Temporary 12-Hour Drain Clamping versus 3-Hour Drain Clamping in Simultaneous Bilateral Total Knee Arthroplasty

Background@#Total knee arthroplasty (TKA) is a procedure that has a risk of perioperative blood loss and allogeneic blood transfusion. The purpose of the present study was to compare the perioperative blood loss and transfusion rate between the 3-hour interval clamping and 12-hour interval clamping of closed suction drainage after simultaneous bilateral total knee arthroplasty (SBTKA). @*Methods@#A total of 122 SBTKAs were enrolled in this retrospective study. A 3-hour clamping protocol was applied in 53 SBTKAs and a 12-hour clamping protocol was applied in 69 SBTKAs. The amount of perioperative blood loss, transfusion requirements, postoperative hemoglobin and hematocrit levels, the lowest hemoglobin and hematocrit levels during hospitalization, readmission within 90 days, and clinical outcomes were compared between the 3-hour clamping group and the 12-hour clamping group. @*Results@#The 12-hour clamping group had fewer patients requiring transfusion (26.1%, 18/69) than did the 3-hour clamping protocol group (49.1%, 26/53) (p = 0.008). The 12-hour clamping group had a lower amount of estimated blood loss (1,426.9 ± 421.5 mL) than did the 3-hour clamping protocol group (1,882.1 ± 445.6 mL) (p < 0.001). The 12-hour clamping group showed higher hemoglobin and hematocrit levels (both p < 0.001) on postoperative day 5 than did the 3-hour clamping group. The lowest hemoglobin and hematocrit levels were higher in the 12-hour clamping group than in the 3-hour clamping group (p = 0.039 and p = 0.016, respectively). Within 1 postoperative month, there were 2 cases of wound dehiscence in each group (p = 0.585). But, at 1 year after the operation, no serious complications occurred in the two groups. @*Conclusions@#Compared to the 3-hour clamping protocol, the 12-hour clamping protocol significantly reduced transfusion requirements, estimated blood loss volume, and hemoglobin and hematocrit levels after SBTKA. We suggest that 12-hour temporary clamping should be considered for reducing transfusion rates.

Clinical significance of C-reactive protein-to-prealbumin ratio in predicting early recurrence in resectable pancreatic cancer

Purpose@#Resectable pancreatic ductal adenocarcinoma (PDAC) has a high risk of recurrence after curative resection; despite this, the preoperative risk factors for predicting early recurrence remain unclear. This study therefore aimed to identify preoperative inflammation and nutrition factors associated with early recurrence of resectable PDAC. @*Methods@#From March 2021 to November 2021, a total of 20 patients who underwent curative resection for PDAC were enrolled in this study. We evaluated the risk factors for early recurrence within 1 year by univariate and multivariate analyses using Cox hazard proportional regression. The cutoff values for predicting recurrence were examined using receiver operating characteristic (ROC) curves. @*Results@#In our univariate and multivariate analyses, C-reactive protein (CRP), CRP-albumin ratio, and CRP-prealbumin ratio, as well as sex and age, were significant independent prognostic factors for early recurrence in PDAC. However, known inflammatory factors (neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios), nutritional factors (albumin, prealbumin, ferritin, vitamin D), and inflammatory-nutritional factors (Glasgow Prognostic Score, modified Glasgow Prognostic Score, albumin-bilirubin) showed no association with early recurrence. In addition, using cutoff values by ROC curve analysis, a high preoperative CRP level of >5 mg/L, as well as high CRP-to-albumin (>5.3) and CRP-to-prealbumin (>1.3) ratios showed no prognostic value. @*Conclusion@#Our results showed that inflammatory and perioperative nutritional factors, especially CRP-to-prealbumin ratio, have significant associations with early recurrence after curative resection in resectable PDAC. Therefore, for such patients, a cautious approach is needed when inflammation and poor nutritional status are present.

