Local Subcutaneous Injection of Erythropoietin Might Improve Fat Graft Survival, Whereas Continuous Infusion Using an Osmotic Pump Device Was Harmful by Provoking an Overwhelming Foreign Body Reaction in a Nude Mouse Model

BACKGROUND: Since the survival of grafted fat requires successful revascularization, we hypothesized that local delivery of erythropoietin (EPO), a hemangiogenic and antiapoptotic factor, might enhance the survival of fat grafts in a nude mouse model. METHODS: Our experiment consisted of 2 parts. The first involved direct injection of EPO or saline at the grafting site before fat grafting and for 4 days afterwards. In the second part, EPO or saline was delivered continuously for 1 week via an osmotic pump device, and a group without an implantable pump represented the control group. After 16 weeks, the surviving fat grafts were weighed and subjected to histomorphometry. RESULTS: In the first experiment, fat graft survival was higher in the EPO-injected group, but not statistically significant (69.2% vs. 59.2%; P=0.21). Histomorphometry showed significantly higher levels of microvessel formation and less cystic degeneration in the EPO-injected group. In the second experiment, the survival rate was significantly lower in both pump groups than in the control group (40.7% in the EPO pump group, 7.7% in the saline pump group, and 66.7% in the control group). CONCLUSIONS: Local injection of EPO into the fat graft site appeared to improve graft survival, with increased angiogenesis, suppressed inflammation, and decreased degeneration. However, the insertion of an osmotic pump exerted detrimental effects on graft survival and the histomorphometric profiles of the fat graft compared with the control group due to the overwhelming foreign body reaction.

Clinical Implication and Risk Factors for Malignancy of Atypical Gastric Gland during Forceps Biopsy

BACKGROUND/AIMS: Although forceps biopsy is performed for suspicious gastric tumors during endoscopy, it is difficult to determine treatment strategies for atypical gastric glands due to uncertainty of the diagnosis. The aim of this study was to investigate clinical implications and risk factors for predicting malignancy in atypical gastric glands during forceps biopsy. METHODS: We retrospectively reviewed medical records of 252 patients with a diagnosis of atypical gastric gland during forceps biopsy. Predictors of malignancy were analyzed using initial endoscopic findings and clinical data. RESULTS: The final diagnosis for 252 consecutive patients was gastric cancer in 189 (75%), adenoma in 26 (10.3%), and gastritis in 37 (14.7%). In the multivariate analysis, lesion sizes of more than 10 mm (odds ratio [OR], 3.021; 95% confidence interval [CI], 1.480 to 6.165; p=0.002), depressed morphology (OR, 3.181; 95% CI, 1.579 to 6.406, p=0.001), and surface nodularity (OR, 3.432; 95% CI, 1.667 to 7.064, p=0.001) were significant risk factors for malignancy. CONCLUSIONS: Further evaluation and treatment should be considered for atypical gastric gland during forceps biopsy if there is a large-sized (>10 mm) lesion, depressed morphology, or surface nodularity.

A Case of Bilateral Diffuse Diabetic Muscle Infarction of the Thighs in a Patient with Good Glucose Control / 임상당뇨병

Diabetic muscle infarction (DMI) is a rare condition that usually occurs in diabetic patients who have longstanding microvascular complication. The typical presentation is a painful swelling with abrupt onset in the lower limbs, particularly involving hyper-intense signals in T2-weighted magnetic resonance imaging (MRI) images. The treatment consists of bed rest, analgesics, and physical therapy. The authors encountered a case of DMI with bilateral tender swelling on the anteromedial aspect of the thighs. DMI is less likely to develop in patients with good glycemic control. Recently, however, a few cases demonstrated that DMI can also develop in patients with good glucose control. However, diffuse and extensive infarction of muscle, such as in our case, is rare. It is important to consider differential diagnoses in order to avoid misdiagnosis and non-essential treatment such as overuse of antibiotics or steroid treatment. In this case, we diagnosed the patient using MRI, muscle biopsy, and electromyography and successful treatment involved bed rest and analgesics. We herein report a case of 76-year-old man with very extensive and diffuse DMI in spite of well-controlled type 2 diabetes.

