Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study

Purpose@#This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC). @*Methods@#This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-toone propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC. @*Results@#A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI. @*Conclusion@#This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Development and External Validation of Survival Prediction Model for Pancreatic Cancer Using Two Nationwide Databases: Surveillance, Epidemiology and End Results (SEER) and Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP)

Background/Aims@#Several prediction models for evaluating the prognosis of nonmetastatic resected pancreatic ductal adenocarcinoma (PDAC) have been developed, and their performances were reported to be superior to that of the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. We developed a prediction model to evaluate the prognosis of resected PDAC and externally validated it with data from a nationwide Korean database. @*Methods@#Data from the Surveillance, Epidemiology and End Results (SEER) database were utilized for model development, and data from the Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP) database were used for external validation. Potential candidate variables for model development were age, sex, histologic differentiation, tumor location, adjuvant chemotherapy, and the AJCC 8th staging system T and N stages. For external validation, the concordance index (C-index) and time-dependent area under the receiver operating characteristic curve (AUC) were evaluated. @*Results@#Between 2004 and 2016, data from 9,624 patients were utilized for model development, and data from 3,282 patients were used for external validation. In the multivariate Cox proportional hazard model, age, sex, tumor location, T and N stages, histologic differentiation, and adjuvant chemotherapy were independent prognostic factors for resected PDAC. After an exhaustive search and 10-fold cross validation, the best model was finally developed, which included all prognostic variables. The C-index, 1-year, 2-year, 3-year, and 5-year time-dependent AUCs were 0.628, 0.650, 0.665, 0.675, and 0.686, respectively. @*Conclusions@#The survival prediction model for resected PDAC could provide quantitative survival probabilities with reliable performance. External validation studies with other nationwide databases are needed to evaluate the performance of this model.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer

Purpose@#Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. @*Methods@#This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. @*Results@#The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. @*Conclusion@#The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

Outcomes after liver transplantation in Korea: Incidence and risk factors from Korean transplantation registry

Background/Aims@#To analyze the incidence and risk factors of outcomes after liver transplantation (LT) in the Korean population. @*Methods@#This study analyzed data from the liver cohort of Korean Organ Transplantation Registry (KOTRY) who had LT between May 2014 and December 2017. Study measures included the incidence of post-LT outcomes in recipients of living donor LT (LDLT) and deceased donor LT (DDLT). Cox multivariate proportional hazards model was used to determine the potential risk factors predicting the outcomes. @*Results@#A total of 2,563 adult recipients with LT (LDLT, n=1,956; DDLT, n=607) were included, with mean±standard deviation age of 53.9±8.9 years, and 72.2% were male. The post-LT outcomes observed in each LDLT and DDLT recipients were death (4.0% and 14.7%), graft loss (5.0% and 16.1%), rejection (7.0% and 12.0%), renal failure (2.7% and 13.8%), new onset of diabetes (12.5% and 15.4%), and hepatocellular carcinoma (HCC) recurrence (both 6.7%). In both LDLT and DDLT recipients, the most common post-LT complications were renal dysfunction (33.6% and 51.4%), infection (26.7% and 48.4%), and surgical complication (22.5% and 23.9%). Incidence of these outcomes were generally higher among recipients of DDLT than LDLT. Multivariate analysis indicated recipient age and DDLT as significant risk factors associated with death and graft loss. DDLT and ABO incompatible transplant were prognostic factors for rejection, and HCC beyond Milan criteria at pre-transplant was a strong predictor of HCC recurrence. @*Conclusions@#This study is a good indicator of the post-LT prognosis in the Korean population and suggests a significant burden of post-LT complications.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer

Purpose@#Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. @*Methods@#This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. @*Results@#The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. @*Conclusion@#The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

Outcomes after liver transplantation in Korea: Incidence and risk factors from Korean transplantation registry

