Impact of technical innovation on surgical outcome of laparoscopic major liver resection: 10 years' experience at a large-volume center

PURPOSE: Laparoscopic major liver resection (major LLR) remains a challenging procedure because of the technical difficulty. Several significant technical innovations have been applied in our center since 2012. They include routine application of bipolar electrocautery, initiation of temporary increase of intra-abdominal pressure during bleeding events from veins to balance the central venous pressure, and use of temporary inflow control of the Glissonean pedicle. This study evaluated the impact of these technique modifications in patients with major LLR. METHODS: Between January 2004 and February 2015, a total of 606 patients underwent LLR at Samsung Medical Center in Seoul, Korea. Major LLR was employed in 233 cases. All major LLR procedures were anatomical resections performed with a totally laparoscopic approach. We compared surgical parameters of right hepatectomy (RH), left hepatectomy (LH), and right posterior sectionectomy (RPS) before and after 2012. RESULTS: Open conversion rates of RH and LH and estimated blood loss in RPS significantly decreased after 2012. The postoperative complication rate of major LLR was 12.7% and was similar before and after 2012. Bile leakage was the most common complication (3.2%). CONCLUSION: The modifications of surgical techniques resulted in good outcomes for laparoscopic major LLR. We recommend routine application of these techniques to improve outcomes, especially in patients requiring major liver resection.

Recurrent Guillain-Barré Syndrome Following Urinary Tract Infection by Escherichia coli

Recurrent Guillain-Barré syndrome (GBS) is a rare, immune-mediated disease of the peripheral nervous system. It has been reported to occur at intervals ranging from four months to 10 years; published case studies suggest that 1%–6% of patients who have had GBS will experience recurrent attacks. The most commonly identified infections coinciding with GBS are Campylobacter jejuni, Haemophilus influenzae, Mycoplasma pneumonia, and cytomegalovirus, while an antecedent infection with Escherichia coli is very uncommon. In this case report, we present a rare episode of recurrent GBS, which followed a urinary tract infection (UTI) by E. coli, and an accompanying literature review. A 75-year-old woman with a prior history of acute motor axonal neuropathy (AMAN), a subtype of GBS, presented with subsequent weakness of limbs and areflexia following 10 days of fever, frequency, and dysuria. Base on nerve conduction studies, cerebrospinal fluid analysis and other clinical investigation, we diagnosed the patient with recurrent GBS caused by E. coli. The patient recovered with mild subjective weakness following treatment of intravenous immunoglobulin with ceftriaxone. We suggest that E. coli causes UTI could be one of the diverse trigger factors involved in recurrent GBS.

Trigeminal Neuralgia Associated with Tentorial Meningioma

No abstract available.

The Influence of Urinary Incontinence and Depression in Elderly on the Quality of the Life / 정신신체의학

OBJECTIVES: Little is known about the influence of urinary incontinence and depression on individual's QOL(Quality of life). We aimed to clarify how the interaction between urinary incontinence and depression influences one's QOL. METHODS: A total of 1262 patients were enrolled in this study from April, 2011 to July, 2011. We estimated the severity of depressive symptoms and QOL, using SGDS-K, EQ-5D. We also investigated the morbidity of urinary incontinence for each patient in person or by questionnaire. Comparisons of QOL between groups with or without depression, with or without urinary incontinence were established using t-test, ANOVA and Scheffe's post hoc analysis. The interaction between urinary incontinence and depression was analyzed by each domain of QOL, using multiple regression analysis. RESULTS: Patients with depression and urinary incontinence showed significantly higher EQ-5D scores on every domain of QOL than other patients, which means significantly lower QOL. Patients with depression, no urinary incontinence reported lower QOL, especially in the domain of ‘usual activity’, ‘anxiety’ and ‘visual analogue scale(VAS)’, whereas those with urinary incontinence, no depression showed lower QOL in ‘motility’, ‘usual activities’ and ‘pain’ domain. Statistically significant interaction effects of two diseases were observed in the domain of ‘VAS’, ‘self care’ and ‘anxiety’. CONCLUSIONS: Comorbidity of urinary incontinence and depression showed significantly lower QOL of patients, compared with urinary incontinence or depression respectively, which implies additive interaction effects of the two diseases. Optimal diagnosis and treatment of depression should be emphasized for patients with urinary incontinence.

