Effectiveness of Autologous Fat Graft in Treating Fecal Incontinence

PURPOSE: The most common risk factor for fecal incontinence (FI) is obstetric injury. FI affects 1.4%–18% of adults. Most patients are unaware when they are young, when symptoms appear suddenly and worsen with aging. Autologous fat graft is widely used in cosmetic surgical field and may substitute for injectable bulky agents in treating FI. Authors have done fat graft for past several years. This article reports the effectiveness of the fat graft in treating FI and discusses satisfaction with the procedure. METHODS: Fat was harvested from both lateral thighs using 10-mL Luer-loc syringe. Pure fat was extracted from harvests and mixed with fat, oil, and tumescent through refinement. Fats were injected into upper border of posterior ano-rectal ring, submucosa of anal canal and intersphincteric space. Thirty-five patients with FI were treated with this method from July 2016 to February 2017 in Busan Hangun Hospital. They were 13 male (mean age, 60.8 years) and 22 female patients (mean age, 63.3 years). The Wexner score was checked before procedure. We evaluated outcome in outpatients by asking the patients. For 19 patients we checked the Wexner score after procedure. RESULTS: Symptom improved in 29 (82.9%), and not improved in 6 (17.1%). In 2 of 6 patients, they felt better than before procedure, although not satisfied. No improvement in 4. Mean Wexner score was 9.7 before procedure. There were no serious complications such as inflammation or fat embolism. CONCLUSION: Autologous fat graft can be an effective alternative treatment for FI. It is safe and easy to perform, and cost effective.

Early Experience With a Partial Stapled Hemorrhoidopexy for Treating Patients With Grades III–IV Prolapsing Hemorrhoids

PURPOSE: Circular stapled hemorrhoidopexy (CSH) is widely used to treat patients with grades III–IV hemorrhoids because of less pain and short hospital stay. However, this procedure is associated with some complications, such as urge to defecate, anal stenosis, staple line dehiscence, abscess and sepsis. To avoid these complications, surgeons perform a partial stapled hemorrhoidopexy (PSH). The aim of this study is to present our early experience with the PSH. METHODS: We retrospectively reviewed the medical records of 58 patients with hemorrhoids who were treated with a PSH at Busan Hang-Un Hospital from January 2016 to June 2016. A specially designed tri-window anoscope was used, and a purse string suture was made at the mucosae of the protruding hemorrhoids through the window of the anoscope. The hemorrhoidopexy was done by using a circular stapler. RESULTS: Of the 58 patients included in this study, 34 were male and 24 were female patients (mean age, 50.4 years). The mean operation time was 12.4 minutes, and the mean postoperative hospital stay was 3.8 days. Three patients experienced bleeding (5.1%) 5 urinary retention (8.6%) and 5 skin tags (8.6%). Urge to defecate, tenesmus, abscess, rectovaginal fistula, anal stricture, incontinence, and recurrence did not occur. CONCLUSION: PSH is a minimally invasive, feasible, and safe technique for treating patients with grades III–IV hemorrhoids. A PSH, instead of a CSH, can be used to treat certain patients with hemorrhoids.

A case of membranous nephropathy as a manifestation of graft-versus-host disease

Nephrotic syndrome (NS) rarely occurs after hematopoietic stem cell transplantation (HSCT) as a late manifestation of graft-versus-host disease (GVHD). Herein, we report a case of HSCT-associated membranous nephropathy in a female patient with aplastic anemia. The patient received an allogeneic HSCT from her human leukocyte antigen-identical brother following myeloablative conditioning chemotherapy. NS occurred 21 months after HSCT without any concurrent features of chronic GVHD. The patient was treated with prednisolone and cyclosporine after renal biopsy confirmed membranous nephropathy, and achieved complete remission. Our report contradicts previous assumptions that concomitant chronic GVHD is responsible for the development of NS, suggesting that NS can develop as a new, independent manifestation of GVHD.

A case of membranous nephropathy as a manifestation of graft-versus-host disease

Nephrotic syndrome (NS) rarely occurs after hematopoietic stem cell transplantation (HSCT) as a late manifestation of graft-versus-host disease (GVHD). Herein, we report a case of HSCT-associated membranous nephropathy in a female patient with aplastic anemia. The patient received an allogeneic HSCT from her human leukocyte antigen-identical brother following myeloablative conditioning chemotherapy. NS occurred 21 months after HSCT without any concurrent features of chronic GVHD. The patient was treated with prednisolone and cyclosporine after renal biopsy confirmed membranous nephropathy, and achieved complete remission. Our report contradicts previous assumptions that concomitant chronic GVHD is responsible for the development of NS, suggesting that NS can develop as a new, independent manifestation of GVHD.