Risk factors for central and lateral lymph node metastasis in papillary thyroid carcinoma / 고신대학교의과대학학술지

Background@#Lymph node metastasis (LNM) is commonly observed in papillary thyroid carcinoma. This study aimed to investigate the risk factors for LNM in patients with papillary thyroid carcinoma. @*Methods@#The clinicopathological factors of 417 patients were investigated, and differences according to the presence or absence of LNM were evaluated. @*Results@#LNM was associated with age 10 mm, multiple and bilateral tumors, tumor involving the lower pole or entire lobe, lymphovascular invasion (LVI), perineural invasion (PNI), and extrathyroidal extension (ETE). Univariable and multivariable analyses showed that age 10 mm, LVI, and ETE were related to central LNM. Male sex, tumor size >10 mm, and LVI were correlated with lateral LNM (p10 mm, multifocality, PNI, ETE, and the absence of lymphocytic thyroiditis (p10 mm, LVI, and ETE were risk factors for central LNM, while male sex, tumor size >10 mm, and LVI were risk factors for lateral LNM. ENE was more commonly observed in lateral LNM, and tumor size >10 mm, multifocal tumors, PNI, ETE, and tumors unrelated to lymphocytic thyroiditis were risk factors for ENE.

Colorectal epithelial neoplasm associated with gut-associated lymphoid tissue

Background@#Colorectal epithelial neoplasm extending into the submucosal gut-associated lymphoid tissue (GALT) can cause difficulties in the differential diagnosis. Regarding GALT-associated epithelial neoplasms, a few studies favor the term “GALT carcinoma” while other studies have mentioned the term “GALT-associated pseudoinvasion/epithelial misplacement (PEM)”. @*Methods@#The clinicopathologic characteristics of 11 cases of colorectal epithelial neoplasm associated with submucosal GALT diagnosed via endoscopic submucosal dissection were studied. @*Results@#Eight cases (72.7%) were in males. The median age was 59 years, and age ranged from 53 to 73. All cases had a submucosal tumor component more compatible with GALT-associated PEM. Eight cases (72.7%) were located in the right colon. Ten cases (90.9%) had a non-protruding endoscopic appearance. Nine cases (81.8%) showed continuity between the submucosal and surface adenomatous components. Nine cases showed (81.8%) focal defects or discontinuation of the muscularis mucosae adjacent to the submucosal GALT. No case showed hemosiderin deposits in the submucosa or desmoplastic reaction. No case showed single tumor cells or small clusters of tumor cells in the submucosal GALT. Seven cases (63.6%) showed goblet cells in the submucosa. No cases showed oncocytic columnar cells lining submucosal glands. @*Conclusions@#Our experience suggests that pathologists should be aware of the differential diagnosis of GALT-associated submucosal extension by colorectal adenomatous neoplasm. Further studies are needed to validate classification of GALT-associated epithelial neoplasms.

The anterolateral ligament of the knee joint: a review of the anatomy, biomechanics, and anterolateral ligament surgery

Residual knee instability and low rates of return to previous sport are major concerns after anterior cruciate ligament (ACL) reconstruction. To improve outcomes, surgical methods, such as the anatomical single-bundle technique or the double-bundle technique, were developed. However, these reconstruction techniques failed to adequately overcome these problems, and, therefore, new potential answers continue to be of great interest. Based on recent anatomical and biomechanical studies emphasizing the role of the anterolateral ligament (ALL) in rotational stability, novel surgical methods including ALL reconstruction and anterolateral tenodesis have been introduced with the possibility of resolving residual instability after ACL reconstruction. However, there is still little consensus on many aspects of the ALL, including: several anatomical issues, appropriate indications for ALL surgery, and the optimal surgical method and graft choice for reconstruction surgery. Therefore, further studies are necessary to advance our knowledge of the ALL and its contribution to knee stability.