The correlation between preoperative volumetry and real graft weight: comparison of two volumetry programs

PURPOSE: Liver volumetry is a vital component in living donor liver transplantation to determine an adequate graft volume that meets the metabolic demands of the recipient and at the same time ensures donor safety. Most institutions use preoperative contrast-enhanced CT image-based software programs to estimate graft volume. The objective of this study was to evaluate the accuracy of 2 liver volumetry programs (Rapidia vs. Dr. Liver) in preoperative right liver graft estimation compared with real graft weight. METHODS: Data from 215 consecutive right lobe living donors between October 2013 and August 2015 were retrospectively reviewed. One hundred seven patients were enrolled in Rapidia group and 108 patients were included in the Dr. Liver group. Estimated graft volumes generated by both software programs were compared with real graft weight measured during surgery, and further classified into minimal difference (≤15%) and big difference (>15%). Correlation coefficients and degree of difference were determined. Linear regressions were calculated and results depicted as scatterplots. RESULTS: Minimal difference was observed in 69.4% of cases from Dr. Liver group and big difference was seen in 44.9% of cases from Rapidia group (P = 0.035). Linear regression analysis showed positive correlation in both groups (P < 0.01). However, the correlation coefficient was better for the Dr. Liver group (R² = 0.719), than for the Rapidia group (R² = 0.688). CONCLUSION: Dr. Liver can accurately predict right liver graft size better and faster than Rapidia, and can facilitate preoperative planning in living donor liver transplantation.

The prognosis in cases of hepatocellular carcinoma after hepatectomy: young patients versus older patients

BACKGROUNDS/AIMS: Hepatocellular carcinoma (HCC) is uncommon in young adults and the prognosis of these patients is still unclear. In this retrospective study, we compared the clinicopathological characteristics and outcomes of young patients with HCC with those of older patients with HCC. METHODS: We retrospectively reviewed the clinicopathological characteristics of a total of 1,124 patients with HCC who underwent hepatectomy at our institution between 2006 and 2010. Patients < or =40 years of age at the time of HCC diagnosis were classified in the younger group. RESULTS: One hundred and three patients (9.2%) were classified in the younger group. whereas, 1021 patients were classified in the older group. The incidences of hepatitis B virus infection, alpha-fetoprotein (AFP) levels, and indocyanine green retention test were all higher in younger patients than in older patients (p<0.05). Disease-free survival and overall survival were longer in older patients than in younger patients, without statistical significance. In younger patients, increased levels of protein induced by vitamin K antagonist-II (PIVKA-II) and alkaline phosphatase, portal vein tumor thrombosis, and intrahepatic metastasis were all predisposing factors for tumor recurrence after hepatectomy. CONCLUSIONS: Although the AFP levels were higher in younger patients with HCC than in older patients with HCC, disease-free survival and overall survival after liver resection were not significantly different between the two groups.

A Case of Cerebella Infarction Caused by Cervical Meningioma

Mechanisms and causes of cerebral infarction, usually two mechanisms, are identified: hemodynamics and thrombotic or thromboembolic causes. Compressive causes by tumor are not reported in the main etiological classifications as Trial of Org10172 in Acute Stroke Treatment (TOAST) classification and ASCO (atherosclerosis, small vessel disease, cardiac source, and other causes). However tumors found in these locations often involve an intracranial portion of the internal carotid artery (ICA) and may compromise cerebral blood flow. Cerebral infarction related to meningioma, the common extra-axial brain tumor in adults, has been rarely reported. We experienced an extremely rare case of cerebellar infarction resulting from direct compression of the vertebral artery by cervical meningioma. To the best of our knowledge, there are no documented cases of a meningioma causing stroke by vertebral artery occlusion. We report on a case of meningioma presenting with cerebellar infarction as a result of vertebral artery compression.

Pathological Laughing and Crying: Pathophysiology and Treatment / 정신신체의학

Pathological laughing and crying(PLC) is a condition that is characterized by episodic, brief, contextually inappropriate, uncontrollable outbursts of laughing and/or crying. It can be observed in patients with various neurological disorders. PLC often causes distress in interpersonal functioning and activities for patients and their families. PLC can be recognized easily with proper understanding of the condition and its nature. Also it generally shows good response to various pharmacological treatments. This review aims to encourage the diagnosis and treatment of PLC by providing definition and clinical presentation of PLC, analysis of its pathophysiology and various current treatment options.