Stepwise Treatment Using Corticosteroids Alone and in Combination with Cyclosporine in Korean Patients with Idiopathic Membranous Nephropathy

PURPOSE: We undertook an observational study to investigate the effects of immunosuppressive treatment on proteinuria and renal function in 179 Korean idiopathic membranous nephropathy patients with nephrotic syndrome. MATERIALS AND METHODS: The primary outcome was regarded as the first appearance of remission and the secondary outcomes as a decline in estimated glomerular filtration rate (eGFR) >50% or initiation of dialysis, and all-cause mortality. Seventy-two (40.2%) and 50 (27.9%) patients were treated with corticosteroids alone (C) and corticosteroids plus cyclosporine (C+C), respectively, whereas 57 (31.8%) did not receive immunosuppressants (NTx). Cyclosporine was added if there was no reduction in proteinuria of >50% from baseline by corticosteroids alone within 3 months. RESULTS: There were no differences in baseline renal function and the amount of proteinuria among the three groups. Overall, complete remission (CR) was achieved in 88 (72.1%) patients by immunosuppressants. In a multivariate analysis adjusted for covariates associated with adverse renal outcome, the probability of reaching CR was significantly higher in the C [hazard ratio (HR), 4.09; p<0.001] and C+C groups (HR, 2.57; p=0.003) than in the NTx group. Kaplan-Meier analysis revealed that 5-year CR rates of C, C+C, and NTx groups were 88.5%, 86.2%, and 56.7% (p<0.001). Ten-year event-free rates for the secondary endpoints in these three groups were 91.7%, 79.9%, and 57.2% (p=0.01). CONCLUSION: Immunosuppressive treatment was effective in inducing remission and preserving renal function in these patients. Therefore, stepwise treatment using corticosteroids alone and in combination with cyclosporine is warranted in these patients.

Percutaneous Excision of a Benign Breast Mass Using Ultrasound-guided, Vacuum-assisted Core Biopsy: A Review of 197 Cases with Long Term Follow-up

PURPOSE: To assess long term results of excising benign masses using ultrasound (US)-guided, vacuum-assisted core biopsy (Mammotome). MATERIALS AND METHODS: We enrolled 163 patients (197 masses) receiving USguided excision using vacuum-assisted core biopsy and follow-up sonography in this retrospective study. The masses were category 3 as determined by ultrasound imaging according to the Breast Imaging Reporting and Data System (BI-RADS) (n=145) or pathologically confirmed as benign masses by a previous core-needle biopsy although category 4a and 4b (n = 52). Pathology, the presence of hematoma and residual tissue, as well as scar formation were assessed. RESULTS: We diagnosed 190 (96.5%) benign masses, 4 (2.0%) malignant masses, and 3 (1.5%) high-risk lesions. Most (176 masses, 91.2%) were excised completely as demonstrated by the follow-up ultrasound examination. Scar changes were minimal (68.7%) or moderate (31.3%), with regression in 53%. CONCLUSION: US-guided excision using vacuum-assisted core biopsy is effective for the removal of benign breast masses. The majority of scars are minimal, with good cosmetic effect. However, subsequent excision should be done for malignant masses or phyllodes tumor because radiologic absence does not guarantee complete removal.

Percutaneous Intervention in Axillary Loop-Configured Arteriovenous Grafts for Chronic Hemodialysis Patients

OBJECTIVE: The purpose of this study was to evaluate the fistulographic features of malfunctioning axillary loop-configured arteriovenous grafts and the efficacy of percutaneous interventions in failed axillary loop-configured arteriovenous grafts. MATERIALS AND METHODS: Ten patients with axillary loop-configured arteriovenous grafts were referred for evaluation of graft patency or upper arm swelling. Fistulography and percutaneous intervention, including thrombolysis, percutaneous transluminal angioplasty and stent placement, were performed. Statistical analysis of the procedure success rate and the primary and secondary patency rates was done. RESULTS: Four patients had graft related and subclavian venous stenosis, two patients had graft related stenosis and another four patients had subclavian venous stenosis only. Sixteen sessions of interventional procedures were performed in eight patients (average: 2 sessions / patient) until the end of follow-up. An interventional procedure was not done in two patients with central venous stenosis. The overall procedure success rate was 69% (11 of 16 sessions). The post-intervention primary and secondary patency rates were 50% and 63% at three months, 38% and 63% at six months and 25% and 63% at one year, respectively. CONCLUSION: Dysfunctional axillary loop-configured arteriovenous grafts almost always had subclavian venous and graft-related stenosis. Interventional treatments are helpful to overcome this and these treatments are expected to play a major role in restoring and maintaining the axillary loop-configured arteriovenous loop grafts.

