Risk Factors for Local Recurrence of Early Gastric Cancer after Endoscopic Submucosal Dissection / 대한내과학회지

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is a widely accepted method of treatment for early gastric cancer (EGC) without lymph node metastasis. However, there have been few studies about factors associated with local recurrence. The aim of our study was to evaluate the risk factors for local recurrence in patients with EGC after ESD. METHODS: We retrospectively analyzed medical records of patients who underwent ESD of EGC at Gachon University Gil Medical Center. From February 2008 to July 2011, ESD for EGC was performed in 222 cases involving 214 patients. Patients with additional treatment after ESD, patients with recurred EGC, and patients with endoscopic follow-up of < 12 months were excluded. After exclusions, a total of 150 cases were included. RESULTS: The mean age of the patients was 63.9 +/- 9.8 years, and 74.3% were male. The en bloc resection rate was 139/150 (92.7%), and the complete resection rate was 131/150 (87.3%). Local recurrence at the ESD site was found in 5 cases (5/150, 3.3%) during a mean follow-up period of 24 months. In multivariate analysis, tumor involvement at the lateral resection margin [HR: 13.12 (1.19 - 145.10); p = 0.036], piecemeal resection [HR: 25.31 (1.24 - 517.57); p = 0.036], and lymphovascular invasion [HR: 485.06 (2.30 - 102449.79); p = 0.024] were associated with local recurrence after ESD. CONCLUSIONS: Local recurrence after ESD was significantly associated with involvement of the lateral resection margin, piecemeal resection, and lymphovascular invasion. Therefore, patients who have these risk factors should be followed up more carefully to detect local recurrence.

Clinical Outcome of Endovascular Treatment of Cerebral Aneurysms in Elderly Patients / 대한뇌혈관외과학회지

OBJECTIVE: Subarachnoid hemorrhage (SAH) is known to have a high mortality rate and increase incidence by aging process. To old aged patients, treatment of cerebral aneurysm is controversial due to multiple factors, regarding underlying disease, life expectancy and treatment risk. We reviewed treatment outcome of the patients older than 65 years who had cerebral aneurysm (s) by using endovascular technique. METHODS: Between 2000 and 2009, 177 patients who aged over 65 years were treated by endovascular management. Among them, 116 patients were presented with SAH and 61 patients were unruptured aneurysm. In SAH group, treatment outcome was evaluated by Glasgow Outcome Scale (GOS) at discharge and modified Rankin Scale (mRS) at 3 months. In unruptured aneurysm group, procedure complication and recurrence of the cerebral aneurysm were evaluated. RESULTS: 177 patients harbored 209 aneurysms in total. GOS for the patients with SAH at discharge was good recovery (n=82, 71%), mild disability (n=7, 6%), severe disability (n=18, 15%), vegetative (n=3, 3%) and death (n=6, 5%). Three months mRS was good condition (mRS 0-2) in 83 patients, poor condition (mRS 3-5) in 26 and death in 1. Regarding the factors related with good recovery in SAH groups, initial Hunt and Hess grade showed statistical significance. In the group of unruptured aneurysm, only 1 patient (1.6%) had a procedure rupture and related in symptomatic intracerebral hemorrhage. CONCLUSION: Based upon our data, coil embolization of cerebral aneurysm was relatively safe and effective to older patients.

A case of Tsukamurella tyrosinosolvens peritonitis associated with continuous ambulatory peritoneal dialysis / 대한내과학회지

A case of Tsukamurella peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD) in a 54-year-old woman is described. Peritonitis is a common complication of peritoneal dialysis in patients with end-stage renal disease. Tsukamurella has been reported to cause rare opportunistic infections in humans, and most cases have been reported in immunocompromised patients or patients with indwelling foreign bodies. This organism is difficult to identify and has been mistaken for Corynebacterium and atypical Mycobacteria. Here, we describe the first case of CAPD-related peritonitis caused by Tsukamurella tyrosinosolvens in Korea. It was treated with CAPD catheter removal.

A case of spontaneous ureteral rupture in a patient on hemodialysis / 대한내과학회지

Spontaneous ureteral rupture is rare, and refers to leakage in the absence of prior ureteral manipulation, external trauma, previous surgery, or any destructive kidney disease. It presents a major diagnostic challenge due to the diversity at presentation. Here, we present a rare case of spontaneous ureteral rupture in a 62-year-old man with a history of fungal pyonephrosis (Candida) on maintenance hemodialysis, causing a large infected urinoma and abscess and a review the literature.