A Case of Acute Motor and Sensory Axonal Neuropathy Following Hepatitis A Infection

Acute motor and sensory axonal neuropathy (AMSAN) are recently described subtypes of Guillain-Barre syndrome characterized by acute onset of distal weakness, loss of deep tendon reflexes, and sensory symptoms. A 21-yr-old male was transferred to our hospital due to respiration difficulties and progressive weakness. In laboratory findings, immunoglobulin M antibodies against hepatitis A were detected in blood and cerebrospinal fluid. The findings of motor nerve conduction studies showed markedly reduced amplitudes of compound muscle action potentials in bilateral peroneal, and posterior tibial nerves, without evidence of demyelination. Based on clinical features, laboratory findings, and electrophysiologic investigation, the patient was diagnosed the AMSAN following acute hepatitis A viral infection. The patient was treated with intravenous immunoglobulin and recovered slowly. Clinicians should consider this rare but a serious case of AMSAN following acute hepatitis A infection.

Korean Red Ginseng Induced Cardioprotection against Myocardial Ischemia in Guinea Pig

This study was designed to evaluate the protective effect of Korean red ginseng (KRG) against ischemia/reperfusion (I/R) injury in isolated guinea pig heart. KRG has been shown to possess various ginsenosides, which are the major components of Panax ginseng. These components are known naturally occurring compounds with beneficial effects and free radical scavenging activity. The heart was induced to ischemia for 60 min, followed by 120 min reperfusion. The hearts were randomly allocated into five groups (n=8 for each group): normal control (N/C), KRG control, I/R control, 250 mg/kg KRG group and 500 mg/kg KRG group. KRG significantly increased hemodynamics parameters such as aortic flow, coronary flow and cardiac output. Moreover, KRG significantly increased left ventricular systolic pressure (LVSP), the maximal rate of contraction (+dP/dtmax) and maximal rate of relaxation (-dP/dtmax). Also, treatment of KRG ameliorated electrocardiographic index such as the QRS, QT and RR intervals. Moreover, KRG significantly suppressed the lactate dehydrogenase, creatine kinase-MB fraction and cardiac troponin I and ameliorated the oxidative stress markers such as malondialdehyde and glutathione. KRG was standardized through ultra performance liquid chromatograph analysis for its major ginsenosides. Taken together, KRG has been shown to prevent cardiac injury by normalizing the biochemical and oxidative stress.

A Case of Right Middle Cerebral Artery Infarction Presenting as Thunderclap Headache

Thunderclap headache refers to a sudden and severe headache that comes unexpectedly, reminding one of a clap of thunder. The initial description of this type of headache was in association with an unruptured intracranial aneurysm. It is known to be a presenting feature of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral venous thrombosis, cervical artery dissection, spontaneous intracranial hypotension, pituitary apoplexy, retroclival hematoma, and hypertensive reversible posterior leukoencephalopathy. A formula for diagnostic assessment of thunderclap headache, such as brain computed tomographic scan and spinal tap, should be established. We experienced a case of cerebral infarction presented with thunderclap headache, diagnosed using diffusion weighted magnetic resonance imaging. We suggest that, even when these patients have shown non-specific findings on neurological examination, brain computed tomography, and cerebrospinal fluid analysis, diffusion MRI should be considered for differential diagnosis of thunderclap headache in emergency medical services.

Lacunar Infarction Following Recurrent Transient Ischemic Attack During Consecutive Hemodialysis / 대한뇌졸중학회지

The link between hemodialysis and cerebrovascular disease has become more apparent. Several reports have suggested that the incidence of ischemic stroke on hemodialysis patients is greater than that on the general populations. We report a case with lacunar infarction following recurrent transient ischemic attack during consecutive hemodialysis.

Simvastatin and Losartan Differentially and Synergistically Inhibit Atherosclerosis in Apolipoprotein E-/- Mice