Successful transfusion-free pancreatectomy in Jehovah's Witness patients

BACKGROUNDS/AIMS: Although perioperative therapies have improved greatly, pancreatectomies still often need blood transfusions. However, the morbidity from blood transfusions, the poor prognosis of blood transfused patients, high cost, and decreasing supply of blood products is accelerating transfusion-free (TF) surgery in the patients who have pacreatectomies. The aim of this study was to assess the feasibility of TF pancreatectomies for patients who are Jehovah's Witness. METHODS: We investigated the possibility of TF pancreatectomies for the Jehovah's Witness patients undergoing pancreatectomies between January 2007 and Februay 2014. There were 4 cases of Whipple's operation, 4 of pylorus-preserving pancreaticoduodenectomy, 2 of radical antegrade modular pancreatosplenectomy and 1 of laparoscopic distal pancreatectomy. All were performed by one surgeon. RESULTS: Most of the TF pancreatecomies patients received perioperative blood augmentation and intraoperative acute normovolemic hemodilution (ANH). They received no blood transfusions at any time during their hospitalization, and pre- and intra-operative data and outcomes were acceptably favorable. CONCLUSIONS: To the best of our knowledge, this report is the first successful consecutive pancreatectomy program for Jehovah's Witness not involving blood transfusion. TF pancreatectomy can be performed successfully in selected Jehovah's Witness. Postoperative prognosis and outcomes should be confirmed in follow up studies.

Postoperative nausea and vomiting after capsicum plaster at the P6 acupoint after laparoscopic cholecystectomy according to gender

BACKGROUND: Postoperative nausea and vomiting (PONV) has a remarkably high reported incidence (70%) in female patients after anesthesia. This study aims to evaluate the clinical effect of capsicum plaster at the P6 acupoint with respect to gender in preventing PONV after laparoscopic cholecystectomy. METHODS: A prospective, placebo-controlled, double-blind study was conducted with 120 patients undergoing laparoscopic cholecystectomy and who were randomly assigned to four groups (n = 30 each): Group MC = male patients with capsicum plaster at the P6 acupoint; Group MP = male patients with placebo tape at the P6 acupoint; Group FC = female patients with capsicum plaster at the P6 acupoint; Group FP = female patients with placebo tape at the P6 acupoint. The treatment tape was applied before the induction of anesthesia and was removed eight hours after the operation. RESULTS: The incidence of nausea was reduced in both genders with application of capsicum plaster at P6 acupoint. No change in vomiting or use of anti-emetics was observed. Satisfaction scores with PONV control were improved with this intervention. No gender difference was observed which actually the initial objective of this study was. CONCLUSIONS: The application of capsicum plaster at the P6 acupoint is a proven antiemetic method in both gender after laparoscopic cholecystectomy, however there are no intergender differences.

Accidental ingestion of a fixed partial denture during general anesthesia: A case report

Swallowing a foreign body of dental origin is a rare occurrence; but, it can be dangerous if the foreign body is large, sharp, and pointed. We report a case in which a large fixed partial denture became dislodged and was ingested while the patient was undergoing general anesthesia, and was removed postoperatively with endoscopy. Anesthesiologists should understand the dangers and recognize this complication when it occurs, and prepare a suitable treatment plan.

Airway management in patient with continuous bleeding lesion of the trachea: a case report / 대한마취과학회지

Hemoptysis requires proper treatment to prevent blood aspiration and asphyxiation. If the patient loses consciousness or is anesthetized, the bleeding inside the trachea may continuously flow into the distal part, which may be fatal. Fatal damage resulting from hemoptysis is mainly caused by asphyxiation, and it is important to find the exact location of the bleeding in order to prevent it from spreading to both lungs. However, endotracheal intubation may increase the bleeding by stimulating the bleeding lesion in the respiratory track, and can make airway management more difficult. We report a successful case of airway management using the cuff and Murphy eye of the endotracheal tube in a patient with tracheal bleeding.

