Aortic Dissection in a Survivor after Cardiopulmonary Resuscitation / 대한구급학회지

We describe a case of traumatic aortic dissection associated with cardiac compression in a patient with anaphylactic cardiac arrest who underwent cardiopulmonary resuscitation (CPR). A 54-year-old man who was scheduled to undergo surgery for gastric cancer went into cardiac arrest caused by an anaphylactic reaction to prophylactic antibiotics in the operating room. Veno-arterial extracorporeal membrane oxygenation (ECMO) was performed. CPR, including chest compressions, was performed for 35 minutes, and the patient was transferred to the intensive care unit (ICU) after spontaneous circulation returned. The patient received ECMO for 9 hours until confirmation of normal cardiac function on transthoracic echocardiography. Twenty days after cardiac arrest, an aortic dissection and fractures in the left fourth and fifth ribs due to chest compression were detected by abdominal computed tomography. The DeBakey type III aortic dissection extended from the distal arch of the thoracic aorta to the proximal level of the renal artery, involving the celiac trunk. It was considered an uncomplicated type B aortic dissection with no sign of malperfusion of the major vessels. This case demonstrates the potential traumatic injuries that can occur after CPR and encourages proper management of mechanical complications in cardiac arrest survivors.

Aortic Dissection in a Survivor after Cardiopulmonary Resuscitation / 대한중환자의학회지

We describe a case of traumatic aortic dissection associated with cardiac compression in a patient with anaphylactic cardiac arrest who underwent cardiopulmonary resuscitation (CPR). A 54-year-old man who was scheduled to undergo surgery for gastric cancer went into cardiac arrest caused by an anaphylactic reaction to prophylactic antibiotics in the operating room. Veno-arterial extracorporeal membrane oxygenation (ECMO) was performed. CPR, including chest compressions, was performed for 35 minutes, and the patient was transferred to the intensive care unit (ICU) after spontaneous circulation returned. The patient received ECMO for 9 hours until confirmation of normal cardiac function on transthoracic echocardiography. Twenty days after cardiac arrest, an aortic dissection and fractures in the left fourth and fifth ribs due to chest compression were detected by abdominal computed tomography. The DeBakey type III aortic dissection extended from the distal arch of the thoracic aorta to the proximal level of the renal artery, involving the celiac trunk. It was considered an uncomplicated type B aortic dissection with no sign of malperfusion of the major vessels. This case demonstrates the potential traumatic injuries that can occur after CPR and encourages proper management of mechanical complications in cardiac arrest survivors.

Higher incidence of gastroesophageal reflux disease after gastric wedge resections of gastric submucosal tumors located close to the gastroesophageal junction

PURPOSE: We hypothesized that gastroesophageal reflux disease (GERD) would be more prevalent after a gastric wedge resection of a submucosal tumor (SMT) located close to the gastroesophageal junction (GEJ) than after a gastric wedge resection of an SMT at other locations because of the damage to the lower esophageal sphincter during surgery. METHODS: Fifty-eight patients with gastric SMT who underwent open or laparoscopic gastric wedge resection between January 2000 and August 2012 at the Department of Surgery, Incheon St. Mary's Hospital were enrolled into this study. The patients were divided into 2 groups according to the location of the tumor, upper or lateral border of the tumor within 5 cm of the GEJ (GEJ 5 cm group). The surgical records, clinicopathologic findings, postoperative GERD symptoms, postoperative use of acid suppressive medications and preoperative and postoperative endoscopic findings were retrospectively reviewed and compared between the 2 groups. RESULTS: There was no difference in the frequency of the preoperative GERD symptoms between the 2 groups, whereas postoperative GERD symptoms and postoperative use of acid suppressive medications were more frequent in the GEJ < or = 5 cm group (P = 0.045 and P = 0.031). However, there were no differences in the follow-up endoscopic findings in terms of reflux esophagitis and Hill's grade between the 2 groups. CONCLUSION: The incidence of GERD was higher after gastric wedge resection of SMTs located close to the GEJ. Hence, adequate care should be taken during the follow-up of these patients.

Totally Laparoscopic Resection for a Large Gastrointestinal Stromal Tumor of Stomach

A debate is currently ongoing about whether a large gastrointestinal stromal tumor (GIST) should be treated by the laparoscopic approach because of the increased risk of tumor rupture during manipulation of the tumor with laparoscopic instruments and the resultant peritoneal tumor dissemination. Herein, we report a case of a large GIST of the stomach which was successfully treated by the laparoscopic approach. A 57 year old female patient visited our institution complaining of postprandial epigastric discomfort. An esophagogastroduodenoscopy and an abdominal computed tomography scan revealed a 10x8 cm sized submucosal tumor at the greater curvature side of the gastric antrum. The patient underwent laparoscopic distal gastrectomy with intracorporeal Billroth-II reconstruction without any breakage of the tumor. Her postoperative course was uneventful and she was discharged on the 7th postoperative day. Even a large GIST of the stomach can safely be treated by the laparoscopic approach when it is performed with proper techniques by an experienced surgeon.

