Impact of a surgical intensivist on the clinical outcomes of patients admitted to a surgical intensive care unit

PURPOSE: An intensivist is a key factor in the mortality of patients admitted to the intensive care unit (ICU). The aim of this study was to evaluate the effect of an intensivist on clinical outcomes of patients admitted to a surgical ICU. METHODS: During the study period, the surgical ICU was converted from an open ICU to an intensivist-directed ICU managed by an intensivist who was board certified in both general surgery and critical care medicine. We compared consecutive patients admitted to the surgical ICU before and after implementing the intensivist-directed care. The primary outcome was ICU mortality, and secondary outcomes were hospital mortality, 90-day mortality, length of hospital stay, ICU-free days, ventilator-free days, and ICU readmission rate. RESULTS: A total of 441 patients were included in this study: 188 before implementation of the intensivist and 253 after implementation. Clinical characteristics were not different between the two groups. ICU mortality decreased from 11.7% to 6.3% (P = 0.047) after implementation, and 90-day mortality also decreased significantly (P = 0.008). The adjusted hazard ratio of the intensivist for ICU mortality was 0.43 (95% confidence interval, 0.22-0.87; P = 0.020). ICU-free days (P = 0.013) and the hospital length of stay (P = 0.032) were significantly improved after implementing the intensivist-directed care. Before implementation period, 16.0% of patients were readmitted, compared with only 9.9% after implementation (P = 0.05). CONCLUSION: Implementing intensivist-directed care in the surgical ICU was associated with significant improvements in ICU mortality and significant clinical outcomes.

Relationship between the risk of bile duct injury during laparoscopic cholecystectomy and the types of preoperative magnetic resonance cholangiopancreatiocography (MRCP)

BACKGROUNDS/AIMS: Bile duct injury is one of the potential severe complications that can occur during laparoscopic cholecystectomy, which can be cause by anatomic variations in the confluence of the bile duct. Recently magnetic resonance cholangiopancreatiocography (MRCP) has become a helpful tool to detect bile duct variation on a preoperative basis and to prevent bile duct injury during laparoscopic cholecystectomy, as well other hepatic surgeries. This study aimed to clarify the types of bile duct on MRCP and to search for a method of avoiding injury during laparoscopic cholecystectomy. METHODS: Between January 2009 and December 2010, 277 patients underwent laparoscopic cholecystectomy with preoperative MRCP in our institution. On a retrospective basis, the bile ducts were categorized into 5 types according to the Couinaud classification system. RESULTS: The proportion of types was revealed type A (70.4%), type B (8.7%), type C (19.5%), type D (0.7%), type E (0%), and type F (0.7%), respectively. Bile duct injury occurred in 4 cases (1.4%) during laparoscopic cholecystectomy. In particular, the possibility of aberrant extrahepatic confluence (Type C and F) represented the highest risk of duct injury (OR=11.89 [CI: 1.21-116.53]). CONCLUSIONS: Preoperative evaluation of the bile duct anatomy is important to avoid injury of duct during laparoscopic cholecystectomy. Specific types of bile duct variation should be considered as a high risk group for bile duct injury.

S-plasty for pilonidal disease: modified primary closure reducing tension / 대한외과학회지

PURPOSE: S-plasty for pilonidal disease reduces the tension on the midline by distributing it diagonally and flattening the natal cleft. The aim of this study was to evaluate the outcomes of S-plasty on simple midline primary closure and the clinical features of pilonidal patients in a low incidence country. METHODS: S-plasty was applied on 17 patients from July 2008 to October 2010. Data of these patients were collected with computerized prospective database forms during a perioperative period and via telephone interview for follow-up. Surgical site infection (SSI) was defined according to the Center for Disease Control guidelines. The severity of surgical site infection was graded. RESULTS: All patients were treated with primary S-plasty. Two patients (11.7%) developed low grade SSI. The average healing time after S-plasty was 18.1 days. No recurrences were observed. The mean follow-up period was 13.5 months (range, 6 to 33 months). CONCLUSION: We have shown that primary S-plasty for pilonidal disease is simple, and its surgical outcomes are compatible to the results of other surgical treatments. We present primary S-plasty as a feasible treatment option in a low incidence country.

Laparoscopic Resection of an Asymptomatic Intra-Abdominal Lymphangioma / 대한내시경복강경외과학회지

An intra-abdominal cystic lymphangioma is a benign neoplasm that rarely occurs within the abdominal cavity. Intra-abdominal cystic lymphangioma is treated by a resection performed through a radical procedure. We report a case of a 37-year-old woman who had an asymptomatic mesenteric cyst that was discovered incidentally during a routine physical check-up. Treatment was completed without complications using a laparoscope.