The use of 3 sugammadex out of 5 reversal of during recovery of rocuronium-induced neuromuscular blockade in a patient with post-tonsillectomy hemorrhage: a case report / 대한마취과학회지

Post-tonsillectomy hemorrhage (PTH) is the most frequent complication of tonsillectomy, and occasionally results in a lethal outcome. A 21-year-old man (height 180 cm, weight 95 kg) was scheduled for a bilateral tonsillectomy and uvulopalatopharyngoplasty for treatment of obstructive sleep apnea. He required 5 rounds of general anesthesia due to recurrent PTH. The anesthesiologist used sugammadex a total of 3 times to achieve the successful reversal of the deep neuromuscular blockade (NMB) induced by rocuronium. After sugammadex 2 mg/kg was administered, the NMB was reversed in 2 minutes each time. Re-administration of rocuronium within a short time interval after sugammadex may result in unpredictable effects of neuromuscular blocking agents. Sugammadex made it possible to perform a rapid, complete reverse when the residual block was maintained by an incomplete reversal of anticholinesterase.

Effects of Long-Term Cryopreservation on Fat Grafts: An Experimental Study

BACKGROUND: Although microfat grafting is now used to augment soft tissue, resorption of some amount of fat is inevitable. There are no consistent guidelines for the duration of fat storage. This study evaluated absolute fat mass and pathological changes according to storage duration. METHODS: Nude mice were injected with fresh fat or fat that had been stored for 3 weeks, 5 months, 9 months, 15 months, or 22 months. After 15 weeks, fat graft weight and pathology (viable cells, structural integrity, microvessel formation, cystic degeneration, fibrosis, and cellular infiltration) were assessed. RESULTS: After 15 weeks, the average weight of the remaining fat was 486 mg in the control group and 298, 160, 180, 106, 88, and 80 mg in the 3-week and 5-, 9-, 15-, 22-, and 36-month storage groups, respectively. The average weight of fat tissue significantly decreased to less than 20% in the 5-month group. Also, there was a significant decrease in structural integrity and an increase in cystic degeneration in the 5-month group. Tissue vascularization tended to decrease according to the duration of cryopreservation. CONCLUSIONS: The mean weight of the fat grafts preserved in a general freezer was reduced by 61.3% compared with that of the fresh fat group, which was not statistically significant. The mean fat graft weight was, however, significantly reduced following storage in a general freezer for longer than 5 months. In addition, there were decreases in viable adipocytes and increases in fibrocystic degeneration and inflammatory changes when long-term preserved fat was grafted.

Mondor's Disease Developed after Ultrasound-assisted Liposuction for Treatment of Axillary Bromhidrosis

Mondor's disease is an uncommon condition characterized by a palpable, cordshaped structure, which causes pain when pressed. Its known pathophysiology is thrombophlebitis of the superficial venous system. Although reported repeatedly, its definite cause is unknown and various possible causes have been identified, including surgery, irradiation, infection, malignancy, and trauma. We diagnosed this case to be Mondor's disease of the antecubital venous system, probably due to thermal injury of the proximal tributaries of the basilic or cephalic vein. Risk of thermal injury to the skin flap or the portal site remains a common complication, and as thermal injury to the blood vessel might also be considered, attention must be given when suctioning the area near a large superficial vessel.

Optimal precurarizing dose of rocuronium to decrease fasciculation and myalgia following succinylcholine administration / 대한마취과학회지