Risk of Emergency Operations, Adverse Maternal and Neonatal Outcomes according to the Planned Gestational Age for Cesarean Delivery

BACKGROUND: The objective of this study was to assess the risk of emergency cesarean deliveries (CDs) and adverse neonatal/maternal outcomes according to the planned gestational age at delivery (GAD) for elective CD. METHODS: The study population consisted of term singleton pregnant women who were booked for elective CD and were subsequently delivered at term by CD, after excluding cases with a trial of labor. The relationship between the planned GAD, risk of emergency CD prior to planned date, and adverse neonatal/maternal outcomes were determined. RESULTS: The frequency of emergency CD, adverse neonatal and maternal outcomes were 9.5%, 4.5%, and 5.9%, respectively. The risk of emergency CD prior to the planned delivery date increased significantly according to the planned GAD (5.8% at 37 weeks, 8.2% at 38 weeks, 13.6% at 39 weeks, and 26.7% at 40 weeks or more of planned GAD, P = 0.005). Emergency CD was associated with an increased risk of adverse maternal outcomes, whereas the risk of adverse neonatal outcomes did not differ. In the total study population including both cases with elective and emergency CD, the risk of adverse maternal outcomes did not increase according to the planned GAD, and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD. CONCLUSION: The risk of emergency CD increased as the planned GAD increased, but the risk of adverse maternal outcomes did not increase and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD in the total study population including elective/emergency CD.

Quantification of the Effect of Vertical Bone Resection of the Medial Proximal Tibia for Achieving Soft Tissue Balancing in Total Knee Arthroplasty

BACKGROUND: Degenerative osteoarthritis of the knee usually shows arthritic change in the medial tibiofemoral joint with severe varus deformity. In total knee arthroplasty (TKA), the medial release technique is often used for achieving mediolateral balancing. But, in a more severe varus knee, there are more difficult technical problems. Bony resection of the medial proximal tibia (MPT) as an alternative technique for achieving soft tissue balancing was assessed in terms of its effectiveness and possibility of quantification. METHODS: TKAs were performed in 78 knees (60 patients) with vertical bone resection of the MPT for soft tissue balancing from September 2011 to March 2013. During operation, the medial and lateral gaps were measured before and after the bony resection technique. First, the correlation between the measured thickness of the resected bone and the change in medial and lateral gaps was analyzed. Second, the possibility of quantification of each parameter was evaluated by linear regression and the coefficient ratio was obtained. RESULTS: A significant correlation was identified between alteration in the medial gap change in extension and the measured thickness of the vertically resected MPT (r = 0.695, p = 0.000). In the medial gap change in flexion, there was no statistical significance (r = 0.214, p = 0.059). When the MPT was resected at an average thickness of 8.25 +/- 1.92 mm, the medial gap in extension was increased by 2.94 +/- 0.87 mm. In simple linear regression, it was predictable that MPT resection at a thickness of 2.80 mm was required to increase the medial gap by 1.00 mm in knee extension. CONCLUSIONS: The method of bone resection of the MPT can be considered effective with a predictable result for achieving soft tissue balancing in terms of quantification during TKA.

Comparison of Clinical and Physiological Efficacies of Different Intermittent Sequential Pneumatic Compression Devices in Preventing Deep Vein Thrombosis: A Prospective Randomized Study

BACKGROUND: There are few comparative studies about the optimal method of pneumatic compression to prevent deep vein thrombosis (DVT). The aim of this prospective randomized study was to compare venous hemodynamic changes and their clinical influences between two graded sequential compression groups (an alternate sequential compression device [ASCD] vs. a simultaneous sequential compression device [SSCD]). METHODS: In total, 34 patients (68 limbs) undergoing knee and spine operations were prospectively randomized into two device groups (ASCD vs. SSCD groups). Duplex ultrasonography examinations were performed on the 4th and 7th postoperative days for the detection of DVT and the evaluation of venous hemodynamics. Continuous data for the two groups were analyzed using a two-tailed, unpaired t-test. Relative frequencies of unpaired samples were compared using Fisher exact test. Mixed effects models that might be viewed as ANCOVA models were also considered. RESULTS: DVT developed in 7 patients (20.6%), all of whom were asymptomatic for isolated calf DVTs. Two of these patients were from the ASCD group (11.8%) and the other five were from the SSCD group (29.4%), but there was no significant difference (p = 0.331). Baseline peak velocity, mean velocity, peak volume flow, and total volume flow were enhanced significantly in both device groups (p < 0.001). However, the degrees of flow and velocity enhancement did not differ significantly between the groups. The accumulated expelled volumes for an hour were in favor of the ASCD group. CONCLUSIONS: Both graded sequential compression devices showed similar results both in clinical and physiological efficacies. Further studies are required to investigate the optimal intermittent pneumatic compression method for enhanced hemodynamic efficacy and better thromboprophylaxis.