A Non-recurrent Laryngeal Nerve that was Unnoticed in a Preoperative Imaging Study: A Case Report / 대한내분비외과학회지

A non-recurrent laryngeal nerve is a rare nerve anomaly that is associated with a developmentally aberrant subclavian artery. During thyroidectomy,this aberrant nerve may become inadvertently damaged, causing permanent ipsilateral vocal cord paralysis. However, it is possible to predict the presence of a non-recurrent laryngeal nerve by preoperative diagnosis of an aberrant subclavian artery. We report a case of thyroid surgery associated with a right non-recurrent laryngeal nerve that was unnoticed preoperatively in a CT scan of the neck, but was encountered incidentally during the thyroidectomy. The preoperative CT scan showed a retroesophageal aberrant right subclavian artery, but it was unnoticed. The female patient underwent a total thyroidectomy with central compartment node dissection for a thyroid cancer. The recurrent laryngeal nerve on the left side was identified, as was the non-recurrent laryngeal nerve on the right side. Postoperatively, the patient had normal vocal cord function. It is possible to predict preoperatively a right non-recurrent laryngeal nerve by identifying an aberrant right subclavian artery on the CT scan of the neck, which likely enables prevention of vocal cord paralysis.

Gasless Endoscopic Thyroidectomy via an Axillary Approach: Short-term Outcomes and Modifications of Approach / 대한내분비외과학회지

PURPOSE: With an accumulation of surgical experience for endoscopic or video-assisted thyroidectomy and improvements in surgical techniques and endoscopic instruments, these procedures have become a valid option for patients with benign thyroid nodules. These applications are now being expanded even to selected patients with low risk thyroid carcinomas. This study was performed to suggest new modified methods of approach on the use of a gasless endoscopic thyroidectomy via an axillary approach and to evaluate the short-term outcomes. METHODS: Between May 2004 and March 2007, 66 female patients underwent a gasless endoscopic thyroidectomy via an axillary approach. Surgical outcomes were evaluated in terms of surgical time, length of hospital stay, the incidence of perioperative complications, and patient opinion at two and four months after surgery. RESULTS: No cases required conversion to open surgery. The mean surgical time was 136.5±31.8 minutes, and the mean length of hospital stay was 4.2±1.1 days. There were two transient recurrent laryngeal nerve palsies, two minor tracheal injuries without air leakage, and two postoperative hemorrhages that required a second surgery. Only one patient (1.9%) and five patients (9.4%) complained of slight hypesthesia or paresthesia in the neck and anterior chest wall, respectively, and only three patients (5.7%) complained of discomfort while swallowing 4 months after surgery. CONCLUSION: Gasless endoscopic thyroidectomy via an axillary approach is a feasible and safe procedure and providesa minimal degree of postoperative complaints. This procedure is now a valid option for the surgical treatment of benign thyroid disease and its applications will broaden in the near future.

Microsatellite Instability in Invasive Ductal Carcinomas / 한국유방암학회지

PURPOSE: Breast cancer shows various molecular and genetic alterations in its development and progression. Microsatellite alterations, and especially microsatellite instability (MSI) and loss of heterozygosity (LOH), have recently been postulated as a novel mechanism of carcinogenesis and as a useful prognostic factor for several gastrointestinal malignancies. LOH is related to the allelic loss of various tumor suppressor genes; however, MSI has been found to be the result of an erroneous DNA mismatch repair system and this has been known to be involved in the carcinogenesis of the hereditary non-polyposis colon cancers and some portion of the sporadic colorectal or gastric cancers. Yet MSI has rarely been studied in invasive ductal carcinoma. Our objectives were to evaluate the MSI and p53 protein expression in invasive ductal carcinomas and to correlate this with various clinicopathological factors. METHODS: The MSI analysis was performed by using polymerase chain reaction with five polymorphic microsatellite markers (the BAT25, BAT26, D2S123, D5S346 and D17S250 loci as recommended by the 1998 NCI International Workshop on Microsatellite Instabilitis and RER phenotypes) in 50 surgically resected tumors and each of their non-tumorous counterpart. The p53 protein expression was studied using immunohistochemistry. RESULTS: MSI and a p53 protein expression were detected in 22% and 54% of the tumors and non-tumorous tissues, respectively. MSI was more frequently detected in tumor grade I, T-stage I, non-metastatic tumor and tumor stage I. Also there were rare cases showing a high grade and stage with metastasis in the MSI-high group, in which more than 3 microsatellite loci had MSI. The p53 expression results correlated well with a higher tumor grade. Correlation between MSI and the p53 expression was not found. CONCLUSION: These results may suggest that MSI may be involved in some portions in mammary carcinogenesis and tumor invasion. Also the clinical use of the MSI status may help to determine a better prognosis among invasive ductal cancer patients.