Background/Aims@#To analyze the incidence and risk factors of outcomes after liver transplantation (LT) in the Korean population. @*Methods@#This study analyzed data from the liver cohort of Korean Organ Transplantation Registry (KOTRY) who had LT between May 2014 and December 2017. Study measures included the incidence of post-LT outcomes in recipients of living donor LT (LDLT) and deceased donor LT (DDLT). Cox multivariate proportional hazards model was used to determine the potential risk factors predicting the outcomes. @*Results@#A total of 2,563 adult recipients with LT (LDLT, n=1,956; DDLT, n=607) were included, with mean±standard deviation age of 53.9±8.9 years, and 72.2% were male. The post-LT outcomes observed in each LDLT and DDLT recipients were death (4.0% and 14.7%), graft loss (5.0% and 16.1%), rejection (7.0% and 12.0%), renal failure (2.7% and 13.8%), new onset of diabetes (12.5% and 15.4%), and hepatocellular carcinoma (HCC) recurrence (both 6.7%). In both LDLT and DDLT recipients, the most common post-LT complications were renal dysfunction (33.6% and 51.4%), infection (26.7% and 48.4%), and surgical complication (22.5% and 23.9%). Incidence of these outcomes were generally higher among recipients of DDLT than LDLT. Multivariate analysis indicated recipient age and DDLT as significant risk factors associated with death and graft loss. DDLT and ABO incompatible transplant were prognostic factors for rejection, and HCC beyond Milan criteria at pre-transplant was a strong predictor of HCC recurrence. @*Conclusions@#This study is a good indicator of the post-LT prognosis in the Korean population and suggests a significant burden of post-LT complications.

The Usefulness of Preoperative Colonoscopic Tattooing with Autologous Blood for Localization in Laparoscopic Colorectal Surgery

Purpose@#In colorectal cancer surgery, it is important to have accurate resection margins. However, it is challenging to localize lesions during laparoscopy. Therefore, to reduce surgical errors, many preoperative localizing methods have been introduced. In this study, we aimed to assess the preoperative feasibility and safety of autologous blood tattooing. @*Methods@#A total of 11 patients underwent preoperative colonoscopic autologous blood tattooing from August 2017 to February 2020. At the start of the surgery, the surgeon assessed the patients for the precision of visibility and other complications such as abscess or spillage. The patients’ characteristics, outcomes, and complications were collected retrospectively. @*Results@#The study comprised 8 men and 3 women, with an average age of 63 years. Ten patients showed precise visibility, and no localization errors were observed during surgery. No complication was observed in all patients. @*Conclusion@#Preoperative autologous blood tattooing is a very useful and safe technique because it has high visibility with no complications. This method does not require additional agents or facilities. A large-scale study will be required to develop standard guidelines.

Which Patients Are a Better Candidate of Laparoscopic Repair in Obturator Hernia Patients?

Purpose@#Obturator hernia is a difficult disease to diagnose. If a surgical treatment is delayed in obturator hernia, a bowel resection may be required due to strangulation. The surgical treatment of this disease is to use a classical laparotomy. Recently, the laparoscopic approach has been reported and reviewed for efficiency. We checked the indicators that determine the most appropriate surgical method according to the patient’s condition. @*Methods@#In the study, a single-institution, retrospective analysis of surgical patients undergoing an obturator hernia surgery between 2003 and 2018 was performed. The patients were divided into a laparoscopic group (5 patients underwent laparoscopic repair; no intestinal resection) and an open group (13 patients who underwent open repair; 10 with and 3 without intestinal resection). The outcomes were compared between the groups. We analyzed the relevant factors that could predict the proper method of surgery. @*Results@#A total 18 patients were included in the study. All patients were female, with body mass index (BMI) of under 21 kg/m2. Of the various factors, only the WBC and CRP counts were the factors that had shown significant differences between the two groups. It is noted that patients with open surgery had a higher WBC counts (10406 versus 6520/μl; p=0.011) and CRP counts (7.84 vs. 0.32 mg/dl; p=0.027). @*Conclusion@#Obturator hernia can be treated with a laparoscopic surgery. The choice of surgical treatment can be considered in advance through the review of the patient’s WBC count or CRP count.

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures. METHODS: Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity. RESULTS: SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM. CONCLUSION: We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.

Single Incision Laparoscopic Appendectomy for Management of Complicated Appendicitis: Comparison between Single-Incision and Conventional

PURPOSE: Single incision laparoscopic appendectomy (SILA) is a widely used surgical procedure for treatment of appendicitis with better cosmesis. However, many surgeons generally tend to choose conventional multiport laparoscopic appendectomy regarding with complicated appendicitis. The aim of this study is to demonstrate the safety and feasibility of SILA for treatment of complicated appendicitis by comparison with 3-ports conventional laparoscopic appendectomy (CLA). METHODS: Retrospective chart review of patients diagnosed appendicitis at single hospital during January 2015 to May 2017 collected 500 patients. Among 134 patients with complicated appendicitis, we compared outcomes for 29 patients who got SILA and 105 patients who got CLA. RESULTS: 179 and 321 patients were treated by SILA and CLA, respectively. 134 (26.8%) patients were treated for complicated appendicitis, 29 patients by SILA and 105 patients by CLA, respectively. There was no case converted to open or added additional trocar in both groups. There were no differences in demographics with regard to age, sex, body mass index (BMI), and American society of anesthesiologists (ASA) scores. There was no difference in mean operating time (58.97±18.53 (SILA) vs. 57.57±21.48 (CLA), p=0.751). The drain insertion rate (6.9% vs 37.1%, p=0.001) and the length of hospital stay (2.76±1.41 vs. 3.97±2.97, p=0.035) were lower in SILA group with significance. There was no significant difference in the rate of surgical site infection (6.9% vs. 6.7%, p=1.000). CONCLUSION: This study demonstrates that SILA is a feasible and safe procedure for treatment of complicated appendicitis.