BACKGROUND: Succinylcholine commonly produces frequent adverse effects, including muscle fasciculation and myalgia. The current study identified the optimal dose of rocuronium to prevent succinylcholine-induced fasciculation and myalgia and evaluated the influence of rocuronium on the speed of onset produced by succinylcholine. METHODS: This randomized, double-blinded study was conducted in 100 patients randomly allocated into five groups of 20 patients each. Patients were randomized to receive 0.02, 0.03, 0.04, 0.05 and 0.06 mg/kg rocuronium as a precurarizing dose. Neuromuscular monitoring after each precurarizing dose was recorded from the adductor pollicis muscle using acceleromyography with train-of-four stimulation of the ulnar nerve. All patients received succinylcholine 1.5 mg/kg at 2 minutes after the precurarization, and were assessed the incidence and severity of fasciculations, while myalgia was assessed at 24 hours after surgery. RESULTS: The incidence and severity of visible muscle fasciculation was significantly less with increasing the amount of precurarizing dose of rocuronium (P < 0.001). Those of myalgia tend to decrease according to increasing the amount of precurarizing dose of rocuronium, but there was no significance (P = 0.072). The onset time of succinylcholine was significantly longer with increasing the amount of precurarizing dose of rocuronium (P < 0.001). CONCLUSIONS: Precurarization with 0.04 mg/kg rocuronium was the optimal dose considering the reduction in the incidence and severity of fasciculation and myalgia with acceptable onset time, and the safe and effective precurarization.

Techniques in Lower Extremity Reconstruction with Supermicrosurgery

PURPOSE: The concept and development of perforator free flaps have led to significant advances in microsurgery. Ongoing developments in perforator free flap surgery are aimed at reducing complications and improving surgical outcomes. The aim of this study was to evaluate the effectiveness and application of supermicrosurgery in free flap surgery. MATERIALS AND METHODS: A total of 267 patients with soft tissue defects of the lower extremity due to various etiologies from January, 2007 to January, 2013. The patients received either an anterolateral thigh free flap (n=83), a superficial circumflex iliac artery free flap (n=152), an upper medial thigh free flap (n=19), or a superior gluteal artery perforator free flap (n=13). Microanastomosis was performed using a perforator-to-perforator technique, either end-to-end or end-to-side. RESULTS: The mean postoperative follow up period was eight months (range: one to 16 months) and flap loss occurred in 11 cases out of 267. All cases of flap loss occurred within two weeks of surgery due to either arterial insufficiency (n=5) or venous congestion (n=6). CONCLUSION: Supermicrosurgery enables the selection of the most efficient perforator for microanastomosis at the defect site. It also reduces the time required for dissection of recipient vessels, and reduces the possibility of injury to major vessels. Microsurgery using a vessel of less than 1 mm has been reported to increase the risk of flap failure; however, using the most advanced surgical tools and developing experience in the technique can produce success rates similar to those found in the literature.

The effect of hand dominance on neuromuscular monitoring at the adductor pollicis muscle / 대한마취과학회지

BACKGROUND: Neuromuscular blockade of the adductor pollicis muscle may be influenced by hand dominance resulting in conflicting results of several studies. The current study examined whether hand dominance could influence the measurements of neuromuscular blockade with acceleromyography at the adductor pollicis. METHODS: The acceleromyographic responses from 0.6 mg/kg of rocuronium were monitored supramaximally in both hands in 31 patients after induction of anesthesia. Onset, maximum effect, and offset of rocuronium were measured and compared in both hands. The train-of-four (TOF) ratios to 0.9 were recorded in all patients. RESULTS: In total, 27 patients were right-handed and 4 patients were left-handed. The mean supramaximal threshold or initial TOF ratio was not different between dominant and nondominant hands. No statistically significant differences were found between 716 paired TOF ratios in both hands. A correlation was seen between the dominant and nondominant hand (Nondominant = 0.931.Dominant + 1.714, R = 0.929). The analysis by the Bland-Altman plot showed an excellent agreement with a bias of 1.6% and limits of agreement of -21.2 to 24.5%. CONCLUSIONS: Dominant and nondominant hands can be used interchangeably for neuromuscular monitoring at the adductor pollicis.

Optimal positive end-expiratory pressure during robot-assisted laparoscopic radical prostatectomy / 대한마취과학회지