Surgical Venous Thrombectomy for Chronic May-Thurner Sysndrome: 2 cases report / 대한흉부외과학회지

May-Thurner syndrome is a deep vein thrombosis of the ilio-femoral vein due to compression of the left common iliac vein by the overlying right common iliac artery. Although, catheter directed thrombectomy (CDT) and thrombolysis with stent insertion has become the standard treatment method for acute or subacute May-Thurner syndrome, because of technical feasibility and lower recurrence rate, however, sometimes this methods make fatal complications. Furthermore, there are few reports on optimal treatment strategies for patients in a chronic state of May-Thurner syndrome,. We now present two cases of chronic (>1 month since onset of symptoms) May-Thurner syndrome treated by surgical thrombectomy and femoral arteriovenous shunt with simultaneous stent insertion after failed endovascular treatment. This technique may provide a significant benefit for patients who are not suitable for conventional endovascular treatment.

Treatment of an Immature Autogenous Arteriovenous Fistula with Percutaneous Transluminal Angioplasty

PURPOSE: The purpose of this study was to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) in facilitating maturation of autogenous arteriovenous fistulae. MATERIALS AND METHODS: There were 12 immature autogenous arteriovenous fistulae. We performed 15 PTAs transvenously. Post-intervention anatomic and clinical successes were estimated, and the 6-month and 1-year primary and secondary patency rates were calculated using Kaplan-Meier analysis. RESULTS: All immature fistulae had underlying stenosis (n=20): arteriovenous anastomosis (n=1) and venous outflow (n=19): 1) within 5 cm from the anastomosis (n=10); 2) more than 5 cm but less than 10 cm from the anastomosis (n=5); 3) more than 10 cm from the anastomosis, including central veins (n=4). Six fistulae had two or more stenoses. Repeat intervention was necessary in two patients. The anatomical success rate was 94.3%, and the clinical success rate was 86.7%. The 6-month and 1-year primary patency rates were 72.7% and 54.5%, and the secondary patency rates were 100% and 81.8%, respectively. CONCLUSION: All immature hemodialysis fistulae have underlying stenosis, most of which are located near the arteriovenous anastomosis. Early interventional procedures are helpful in the salvage and maintenance of immature arteriovenous fistulae, with a high degree of success.

Spiral CT Findings of Chromophobe Renal Cell Carcinoma: Correlation with Pathologic Features and Prognosis

PURPOSE: To describe the spiral CT findings of CRCC and to correlate these with the pathologic features, nuclear grading, tumor staging, and prognosis. MATERIALS AND METHODS: We encountered eleven cases of CRCC among 167 cases of histopathologically proven RCC, retrospectively evaluating the spiral CT findings of CRCC including tumor size, internal texture, attenuation, margin, and the involvement of veins or lymph nodes. In addition, the CT findings were correlated with the pathologic features, Fuhrman's nuclear grade, Robson's staging, and the prognosis. Between 27 and 80 (mean, 49.6) months later, the follow-up CT scans of tea patients were examined for tumor recurrence. RESULTS: All tumors, which ranged in size from 2.5 to 15 (mean, 7.7) cm, were solid and well demarcated from renal parenchyma. Pre-contrast CT scans showed that their attenuation was equal to (n=1) or slightly lower (n=10) than that of renal parenchyma, and on early and delayed phase post-contrast enhanced scans, attenuation was low in all cases. In three, focal areas in which attenuation was lower than in the rest of the tumor were observed; histopathologically, these represented hyalinization. There was neither venous nor lymph node involvement, and no distant metastasis. Histopathologic examination demonstrated cystic change (n=1), hemorrhage or necrosis (n=5), complete encapsulation (n=3) and perirenal fat infiltration (n=3). Nuclear grading was II (n=6) or III (n=5), and tumor staging was I (n=8) or II (n=3). Among the five cases in which the nuclear grade was III, three were stage I and two were stage II. Follow-up scans showed no evidence of tumor recurrence, and all patients survived. CONCLUSION: Pre-, early- and late-phase post-contrast enhonced spiral CT scans showed that the attenuation of a CRCC was lower than that of renal parenchyma. Even where the nuclear grade was higher, a well-demarcated soild mass was observed, the tumor stage was lower and the prognosis better.