BACKGROUND AND OBJECTIVES: Since statins and angiotensin receptor blockers are a frequently prescribed combination in patients with atherosclerotic cardiovascular diseases, we tested the interactive effects of simvastatin and losartan on atherosclerosis in apolipoprotein E (apoE)-/- mice. MATERIALS AND METHODS: Apolipoprotein E-/- mice were fed a high-fat, high-cholesterol (HFHC) diet for 12 weeks, with and without simvastatin (40 mg/kg) and/or losartan (20 mg/kg). The mice were divided into 5 groups and were fed as follows: regular chow (control diet, n=5), HFHC diet (n=6), HFHC diet with losartan (n=6), HFHC diet with simvastatin (n=6), and HFHC diet with both losartan and simvastatin (n=6). RESULTS: Losartan treatment in apoE-/- mice significantly decreased atherosclerotic lesion areas in whole aortic strips stained with Oil Red O. The plaque area measured at the aortic sinus level was reduced significantly by 17% (HFHC; 346830.9+/-52915.8 microm2 vs. HFHC plus losartan; 255965.3+/-74057.7 microm2, p<0.05) in the losartan-treated group. Simvastatin and simvastatin plus losartan treatments reduced macrophage infiltration into lesions by 33% (HFHC; 183575.6+/-43211.2 microm2 vs. HFHC plus simvastatin; 120556.0+/-39282.8 microm2, p<0.05) and 44% (HFHC; 183575.6+/-43211.2 microm2 vs. HFHC plus simvastatin and losartan; 103229.0+/-8473.3 microm2, p<0.001, respectively). In mice fed the HFHC diet alone, the smooth muscle cell layer in the aortic media was almost undetectable. In mice co-treated with losartan and simvastatin, the smooth muscle layer was more than 60% preserved (p<0.05). Given alone, losartan showed a slightly stronger effect than simvastatin; however, treatment with losartan plus simvastatin induced a greater inhibitory effect on atherosclerosis than either drug given alone. Serum lipid profiles did not differ significantly among the groups. CONCLUSION: Losartan displayed anti-atherosclerotic effects in apoE-/- mice that were equivalent to or greater than the effects of simvastatin. Combined treatment with these drugs had greater effect than either drug alone.

Comparisons of Oxidative Stress during Laparoscopic Cholecystectomy and Open Cholecystectomy

PURPOSE: During oxidative stress, the levels of oxygen free radical increase dramatically, which plays a role in apoptosis, aging and is chemic injury, but also leads to positive effects such as induction of host defense genes and mobilization of ion transport systems. It has been suggested that the advantages of laparoscopic surgery are closely related to the reduced oxidative stress that occurs during laparoscopic cholecystectomy (LC) when compared to open cholecystectomy (OC). This study was conducted to compare oxidative stress markers including total antioxidant status (TAS), superoxide dismutase (SOD) and gluthathione reductase (GR) between the LC group and OC group to determine if these surgical procedures result in different patterns of oxidative stress. METHODS: Our prospective study included fifty patients with symptomatic cholelithiasis and cholecystitis, of whom 25 underwent LC and 25 underwent OC. The plasma levels of oxidative stress markers (TAS, SOD, and GR) were measured preoperatively and on the 1st, 2nd and 3rd postoperative days. RESULTS: The postoperative hospitalization days differed significantly between the two groups (p0.05). An acceptable postoperative decrease in SOD was observed in the OC group, especially after the 2nd postoperative day (p0.05) upon analysis of covariance. A significant postoperative decrease in the level of SOD was observed in the OC group, especially after the 2nd postoperative day (p<0.01), and there was also a significant difference in the serial change in SOD between groups (p=0.020). The level of GR in the OC group decreased significantly on the 2nd postoperative day (p=0.022). Moreover, ANCOVA revealed a significant difference in the serial changes in thelevel of GR between the two groups (p=0.039). CONCLUSION: Our study compared oxidative stress between LC and OC groups based on the levels of TAS, SOD, and GR. We found that minimally invasive surgery, such as laparoscopic cholecystectomy, produced less oxidative stress than open surgery.

A Field Study of the Conditions of the Elderly in Rural Community ; The Correlation between of Sleep Quality and Quality of Life / 신경정신의학

OBJECTIVES: This study aimed to investigate how sleep quality affects quality of life in the elderly of rural communities. METHODS: 877 elderly people aged 60 or over living in C towns participated in the study. They responded to the Pittsburgh Sleep Quality Index, EuroQol-5 dimension, Korean version of the short from of Geriatric Depression Scale, Mini-Mental State Examination for Dementia Screening and the presence of urinary incontinence. RESULTS: Most scores of the items of the quality of life index, except self-management, showed significant correlations with the total score of the sleep quality test. Statistically significant differences were found between the positives and the negatives of the sleep quality test in the scores of all the detailed items of the quality of life index. Among the detailed items of quality of sleep, subjective quality of sleep showed the highest correlation. CONCLUSION: The present study found that the subjective indicators such as subjective sleep quality and sleep disturbance affected quality of life in the rural lives of elderly people more than the objective indicators such as sleep durations or sleep latency periods. Based on the results of these studies, we concluded that a methodological approach and a management model to treating insomnia to improve the quality of life of the elderly would need to be developed and applied.