Klebsiella pneumoniae Multi-organ Infection not Accompanied by Liver Abscess : Report of 2 Cases

Klebsiella pneumoniae is a pathogen that causes a wide range of infections in human, and has a tendency to metastasize to multiple organs. We report two rare cases of K. pneumoniae infection that have spread to multiple organs without being accompanied by liver abscess. A 59-year-old man (case 1) was admitted due to left knee pain. Microbiologic and radiologic studies revealed bacteremia, septic arthritis, pneumonia, prostatitis, and endophthalmitis caused by K. pneumoniae. A 48-year-old man (case 2) was admitted due to febrile sensation. Microbiologic and radiologic studies revealed bacteremia, pneumonia, urinary tract infection, endophthalmitis, and cerebritis caused by K. pneumoniae. With appropriate use of effective antibiotics and therapeutic measures, the patients recovered but with some sequelae.

A Case of Vertebral Osteomyelitis with Spinal Epidural Abscess Caused by Streptococcus constellatus

We report a case of vertebral osteomyelitis with epidural abscess caused by Streptococcus constellatus. The patient was present with fever, back pain, and dyspnea for 1 week. The patient was previously healthy and did not have any predisposing factor. After evaluation, the patient was diagnosed as Streptococcus constellatus vertebral osteomyelitis. He was successfully treated with surgical debridement and antibiotic therapy. To the best of our knowledge, this is the first case of S. constellatus vertebral osteomyeltis with epidural abscess to be reported in Korea.

Klebsiella pneumoniae Multi-organ Infection not Accompanied by Liver Abscess : Report of 2 Cases

Klebsiella pneumoniae is a pathogen that causes a wide range of infections in human, and has a tendency to metastasize to multiple organs. We report two rare cases of K. pneumoniae infection that have spread to multiple organs without being accompanied by liver abscess. A 59-year-old man (case 1) was admitted due to left knee pain. Microbiologic and radiologic studies revealed bacteremia, septic arthritis, pneumonia, prostatitis, and endophthalmitis caused by K. pneumoniae. A 48-year-old man (case 2) was admitted due to febrile sensation. Microbiologic and radiologic studies revealed bacteremia, pneumonia, urinary tract infection, endophthalmitis, and cerebritis caused by K. pneumoniae. With appropriate use of effective antibiotics and therapeutic measures, the patients recovered but with some sequelae.

A Case of Vertebral Osteomyelitis with Spinal Epidural Abscess Caused by Streptococcus constellatus

We report a case of vertebral osteomyelitis with epidural abscess caused by Streptococcus constellatus. The patient was present with fever, back pain, and dyspnea for 1 week. The patient was previously healthy and did not have any predisposing factor. After evaluation, the patient was diagnosed as Streptococcus constellatus vertebral osteomyelitis. He was successfully treated with surgical debridement and antibiotic therapy. To the best of our knowledge, this is the first case of S. constellatus vertebral osteomyeltis with epidural abscess to be reported in Korea.

A Case of Primary Hepatic Angiosarcoma after Renal Transplantation / 대한신장학회지

Malignancy is one of the important complications after renal transplantation, and decreases both patient survival and graft survival. Hepatic angiosarcoma is the most common sarcoma in liver, but a rare malignant tumor which occupies about 2% of all hepatic malignancies. We report a case of primary hepatic angiosarcoma after renal transplantation, the first case of post-transplantation angiosarcoma in Korea. A 27-year old man had received a living related renal transplantation. He was admitted due to clinical manifestations of liver cirrhosis such as ascites, spontaneous bacterial peritonitis, and varix bleeding at 8 months after transplantation. Whole liver was infiltrated with angiosarcoma; therefore, he was managed only by supportive care. Considering the poor prognosis of hepatic angiosarcoma, both careful screening of malignancy before transplantation and periodic surveillance of malignancy after transplantation are essential.