Laparoscopic Gastric Wedge Resection and Prophylactic Antireflux Surgery for a Submucosal Tumor of Gastroesophageal Junction

A laparoscopic wedge resection for a submucosal tumor, which is close to the gastroesophageal junction, is technically challenging. This can be a dilemma to both patients and surgeons when the tumor margin involves the gastroesophageal junction because a wedge resection in this situation might result in a deformity of the gastroesophageal junction or an injury to the lower esophageal sphincter, which ultimately results in lifelong gastroesophageal reflux disease. The patient was a 42 year-old male, whose preoperative endoscopic ultrasonographic finding did not rule out a gastrointestinal stromal tumor. He underwent a laparoscopic gastric wedge resection and prophylactic anterior partial fundoplication (Dor) and was discharged from hospital on the fifth postoperative day without any complications. There were no symptoms of reflux 5 months after surgery. A laparoscopic wedge resection and prophylactic anti-reflux surgery might be a good surgical option for a submucosal tumor at the gastroesophageal junction.

Robot-assisted Excision of a Huge Choledochal Cyst and Roux-en-Y Hepaticojejunostomy using the da Vinci(TM) Surgical System / 대한내시경복강경외과학회지

Choledochal cysts are cystic dilatations of the extrahepatic biliary tree, the intrahepatic bile ducts or both. Because they can develop malignant components, the principle treatment is total excision of the cyst with biliary-enteric reconstruction, and this has been attempted with using minimally invasive techniques. But most reports have uniformly emphasized the technical challenge of laparoscopically correcting a choledochal cyst because of the restricted movements of the laparoscopic equipment. On the other hand, a robotic surgical system with three-dimensional visualization, tremor reduction, motion scaling and wristed instrumentation was introduced in the recent years. Herein, we present a case of the robotic approach to a huge choledochal cyst in an adult.

Cytarabine and Idarubicin Induction Chemotherapy in Patients with Acute Myelogenous Leukemia / 대한혈액학회지

BACKGROUND: About 60~80% of previously untreated patients with acute myelogenous leukemia (AML) achieve complete remission (CR) when treated with cytarabine and anthracycline. Anthracycline is one of the most important chemotherapeutic agents in AML. It has been claimed that idarubicin showed superior complete remission rate than daunorubicin, which is not completely established. We evaluated idarubicin in combination with cytarabine (AI) as an induction chemotherapy in patient with AML. METHODS: Thirty one patients with newly diagnosed acute myelogenous leukemia were enrolled. Remission induction emotherapy was consisted of cytarabine (100mg/m2 IV over 24 hours on day 1~7) and idarubicin (12mg/m2 IV over 30 minutes on day 1~3). After achievement of CR, patients underwent consolidation therapy with high- dose cytarabine and/or bone marrow transplantation. RESULTS: Median age of the patients was 43 years (range; 17~62) and M2 was the most common subtype. The CR rate was 71% (22/ 31). The median overall and disease-free survival were 67 weeks (95% confidence interval, CI; 43~91) and 65 weeks (95% CI; 26~104), respectively with a median follow-up of 48 weeks. Major toxicities were fever and infection during the neutropenic period. There were three treatment-related mortalities. Causes of death were refractory AML in 1 patient and infection in 2 patients. CONCLUSION: AI induction chemotherapy seems to be effective and safe regimen as an induction chemotherapy in AML.

A Case of Waldenstrom's Macroglobulinemia Presented as a Compression Fracture of Spine / 대한혈액학회지

Waldenstrom's macroglobulinemia is a rare disease of plasmacytoid lymphocyte proliferation usually presented without bone lesion which is the common presenting symptom in multiple myeloma. We report a 50-year-old female with Waldenstrom's macroglobulinemia presented as a bony lesion without many other features common in this diesease. She was admitted with the chief complaint of low back pain and low extremity paresthesia for two months. Bone marrow biopsy and aspiration, protein and immune electrophoresis showed findings consistent with Waldenstr m's macroglobulinemia. Magnetic resonance imaging of thoracic spine showed pathologic compression fracture in T6 and T7 with posterior epidural mass at T6 to T7 level. We report this unusual case of Waldenstrom's macroglobulinemia presented as compression fracture of thoracic spine with a review of literatures.

A Case of Gastritis Cystica Profunda Associated with Gastric Perforation and Hypertrophic Gastric Folds / 대한소화기내시경학회지

Gastritis cystica profunda (GCP) is a rare disease in which cystically dilated gastric foveolae or glands extend into the muscularis mucosae or below. The pathogenesis of GCP has been described as an interruption of the muscularis mucosae and migration of epithelial elements to submucosa caused by presence of suture materials after surgery or erosion of the gastric mucosa in chronic gastritis and ischemia. Macroscopically, GCP may present not only as a giant gastric mucosal folds but also as a submucosal tumor or as solitary or diffuse polyps. An endoscopic ultrasonographic (EUS) findings clearly differ from findings in the other disordes. The combination of EUS and mucosectomy appears to be very useful for the diagnosis of GCP. Therefore, all unnecessary surgical procedures should be avoided in cases of GCP. We report a case of GCP associated with gastric perforation which presented as diffuse giant gastric folds and clinically advanced gastric cancer was suspected.

An Unusual Case of Guide Wire Fracture during Coronary Artery Stenting for Bifurcation Lesion

The complications associated with the use of a guide wire, used during angioplasy, are rare and often go unrecognized. However, occasionally the guide wire itself may cause serious complications such as perforation or dissection of the distal coronary artery. A guide wire fracture during angioplasty is a rare complication, however entrapment and uncoiling of the guide wire can cause fracture. We report a case of guide wire fracture that developed by entrapment of the distal bending portion during stenting for bifurcation lesion. The broken free end of the guide wire remained within the stent strut, and urgent surgical intervention was necessary for its retrieval. We experienced a case of entrapment and fracture of the guide wire during stenting that was successfully surgically removed.