Relationship between the depth of cingulate sulcus on neonatal high resolution cranial ultrasound and gestational age / 소아과

PURPOSE: It is critical that the exact gestational age of a newborn baby, especially premature baby, be determined to evaluate the status of a disease and its management and to estimate the prognosis of a patient. This study aimed to investigate an easy and accurate method to estimate gestational age on cranial ultrasound, requiring minimal additional time and equipment. METHODS: A high-resolution coronal sonographic image was obtained via the anterior fontanel with a 5-12 Mhz linear probe after the usual cranial sonographic examination. We measured the depth of cerebral hemisphere, thickness of corpus callosum, and depth of cingulate sulcus and obtained the correlations between these factors and gestational age. RESULTS: Depth of cingulate sulcus had the highest correlation coefficiency with gestational age (r=0.878, P=0.000). All the cases, except for 2 cases, had a gestational age of more than 37 weeks, when the depths of cingulate sulcus were more than 0.55 cm, and had a gestational age less than 34 weeks, when the depths of cingulate sulcus were less than 0.35 cm. CONCLUSION: Measurement of the depth of cingulate sulcus was a simple and accurate method to estimate the gestational age on cranial ultrasound. The gestational age is more than 37 weeks, when the depth of cingulate sulcus is more than 0.55 cm, and is less than 34 weeks, when the depth of cingulate sulcus is less than 0.35 cm.

Neuropsychiatric Aspects of Traumatic Brain Injury: Symptoms and Pharmacotherapy / 대한정신약물학회지

Traumatic brain injury (TBI) is well recognized as a disability category with high incidence and prevalence as well as considerable impact on survivors and their families. Neuropsychiatric symptoms such as cognitive deficit, psychosis, depression, mania, anxiety are common after TBI. Treatment of the neuropsychiatric symptoms associated with TBI should result in decreased handicap, improved quality of life, and decreased societal impact. This article discusses the clinical approach to treating patients with neuropsychiatric complications following TBI.

CT and MR Imaging Analysis of Calcification Suspensions of Different Types and Concentrations

BACKGROUND: High-density calcifications on CT images can appear as high signals on T1-weighted MR images, but with differing extents and degrees. This study investigated CT and MR images of calcifications of various types and concentrations. METHODS: We analyzed CT and MR images of two cases of bilateral basal ganglia calcifications and experimental suspensions of calcifications of different types and concentrations. RESULTS: The density of CT calcifications increased in proportion to their concentration regardless of their type. However, the MR signals differed with the types and concentrations of calcification. A high signal was one of the most noticeable signs on T1-weighted MR images for calcium phosphate, and it increased for concentrations up to 0.2 g/mL before leveling off. The signal for all types of calcification decreased on T2-weighted and especially fluid-attenuated inversion recovery (FLAIR) images. CONCLUSIONS: High signals are characteristic of calcification on T1-weighted MR images, and are often stronger than those on CT images. A low signal appears consistently on FLAIR MR images regardless of the calcification type. These findings might be helpful in evaluating calcifications apparent in MR images.

Risk Factors of Postoperative Delirium in Elderly Patients with Hip Fractures

PURPOSE: To find out the relationship between various risk factors and post-operative delirium in elderly patients with hip fractures. MATERIALS AND METHODS: Out of 135 patients older than 65 years old who underwent the surgery for hip fracture in our department, between the periods of March 2003 to March 2005, 14 patients (10.4%) developed post-operative delirium and 121 patients (89.6%) did not. We studied risk factors of post-operative delirium in two groups. RESULTS: In chi-square test between delirium group and non-delirium group, the patients were more likely to develop post-operative delirium if they had previous episodes of delirium, abnormal cognitive function, low walking ability before admission, high dependency on ADL (Activities of Daily Living), other medical accompanying diseases, history of dementia, post-operative hypoxia, post-operative electrolyte imbalance, low post-operative hemoglobin and hematocrit, low post-operative albumin and were older than 75 years old (p<0.05). Sex, type of fracture, anesthesia and the time between admission and operation did not show much difference between the two groups. CONCLUSION: The risk factors of postoperative delirium in elderly patients with hip fracture have a tendency to be multifactorial. Therefore, we conclude that being prepared by thorough understanding of the risk factors and their relationships will help prevent post-operative delirium and result in good postoperative prognosis.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

No abstract available.