MR Imaging Findings of Patellar Tendon after Anterior Cruciate Ligament Reconstruction with Bone-Tendon-Bone Autograft

PURPOSE: To evaluate the postoperative changes occurring in the patellar tendon after reconstruction of the anterior cruciate ligament (ACL) using the central one-third of the patellar tendon together with patellar and tibial bony plugs. MATERIALS AND METHODS: Ten patients with ACL injury underwent sagittal and coronal T1-weighted MR imaging of both postoperative and normal knee joints. In all cases, reconstruction of the ACL was performed using the central one-third of the patellar tendon, together with patellar and tibial bony plugs. During the follow-up period of 6-27 months, patient were clinically stable. We compared the length, signal intensity and contour of both patellar tendons, as seen on MR images. RESULTS: No defects was found in harvested patellar tendons, and MR images showed high signal intensity within harvested tendons in six of the ten patients. In seven of ten, patellar tendons had irregular margins and were poorly delineated from adjacent tissue. The mean length of patellar tendons was 44.2+/-2.9 mm in normal knee and 43.9+/-3.1mm in postoperative knee, while their mean thickness in postoperative knee, measured at mid-portion, averaged 4.3+/-1.2 mm. There were no statistically significant differences (p>0.05). The greatest mean thickness of patellar tendon was 6.9+/-1.2 mm and 4.3+/-0.5mm in normal and postoperative knee, respectively. Thus, on average, postoperative patellar tendon was 161% thicker than normal tendon (p<0.05). CONCLUSION: In clinically stable patients, patellar tendons after graft harvesting had a higher signal intensity, worse-defined margins and a greater thickness than normal. We suggest that these are the normal postoperative findings.

Nodular Hepatocellular Carcinoma: Findings of Single-Level Dynamic CT During Hepatic Arteriography

PURPOSE: To evaluate the hemodynamics of nodular hepatocellular carcinoma (HCC) using single-level dynamic CT during hepatic arteriography (CTHA) according to the size of the nodule. MATERIALS AND METHODS: Forty 40 patients with nodular HCC confirmed histologically or radiologically underwent single-level dynamic CTHA. Contrast media was injected via the hepatic artery for 20 seconds at a rate of 1.2 ml/sec. Images were obtained prior to this and thereafter at 3-second intervals until 30 seconds after the start of injection, and additional images at 45 and 60 seconds. The CTHA findings were retrospectively reviewed, and cases were assigned to one of three groups, according to the size of the tumor [ 5 cm (group III, n =16)]. We focused on onset time of contrast enhancement (CE), peak CE time and density, and duration of plateau. The patterns of CE were classified as homogeneous, heterogeneous, peripheral, or "nodule in nodule ". RESULTS: The onset time of CE was 3 seconds and mean peak CE time was 18.8 seconds. A plateau was noted in all groups (mean duration, 6.8 seconds). Mean peak CE time and density were 16.5 seconds and 294.1 HU in group I, 18.5 seconds and 324.1 HU in group II, and 20.1 seconds and 114.0 HU in group III. The most frequent pattern of CE (83%) was homogeneous, and this was found in group I. The small HCC group (group I) showed a faster mean peak CE time than the large group (group III) (p < 0.05), and this latter showed a lower peak CE density than the other groups (p < 0.05). In groups II and III, "nodule in nodule "(72%) and heterogeneous patterns (69%) were, respectively, the most frequent findings. CONCLUSION: Single-level dynamic CTHA is useful in evaluating the hemodynamics of HCC.

Transurethral Exchange of Double-J Ureteral Stent Using Goose-Neck Snare

PURPOSE: To evaluate the usefulness of transurethral exchange of double-J ureteral stent as an effective alternative to the cystoscopic approach. MATERIALS AND METHODS: There were 20 exchange cases involving seven patients (six women and one man) who initially underwent antegrade manipulation of a double-J ureteral stent. Indications for stent placement were ureteral stricture caused by malignancy in six patients [cervical carcinoma (n=5), stomach carcinoma (n=1) ], and renal tuberculosis in one. An 8-F Nelaton catheter was inserted in the bladder via the urethra and contrast material was injected until the bladder was fully distended. The distal end of a double-J ureteral stent was extracted to the urethral orifice using a goose-neck snare and a 0.035 "stiff guide wire was then advanced to the renal pelvis through the stent. After that, the stent was removed and a 4-F Cobra catheter was advanced to the renal pelvis along the guide wire. Contrast material was injected through the catheter, and the renal pelvis, calyx and ureter were opacified. The 0.035 "stiff guide wire was again inserted via the catheter, a new double-J ureteral stent was inserted, and the catheter removed. Finally, the new double-J stent was properly located within the renal pelvis and the bladder. RESULTS: Double-J ureteral stents were successfully exchanged in 19 of 20 exchange cases. After the procedure, all patients reported tolerable, minimal lower abdominal pain. CONCLUSION: Transurethral exchange of double-J ureteral stent is a useful alternative to cystoscopy.