Co-circulation of Two Genotypes of Hepatitis A Virus from Sporadic Cases in Northeastern Area of Seoul, Korea / 대한진단검사의학회지

BACKGROUND: In previous studies, most hepatitis A virus (HAV) isolates had been genotype IA in Korea. Recently, a small number of different genotypes were reported with an upsurge of acute hepatitis by HAV. We investigated the distribution of HAV genotypes. METHODS: RNA was extracted from anti-HAV IgM positive sera which were collected from March 2007 to February 2008 at a tertiary care hospital in Northeastern Seoul, Korea. Nested reverse transcription (RT)-PCR and direct sequencing for VP1/P2A region of the HAV were performed. RESULTS: A total of 699 cases with suspected acute hepatitis were tested for anti-HAV IgM, and positive results were obtained in 56 sera (8.0%), which were collected 2 to 15 days (median, 7 days)after the onset of symptoms. Of the 56 seropositive samples, 52 (92.9%) were positive for HAV RNA, among which 28 isolates (53.8%) belonged to genotype IA and the remaining 24 (46.2%) belonged to genotype IIIA. Both IA and IIIA genotypes were isolated from 6-7 neighboring administrative districts throughout the year without geographic or seasonal restrictions. CONCLUSIONS: Co-circulation of two distinct HAV genotypes (IA and IIIA) was observed from the northeastern Seoul for the year studied.

Role of Three-dimensional Computed Tomography Angiography in the Follow-up of Patients with Aneurysm Clips

OBJECTIVE: The purpose of this study is to assess the usefulness of three-dimensional computed tomography angiography (3D-CTA) as a postoperative follow-up examination after intracranial aneurysms have been clipped. METHODS: Between January 2002 and June 2005, 522 consecutive patients received treatment for intracranial aneurysms. A retrospective analysis of 310 patients with postoperative 3D-CTAs was performed to evaluate aneurysmal remnants and de novo aneurysms. This study was conducted in 271 patients with at least immediate and 6-month routine 3D-CTAs for postoperative clipped aneurysm and 39 patients with 3D-CTAs for clipped aneurysm before 2002 when there was no 3D-CTA in our hospital. RESULTS: Eight patients had abnormal CT angiographic findings. Aneurysm remnants were revealed in 4 patients and de novo aneurysms were discovered in 5 patients. Two patients were found at the postoperative 6-month 3D-CTA performed routinely. In 1 patient, the aneurysm was demonstrated on the way to the examination of syncope. In 2 patients, the author recommended 3D-CTA although there was no symptom because the patients had visited our institute long time ago (5.1, 4.5 years). Of the 8 patients, 2 remnants and 1 de novo aneurysm were treated by endovascular treatment. Three de novo aneurysms at the middle cerebral artery and 1 pericallosal artery aneurysm were treated by direct clipping because these aneurysms were not suitable for the endovascular treatment in point of anatomical configuration. One patient with both remnant and de novo aneurysm was treated conservatively. CONCLUSION: 3D-CTA is an available, non-invasive diagnostic tool for the postoperative follow-up examination of aneurysmal state in patients after clipping.

Intracranial Aneurysms in the 3rd and 4th Decades in Comparison with Those in the 8th and 9th Decades

OBJECTIVE: This study is performed to compare older with younger groups about clinical characteristics and overall outcome of treatments for the intracranial aneurysms. METHODS: We retrospectively investigated 633 patients with cerebral aneurysms who were admitted to our institute from January 2000 to May 2004. The authors divided the patients of cerebral aneurysm into two groups, one the third, fourth decades and the other eighth, ninth decades, analyzed clinical characteristics and overall outcome of treatments. RESULTS: There were 57 patients (9.0%) under 39years old and 58 patients (9.2%) over 70. The female to male sex ratio was 0.5:1 in the younger group(YG) and 7.3:1 in the older group(OG), showing a female predominance with increasing age. In the YG, aneurysms were found in anterior communicating artery(A-com) (44.8%), middle cerebral artery (31.0%). In the OG, aneurysm of posterior communicating artery (30.1%) was most common followed by that of A-com (26.9%). More smokers and alcoholics were found in the YG. Older age was related to poor Hunt-Hess grade, Fisher's grade on admission, high incidence of unruptured aneurysms, and endovascular surgery. There was a higher prevalence of hypertension, intraventricular hematoma, hydrocephalus, and rebleeding in the preoperative state in the OG and postoperative complications including hydrocephalus, subdural fluid collection, and systemic complications. Overall outcome was poorer with advancing age (p=0.01). CONCLUSION: The patients with aneurysms in the YG have distinct characteristics compared to those in the OG. Because of a good clinical grade on admission, a thin subarachnoid clot, and low incidence of perioperative complications, the overall outcomes of the young patients were better than those of the old patients.