Successful laparoscopic surgery for 14-month-old infant with ovarian torsion

The prevalence of ovarian torsion is 4.9 among 100,000 females between ages 1 to 20 years. The diagnosis of ovarian torsion in children, especially in infants, is very difficult. Since they cannot explain related symptoms accurately, and reproductive organs lie high in the abdomen, physical examination shows unclear findings. For these reasons, we use imaging studies, such as ultrasonography and magnetic resonance imaging, to diagnose ovarian torsion. However, it is of limited value to diagnose by using these modalities alone. Therefore, clinical suspicion is important for diagnosis. Though pediatric laparoscopic surgery was introduced 20 years ago, it has been widely performed since the mid 1990s with the development of 3-mm instruments. In addition, usually the pediatric operation is done in the pediatric surgery office, even though it is a gynecologic procedure. In addition, laparotomy is still more frequently conducted in current clinical practice, although the frequency of laparoscopic surgery has increased. However, it is thought that expert gynecologic surgeons can perform pediatric laparoscopic operations if they pay attention to some precautions. We report herein the case of a 14-month-old infant who underwent emergency laparoscopic untwisting of ovarian torsion successfully without complications by a gynecologic surgeon, with a brief review of the literature.

Metastatic malignant melanoma with peritoneal seeding in a young woman: A case report

Malignant melanomas of the uterus, either primary or metastatic, are extremely rare. They can be mistaken as other tumors, such as uterine sarcomas during diagnosis. We describe here the first case of a metastatic melanoma of the uterus with peritoneal seeding in a young woman. It was first diagnosed as a uterine sarcoma from a frozen-section biopsy.

Comparative Study of Two Techniques for Ligament Balancing in Total Knee Arthroplasty for Severe Varus Knee: Medial Soft Tissue Release vs. Bony Resection of Proximal Medial Tibia

PURPOSE: Bony resection of the proximal medial tibia, an alternative technique for soft tissue balancing in total knee arthroplasty (TKA), was compared to the conventional medial soft tissue release technique. MATERIALS AND METHODS: From June 2005 to June 2007, we performed 40 TKA in 27 patients with > or =10degrees tibio-femoral varus deformity. The conventional, medial soft tissue release technique was applied in 20 cases and bony resection of proximal medial tibia in the other 20 cases (vertical osteotomy group). Total operation time, knee range of motion (ROM), hospital for special surgery (HSS) scores, and tibio-femoral medial-lateral gap ratio in 0degrees, 90degrees, and 130degrees flexion at postoperative 6 months were compared between the groups. RESULTS: The total operation time was shorter in the vertical osteotomy group. Tibio-femoral medial-lateral gap ratio in 130degrees flexion was closer to 1 in the vertical osteotomy group (p=0.000). There was no significant difference in the ROM, HSS score, or tibio-femoral medial-lateral gap ratio in 0degrees and 90degrees flexion at postoperative 6 months. CONCLUSIONS: In severe varus knees, bony resection of proximal medial tibia can be considered as an alternative technique, in order to decrease total operation time and to obtain medial-lateral, soft-tissue balance in deep flexion.