BACKGROUND: Increased intra-abdominal pressure during laparoscopic surgery causes cephalad displacement of the diaphragm, resulting in the formation of atelectasis, which can be overcome by positive end-expiratory pressure (PEEP). The aim of this prospective study was to investigate the level of optimal PEEP to maintain adequate arterial oxygenation and hemodynamics during robot-assisted laparoscopic radical prostatectomy (RLRP). METHODS: One hundred patients undergoing RLRP were randomly allocated to one of five groups (n = 20) (0, 3, 5, 7 and 10 cmH2O of PEEP). Hemodynamic variables and respiratory parameters were measured at baseline with the patient in the supine position; at 30 min, 1, 2, 3 and 4 h during CO2 insufflation with the patient in the post-Trendelenburg position; and after deflation in the supine position with increasing PEEP. RESULTS: The PaO2 levels and alveolar-arterial difference in oxygen tension (AaDO2) were improved in patients with PEEPs compared with patients in whom PEEP was not used. The application of PEEP (10 cmH2O) resulted in higher PaO2 levels compared to those with lower PEEP levels, but excessive peak airway pressure (PAP) was sometimes observed. The application of a PEEP of 7 cmH2O resulted in similar PaO2 levels without causing excessive PAP. There was a significant difference in central venous pressure between the groups, but there were no significant differences in heart rate, mean arterial pressure or minute ventilation between the groups. CONCLUSIONS: A PEEP of 7 cmH2O is associated with the greater improvement of PaO2 and AaDO2 without causing excessive PAP during RLRP.

Antiemetic efficacy of capsicum plaster on acupuncture points in patients undergoing thyroid operation / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) occurs in up to 63-84% of patients after thyroid surgery. This study aims to assess the effects of using a capsicum plaster to reduce PONV after thyroid surgery at either the Chinese acupuncture point (acupoint) Pericardium 6 (P6) or Korean hand acupuncture point K-D2. METHODS: One-hundred eighty-four patients who underwent thyroid surgery were randomized in four groups (n = 46 each): control group = inactive tape at P6 acupoints and on both shoulders as a nonacupoint; P6 group = capsicum plaster at P6 points and inactive tape on both shoulders; K-D2 group = capsicum plaster at K-D2 acupoints and inactive tape on both shoulders; Sham group = capsicum plaster on both shoulders and inactive tape at P6 acupoints. The capsicum plaster was applied before the induction of anesthesia and removed at 8 hr after surgery. RESULTS: The incidence and severity of nausea and vomiting and the need for rescue antiemetics were decreased in the patients in the P6 and K-D2 groups compared to the patients in the control and sham groups (P < 0.001). The patients in the P6 and K-D2 groups also reported that they were more satisfied (P < 0.05). CONCLUSIONS: We conclude that the capsicum plaster at the P6 and K-D2 acupoint was a promising antiemetic method for the patients undergoing thyroid surgery.

Antioxidant effects of methylprednisolone and hydrocortisone on the impairment of endothelium dependent relaxation induced by reactive oxygen species in rabbit abdominal aorta / 대한마취과학회지

BACKGROUND: The reperfusion following ischemia produces reactive oxygen species (ROS). We studied the influences of methylprednisolone (MPD) and hydrocortisone (CRT) on ROS effects using the endothelium of rabbit abdominal aorta. METHODS: Isolated rabbit aortic rings were suspended in an organ bath filled with Krebs-Henseleit (K-H) solution. After precontraction with norepinephrine, changes in arterial tension were recorded following the cumulative administration of acetylcholine (ACh). The percentages of ACh-induced relaxation of aortic rings before and after exposure to ROS, generated by electrolysis of K-H solution, were used as the control and experimental values, respectively. The aortic rings were pretreated with MPD or CRT at the same concentrations, and the effects of these agents were compared with the effects of ROS scavenger inhibitors: superoxide dismutase inhibitor, diethylthiocarbamate (DETCA), and the catalase inhibitor, 3-amino-1,2,4-triazole (3AT). RESULTS: Both MPD and CRT maintained endothelium-dependent relaxation induced by ACh in a dose-related manner in spite of ROS attack. The restored ACh-induced relaxation of MPD and CRT group was not attenuated by pretreatment of 3AT and DETCA. CONCLUSIONS: MPD and CRT preserve the endothelium-dependent vasorelaxation against the attack of ROS, in a dose-related manner. Endothelial protection mechanisms of MPD and CRT may be not associated with hydrogen peroxide and superoxide scavenging.

