was only 5.9%. This suggested the predominence of local factors in thyroid regeneration. Meanwhile, with the double immunostaining of calcitonin and PCNA discriminate between follicular cells and C-cells among the PCNA positive cells, PCNA positive C-cells were very rare. The immunostaining of laminin, fibronectin, and collagen IV showed varying intensity with the progress of regeneration. Stainability for collagen IV was maintained in all groups with some increase in 5- and 7-day groups. Laminin was well localized to the basement membrane of the control follicle, and the staining intensity for laminin was markedly increased with additional cytoplasmic staining in follicular cells in 1- to 3-day groups and then decreased to attain the control level in 10-day group. In case of fibronectin, the control follicle showed scarce staining, but the resected group showed strong positivity for fibronectin with the most intense staining in 1- to 3-day groups. Immunostaining for fibronectin still showes in 10-day group with the gradual disappearance of immunoreactivity in the center of the lobe. This study revealed the accompaning changes of the basement membrane components during the regeneration process of partially resected thyroid glands. Among them, collagen IV seems to support the structural integrity of the basement membrane. Laminin and fibronectin were supposed to be related to the thyroid follicular regeneration.

A clinical analysis of incisional hernia

No abstract available.