Association between serum anti-Mullerian hormone level and ovarian response to mild stimulation in normoovulatory women and anovulatory women with polycystic ovary syndrome / 대한생식의학회지

OBJECTIVE: To evaluate the correlation between serum levels of anti-Mullerian hormone (AMH) and ovarian response to mild stimulation in normoovulatory women and anovulatory women with polycystic ovary syndrome (PCOS). METHODS: Seventy-four cycles of mild stimulation (clomiphene citrate+gonadotropin followed by timed intercourse or intrauterine insemination) performed in normoovulatory women (57 cycles) and anovulatory women with PCOS (17 cycles). Ovarian sensitivity was defined by the number of mature follicles (> or =14 mm) on triggering day per 100 IU of gonadotropin. A correlation between ovarian sensitivity and the baseline serum AMH level (absolute or multiples of the median [MoM] value for each corresponding age) was calculated. Correlation between ovarian response and serum AMH level was evaluated. RESULTS: Ovarian sensitivity to mild stimulation was positively correlated with absolute serum AMH (r=0.535, p0.05, r=-0.265, p>0.05, respectively). CONCLUSION: Ovarian response to mild stimulation is possibly predicted by the serum AMH level in normoovulatory women, but not in anovulatory women with PCOS.

Primary Perivascular Epithelioid Cell Tumor (PEComa) of the Liver: A Case Report and Review of the Literature

Perivascular epithelioid cell tumor (PEComa) is a mesenchymal tumor consisting of distinctive perivascular epithelioid cells, and is commonly detected in the uterus. The liver is an uncommon site for primary PEComa. In this study, we report a case of primary hepatic PEComa in a 36-year-old woman. Upon gross examination, the tumor was a well-defined, brownish solid mass, measuring 6.5x5.2x4.5 cm. Microscopically, the tumor consisted largely of epithelioid cells and some spindle cells with a clear to eosinophilic cytoplasm and a rich network of delicate capillaries in the stroma. With the exception of their relatively large size and microscopically sinusoidal infiltrative growth pattern, all other histopathologic features of the tumor were consistent with their being benign. The tumor cells were positive for human melanoma black-45 and smooth muscle actin, and negative for cytokeratin-cocktail and c-kit.

Primary Perivascular Epithelioid Cell Tumor (PEComa) of the Liver: A Case Report and Review of the Literature

Perivascular epithelioid cell tumor (PEComa) is a mesenchymal tumor consisting of distinctive perivascular epithelioid cells, and is commonly detected in the uterus. The liver is an uncommon site for primary PEComa. In this study, we report a case of primary hepatic PEComa in a 36-year-old woman. Upon gross examination, the tumor was a well-defined, brownish solid mass, measuring 6.5x5.2x4.5 cm. Microscopically, the tumor consisted largely of epithelioid cells and some spindle cells with a clear to eosinophilic cytoplasm and a rich network of delicate capillaries in the stroma. With the exception of their relatively large size and microscopically sinusoidal infiltrative growth pattern, all other histopathologic features of the tumor were consistent with their being benign. The tumor cells were positive for human melanoma black-45 and smooth muscle actin, and negative for cytokeratin-cocktail and c-kit.

A Case of Fatal Pulmonary Embolism after Arthroscopic Partial Meniscectomy

Pulmonary embolism is a serious and fatal complication in orthopedic surgery. Most cases of pulmonary embolism in knee surgery have been reported after knee arthroplasty, but this is rare after arthroscopy. We describe here a case of fatal pulmonary embolism after arthroscopic partial meniscectomy in a female patient who was without any remarkable risk factors.