Surgical Resuscitation of a Patient with Cerebral Herniation Secondary to Massive Hemorrhage in the Basal Ganglia: Ultrasound-monitored Aspiration

The authors report a case of hyperacute, massive hemorrhage in the left basal ganglia with severe midline shift that was treated successfully by the ultrasound-monitored free hand aspiration technique. Every effort was made to shorten time until removal of considerable amount of the hematoma and minimize duration of cerebral herniation, avoiding additional irreVersible neurological deficit. A burr hole aspiration technique was preferred to standard craniotomy procedure, and any time-consuming procedures such as stereotactic frame application were abandoned. A burr hole was localized on the basis of computed tomography images simply and quickly with a ruler, and safety of the aspiration procedure was augmented by real-time ultrasound monitoring. Such minimally invasive technique relieved cerebral herniation successfully while avoiding time consumption and the morbidity of major craniotomy procedure. Early resuscitation of the patient with cerebral herniation in this case resulted in excellent recovery of the patient's neurological deficit. The patient's mentality started to improve rapidly and was clear six months after the surgery.

Neurosurgical Approaches to and through the Frontal Sinus using Osteoplastic Frontal Sinusotomy

OBJECTIVE: The frontal sinus is frequently a troublesome anatomical obstacle to gain access to the medial anterior cranial base. Surgical approaches to and through the frontal sinus using osteoplastic frontal sinusotomy provide significant advantages to the treatment of lesions of the medial anterior cranial base in addition to the frontal sinus itself. However, appropriate management is necessary to avoid postoperative complications such as cerebrospinal fluid leakage, infection, mucocele formation, and deformity of the forehead. METHODS: The advantages and shortcomings of the approach along with the surgical technique are reported based on our clinical experience with pertinent literature review. The approach using the osteoplastic frontal sinusotomy was applied to two cases of osteoma in the frontal sinus, seven cases of craniofacial tumors, a case of chordoma in the sphenoid and clivus, and two cases of intradural lesions in the anterior cranial fossa. The frontal sinus was managed in such a way as to prevent the postoperative complications. RESULTS: All patients underwent gross total resection of the tumors. With a mean follow-up of 26 months, there were no postoperative complications related to frontal sinus violation. CONCLUSION: The neurosurgical approaches via the frontal sinus using osteoplastic frontal sinusotomy are versatile for various lesions of the anterior cranial base in patients with large frontal sinuses. In situations that the frontal sinus have to be violated to approach medial anterior cranial base, the osteoplastic frontal sinusotomy provides such advantages as optimal frontal sinus control to prevent postoperative complications; increases viewing angle with superior trajectory from nasofrontal suture; lower incidence of pnemocephalus due to minimal dural exposure; and excellent cosmesis without frontal burr holes.

Intubation Difficulty in Patient with Pseudoankylosis of Temporo-mandibular Joint after Pterional Craniotomy

The authors report on a severe case of pseudoankylosis of the temporo-mandibular(TM) joint following a pterional craniotomy and the intubation difficulty encountered in the second surgery. Preventive and therapeutic aspects in addition to the clinical pitfalls of the case are discussed.

Difficult Intubation during Induction of a Patient with Pseudoankylosis of the Temporo-mandibular Joint after Pterional Craniotomy: A case report / 대한마취과학회지

We describe here a case of difficult intubation due to pseudoankylosis of the temporo-mandibular joint after a pterional craniotomy. A 50-year-old female was admitted to our hospital presenting with severe headache. According to her angiogram, a ruptured aneurysm in left posterior communicating artery (PCoA) and an unruptured right PCoA aneurysm were detected. We the operation in two-steps; the first operation for the left PCoA proceeded without any problem, and the tracheal intubation also was not difficult. Four weeks later, while inducing the general anesthesia for her second operation, severe trismus was detected after the infusion of propofol 120 mg. While ventilating the patient with a well-fitted mask, we performed several attempts of conventional tracheal intubation, and the patient was finally managed using a ProSealTM laryngeal mask airway with controlled ventilation. According to patient's history, trismus has also occurred after her first operation. We think that the reason for her trismus was a result of contracture of the temporalis muscle after her first pterional craniotomy.