Hemodynamic parameters during robotic radical prostatectomy in elderly patients with increased cardiac risk

BACKGROUND: We studied the hemodynamic changes associated with steep Trendelenburg position and prolonged pneumoperitoneum during robot-assisted laparoscopic prostatectomy in elderly patients with cardiac diseases. METHODS: Hemodynamic variables were measured at baseline supine position, at 30 min, 1, 2, 3 and 4 h during CO2 insufflation in post-Trendelenburg position, and after deflation in the supine position. RESULTS: In comparison with normal subjects, the cardiac index and systemic vascular resistance index of patients with cardiac diseases were significantly affected by the Trendelenburg position and pneumoperitoneum (P < 0.001). However, other variables of heart rate, mean arterial pressure and central venous pressure were not differed between the groups. CONCLUSIONS: We conclude that attention should be paid to maintain adequate hemodynamic status during prolonged pneumoperitoneum in the Trendelenburg position, and which is unfeasible in patients with severe heart failure and unstable angina.

Bispectral index and their relation with consciousness of the patients who receive desflurane or sevoflurane anesthesia during wake-up test for spinal surgery for correction / 대한마취과학회지

BACKGROUND: Wake-up tests may be necessary during surgery for kypho-scoliosis to ensure that spinal function remains intact. It is difficult to predict the time when patients can respond to a verbal command. We evaluated the effectiveness of the bispectral index (BIS) and its relation to patients' levels of consciousness in wake-up tests during desflurane and sevoflurane anesthesia. METHODS: Eighteen patients each were enrolled in the desflurane and sevoflurane groups for spinal correction surgery. We measured BIS values, blood pressure, heart rate, and consciousness state and time, at the points when patients responded during the wake-up test. RESULTS: The BIS values when patients made fists upon a verbal command (T3) were 86.7 +/- 7.5 for desflurane and 90.3 +/- 5.4 for sevoflurane. Patients in the desflurane group had significantly shorter wake up delays than those in the sevoflurane group (6.9 +/- 1.8 min vs. 11.8 +/- 3.6 min). However, there was no difference between the groups in the time between the response to a verbal command and the time when a patient moved their toes in response to verbal commands. No recall of the wake-up tests occurred in either group. CONCLUSIONS: The values obtained using the BIS index could to some extent predict the time of a patient's and would be informative during desflurane and sevoflurane anesthesia. Moreover, desflurane permitted faster responses to verbal commands than sevoflurane, and allowed the wake-up test to be performed sooner.

Effect of Combination Graft of Choukroun's Platelet-rich-fibrin with Silk Fibroin Powder in the Peri-implant Defects

A comparison of the accuracy of ulnar versus median nerve stimulation for neuromuscular monitoring / 대한마취과학회지

BACKGROUND: Inexperienced anesthesiologists are frequently unclear as to whether to stimulate the ulnar or median nerve to monitor the adductor pollicis. The primary purpose of this study was to determine whether monitoring the adductor pollicis by positioning the stimulating electrodes over the median nerve is an acceptable alternative to applying electrodes over the ulnar nerve. METHODS: In 20 patients anesthetized with propofol and remifentanil, one pair of stimulating electrodes was positioned over the ulnar nerve. A second pair was placed over the median nerve on the other hand. The acceleromyographic response was monitored on both hands. Rocuronium 0.6 mg/kg was administered. Single twitch (ST) and train-of-four (TOF) stimulations were applied alternatively to both sites. RESULTS: None of the patients showed a twitch response at either site after injection of rocuronium. There were no differences in the mean supramaximal threshold, mean initial TOF ratio, or mean initial ST ratio between the two sites. Bland-Altman analysis revealed a bias (limit of agreement) in the TOF and ST ratios over the median nerve of 7% (+/- 31%) and 26% (+/- 73%), respectively, as compared with the ulnar nerve. The median nerve TOF ratio was overestimated by 16.2%, as compared with that of the ulnar nerve value, and the median nerve ST ratio was overestimated by 72.9%, as compared to that of the ulnar nerve. CONCLUSIONS: The ulnar and median nerves cannot be used interchangeably for accurate neuromuscular monitoring.