Expression of Minichromosome Maintenance Protein 7 and Smad 4 in Squamous Cell Carcinoma of the Esophagus

BACKGROUND: Minichromosome maintenance protein 7 (MCM 7) performs a direct role in the initiation of DNA replication, which suggests that it may prove useful as a marker of cell proliferation. Smad 4 is a tumor suppressor gene that mediates the transforming growth factor beta pathway. The principal objective of this study was to characterize the expression of MCM 7 and Smad 4 and to analyze their relationship to clinicopathological parameters in patients with esophageal squamous cell carcinoma. METHODS: Expression levels of MCM 7 and Smad 4 were evaluated via immunohistochemistry on formalin-fixed and paraffin-embedded tissues from 67 cases of esophageal squamous cell carcinoma. RESULTS: High levels of MCM 7 expression were detected in 53 cases (74.6%), and were associated with higher T stages (p = 0.030). Kaplan-Meier survival curves demonstrated that patients with higher levels of MCM 7 expression had poorer prognoses, although this association was not significant (p = 0.086). Loss of Smad 4 expression was noted in 18 cases (23.4%), and was not associated with clinicopathological characteristics, including MCM 7 expression, or prognosis. CONCLUSIONS: MCM 7 expression is associated with the invasiveness of esophageal squamous cell carcinoma. Altered expression of Smad 4 does not appear to have pathobiological significance in esophageal carcinoma.

Vascular Imaging Using Confocal Microscopy

No abstract available.

Diagnosis and Treatment for Delayed Pseudoaneurysm of Deep Femoral Artery: A Case Report / 대한정형외과학회잡지

Post-traumatic arterial injuries are often reported in crushing or penetrating gun-shot injuries that include massive soft tissue damage. In most cases, the injured arteries are treated with early repair or reconstruction surgery. When there is a delayed in diagnosis, a pseudoaneurysm might be detected several weeks or months after the trauma. Pseudoaneurysms after femoral fracture are usually detected in the superficial femoral arteries, but rarely in the very deep femoral arteries, which are protected by the vastus medialis. There are many reports on post-traumatic pseudoaneurysms, most of which are in the superficial femoral arteries, and there are few reports with normal findings in an early angiogram. We report a pseudoaneurysm of the deep femoral artery with a normal angiogram in the early stage that was diagnosed and treated 4weeks after the trauma.

Mitochondrial Dysfunction in Diabetic Cardiomyopathy / 당뇨병

Metabolic syndrome and diabetes are associated with increased risk of cardiac dysfunction independently of underlying coronary artery disease. The underlying pathogenesis is partially understood but accumulating evidence suggests that alterations of cardiac energy metabolism might contribute to the development of contractile dysfunction. Recent findings suggest that myocardial mitochondrial dysfunction may play an important role in the pathogenesis of cardiac contractile dysfunction in type 2 diabetes. This review is focused on evaluating mechanisms for the mitochondrial abnormalities that may be involved in the development and progression of cardiac dysfunction in diabetes.

Association of Adiponectin and Hepatic Steatosis in Adults with Normal Transaminase Levels / 당뇨병

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome including insulin resistance, hypertension, dyslipidemia, central obesity, type 2 diabetes, and cardiovascular disease. In NAFLD, insulin resistance plays an important role in the progression of liver damage. In this study, we evaluated insulin resistance, plasma adiponectin, hepatic steatosis, and their association in adults with normal liver transaminase concentrations. METHODS: We analyzed 111 subjects, aged over 20 years old, who visited the Health Management Center at Chung-Ang University Hospital between May 2006 and August 2006. They had neither history nor clinical evidence of diabetes, cardiovascular or liver disease. They were divided into three groups by the degree of hepatic steatosis based on ultrasound findings. Anthropometric parameters were measured and blood samples were drawn after eight hours of fasting. RESULTS: Hepatic steatosis had a positive correlation with body mass index, waist circumference, blood pressure, triglycerides, HOMA-IR, and QUICKI. Moreover, it had a negative correlation with high-density lipoprotein cholesterol and adiponectin. Triglycerides, Adiponectin, and QUICKI were independent variables in predicting the degree of hepatic steatosis. CONCLUSION: This finding suggests that triglycerides and plasma adiponectin are independent predictors of hepatic steatosis in adults with normal liver transaminase concentrations.