Induction of Apoptosis in Synovial Cells from Patients with Rheumatoid Arthritis / 대한면역학회지

Homeostasis of multicellular organism is controlled by proliferation and differentiation of cells as well as by cell death. The defects in programmed cell death contribute to the pathogenesis of rheumatoid arthritis (RA) and systemic lupus erythematous. RA is considered to be a proliferating disorder of synovial tissue which is accompanied by inflammatory cell infiltration and bone erosion. The aim of the study was to find whether potent inducers of apoptosis could be induced apoptosis in RA synovial cells. We examined the effects of drugs, such as dexamethasone, methotrexate, hydrogen peroxide, and ceramide on induction of apoptosis in cultured RA synovial cells. Used drugs did not induced apoptosis in RA synovial cells. Finally Fas antigen-mediated apoptosis of RA synovial cells was investigated by the addition of anti-Fas antibody. To examine the ICE (interleukin-1p-convertase; caspase-1) expression in synovial cells, RT-PCR of caspase-1 gene was performed. In synovial cells of RA, Fas induces that caspase-1 activation cause apoptosis.

Personality Change after Aneurysmal Surgery of Anterior Communicating Artery

The neuropsychological consequences of ruptured intracranial aneurysms are being given increasing attention with the recent increase in survival by surgical repair of the aneurysms. The territory of anterior communicating artery(AcoA) seems to be particularly susceptible to neurobehavioral impairments. They include amnesia. Confabulation, and personality change. The neurobehavioral changes have been collectively referred to as the "AcoA syndrome". The study of amnesia and confabulation was extensive for several decades, but the personality change after anterior communicating artery aneurysm rupture seems to have been given less attention. The present study used the MMPI to assess the personalities of 15 AcoA aneurysmal patients and a control group of 19 patients with subarachnoid hemorrhage from aneurysms located at other sites. Overall, AcoA patients showed no remarkable differences in personality in comparison with the control group. However, 5 patients with abnormal MMPI profiles that have abnormally incre ased depression subscale score and an associated increased scores on psychopathic deviance, hysteria, psychasthenia and schizophrenia subscales were detected by cluster analysis, and 4 of them had causable focal lesions such as basal forebrain, ventromedial frontal lobe, and medial frontal lobes about interhemispheric fissure on brain CT. Also, a group with the worst initial clinical state, Hunt and Hess grade IV, developed more personality impairment than the group with Hunt and Hess grade I-II-III regardless of the aneurysmal location. They showed increased scores on depression, psychopathic deviance and schizophrenia subscales.

A Comparison of Posterolateral and Posterior Interbody Fusion in the Surgical Treatment of Lumbar Spondylolisthesis

From November 1992 to October 1994, 71 patients with spondylolisthesis underwent transpedicular fixation and fusion using VSP system. Two groups of were studied, in order to compare comcomitant posterolateral and posterior lumbar interbody fusion with regard to operating time, blood loss, degree of reduction, fusion rate, clinical results, and complications. Results showed 31 good, 11 fair, and 3 poor in the posterolateral fusion group and 23 good, 1 fair, and 2 poor in the posterior lumbar interbody fusion group. Implant failure occurred in 2 patients and consisted of screw breakage. Posterior lumbar interbody fusion with internal fixation provides a highly successful method for maintaining interbody height and obtaining arthrodeis.

Echocardiographic Evaluation of Cardiac Functions in Normal Korean Adults

To evaluate the cardiac functions we examed the M-mode echocardiography with measurements of blood pressure, heart rate and body surface area in 55 normal Korean adults(male 30 persons, female 25 persons) of mean age, 41.7+/-12.3 years. (1) Interventricular septal thickness is 9.5+/-1.7mm and left ventricular posterior wall thickness are 8.6+/-1.5mm at end-diatole, 14.0+/-2.1mm at end-systole. (2) Diastolic and systolic left ventricular internal dimensions are 49.1+/-4.8mm and 31.3+/-5.0mm, respectively. (3) Left ventricular mass by Penn Convention method is 174.4+/-52.1g and left ventricular mass index is 103.2+/-28.8g/m2. (4) Relative wall thickness is 0.35+/-0.06. (5) Left ventricular volumes by Teichholz's method are 114.9+/-27.6ml at diastole and 40.2+/-17.2ml at systole. Therefore, stroke volume is 74.7+/-16.9ml and stroke volume index is 44.5+/-10.7 ml/m2. (6) Cardiac output is 4944+/-1058 ml/min and cardiac index is 2951+/-666 ml/min/m2. (7) Total peripheral resistance is 1454+/-356 dynes-sec-cm(-5) and total peripheral resistance index is 2472+/-623 dynes-sec-cm(-5).m2. (8) Fractional shortening is 36.5+/-6.0% and pressure-volume ratio is 3.27+/-1.19 mmHg/ml. (9) End-systolic wall stress is 61.3+/-19.7x10(3) dynes=cm2. (10) Atrial emptying index is 0.66+/-0.18.