Pseudolesions around the Gallbladder Fossa: Comparison of Frequency and Radiological Characteristics in Multiphasic CT, CTAP, and CTHA

PURPOSE: The purpose of this study is to compare the frequency with which pseudole-sions around the gallbladder (GB) fossa are revealed by multiphasic CT, by CT during arterial portography (CTAP), and by CT during hepatic arteriography (CTHA) and to determine their radiological characteristics. MATERIALS AND METHODS:Multiphasic CT, CTAP, and CTHA examinations of 81 patients without pathology of the GB and around the GB fossa were evaluated for pseudolesion around the GB fossa. The definition of pseudolesion was as follows: 1) hyperattenuation during the arterial phase and isoattenuation during the delayed phase of multipha-sic CT, or perfusion defect on CTAP and hyperattenuation on CTHA; 2) no Lipiodol tagging on Lipiodol CT; 3) all findings observed adjacent to the gallbladder fossa; and 4) no interval change on follow-up CTAP and CTHA. We compared the frequency of pseudolesions around the GB fossa, as seen on multiphasic CT, CTAP, and CTHA, and determined their size, location, and shape, as revealed by CTHA. RESULTS: The frequency of pseudolesion was 2.5% (2/81) on multiphasic CT, while on CTAP or CTHA, the frequency was 53.1% (43/81), and 58 pseudolesions were identi-fied. Of 58 pseudolesions, 56 were revealed by CTAP and 57 by CTHA. Forty-nine of 58 pseudolesions were larger and all pseudolesions showed more contrast to parenchyma on CTHA than on CTAP. The location of pseudolesions was segment V(32 of 58), IV (25 of 58), and VI (1 of 58), and their size ranged from 5 to 30 (mean, 17.5)mm. Pseudolesions were wedge-shaped (48 of 58), oval (6 of 58), bandlike (3 of 58), or round (1 of 58). CONCLUSION: CTAP and CTHA frequently revealed pseudolesion around the GB fossa. The radiological characteristics of these modalities help differentiate pseudolesions from true tumoral hepatic lesions.

Double Uncture fo Single Common Femoral Artery for CT Hepatic Arteriography and CT Arterial Portography

PURPOSE: To evaluate the safety and efficacy of double puncture of a single common femoral artery for CThepatic arteriography(CTHA) and CT arterial portography(CTAP) in patients with hepatocellular carcinoma. MATERIAL AND METHODS: Between October and December 1995, 35 patients with hepatocellular carcinoma underwent doublepuncture of a single common femoral artery for combined CTHA and CTAP. Preangiographic laboratory data were asfollows : platelet count from 28,000 to 250,000/mm3 (average, 124,500/mm3) ; prothrombin time from 45.8% to100%(average, 85.3%). In the inguinal area, a pair of 21G puncture needles were used unilaterally for the firsttwo femoral punctures, at a distance of 5-7mm ; a 0.018" guidewire for the insertion of a 4-F sheath in a coaxialmicropuncure introducer set ; and a 0.035" guidewire and 4 F check-flo sheath for the insertion of 4-F catheters.After being moved to the CT room, patients then underwent spiral CTHA and CTAP for further detection ofhepatocellular carcinoma nodules. Transarterial chemoembolization followed, and the punctured site was thencompressed by the usual finger compression method. After initial compression and one day later, we observed thepuncture site for complications such as hematoma formation, thromboembolization or arteriovenous fistula ; ect. RESULTS: Except for the formation of two mild hematomas, no remarkable severe complications were noted. Fifteenpatients who had previously undergone combined spiral CTHA and CTAP using the bilateral femoral puncture method(with a 5-F check-flo sheath) felt more comfortable than when an earlier method was used. CONCLUSION: For combinedCTHA and CTAP, double puncture of a single common femoral artery is safer and more comfortable than the bilateralfemoral puncture method.