Human epidermal growth factor receptor 2 expression in gastric cancer patients treated with curative intent gastrectomy

PURPOSE: This study aimed to clarify the association between human epidermal growth factor receptor 2 (HER-2) status and the clinicopathologic factors of patients who underwent curative intent gastrectomy.METHODS: From June 2011 to May 2015, curative intent gastrectomy was performed in 441 patients at Konyang University Hospital. Among them, we evaluated the HER-2 status in 113 patients. Data on clinicopathologic parameters such as age, sex, histological subtype, endoscopic Lauren classification, tumor location, size, presence of lymphovascular invasion, invasion depth, pathologic stage, HER-2 overexpression, recurrence and survival were obtained. In this study, pathological HER-2 intensity scores of 0, 1+, and 2+ were assumed to be negative, 3+ only was to be positive for overexpression.RESULTS: In a total of 113 cases who underwent curative intent gastrectomy with HER-2 testing, 16 (14.2%) cases had positivity of HER-2 overexpression. HER-2 overexpression had significant associations with tumor stage (19.0% in I-IIIb vs. 2.9% in IIIc-IV, P=0.036). Survival analysis of HER2 overexpression has no significant difference.CONCLUSION: In this study, HER-2 overexpression rate was 14.2% and patient tumor stage had significant association with HER-2 overexpression.

Predictive factor for excessive myelosuppression in patients receiving chemotherapy for breast cancer

PURPOSE: Myelosuppression, particularly neutropenia, is one of the most frequent and serious toxicity seen in patients with breast cancer undergoing systemic chemotherapy. However, the predictive factors for development of severe neutropenia in chemotherapy remain unknown. We therefore evaluated predictive factors for excessive myelosuppression.METHODS: We retrospectively analyzed 341 patients with breast cancer treated with chemotherapy from 2000 to 2012. Clinicopathological characteristics, number of using of granulocyte colony-stimulating factor (G-CSF), and pretreatment hematologic values were extracted from the electronic medical record system. Patients were sorted 2 groups by number of using G-CSF in each chemotherapeutic regimens; group 1 is more G-CSF (within high 20 percentile) and 2 less G-CSF using group (within lower 20 percentile).RESULTS: Number of using G-CSF was ranged 0–83 (mean 10.76). One hundred one patients were in group 1 and 65 patients were in group 2. Mean of number of G-CSF using was 0.21 in group 1 and 28.02 in group 2. Pretreatment white blood cell, hemoglobin and platelet count were lower in group 2 than in group 1 (6.88×10³/µL vs. 5.97×10³/µL, 12.63 g/dL vs. 11.90 g/dL, and 275.95×10⁴ µL vs. 227.37×10⁴ µL). There were no statistically differences in other clinicopathologic characteristics such as age, body mass index or comorbidities, hormonal receptor, stage, and other pretreatment hematologic values.CONCLUSION: Pretreatment white blood cell count, hemoglobin and platelet count can be used to identify patients at increased risk of significant myelosuppression undergoing chemotherapy with breast cancer. This information can be used to target high-risk patients for prophylactic treatment.

Risk factors for conversion to conventional laparoscopic cholecystectomy in single incision laparoscopic cholecystectomy

PURPOSE: The aim of this study was to investigate the risk factors for conversion to conventional laparoscopic cholecystectomy (CLC) in single incision laparoscopic cholecystectomy (SILC) along with the proposal for procedure selection guidelines in treating patients with benign gallbladder (GB) diseases. METHODS: SILC was performed in 697 cases between April 2010 and July 2014. Seventeen cases (2.4%) underwent conversion to conventional LC. We compared these 2 groups and analyzed the risk factors for conversion to CLC. RESULTS: In univariate analysis, American Society of Anesthesiologist score > 3, preoperative percutaneous transhepatic GB drainage status and pathology (acute cholecystitis or GB empyema) were significant risk factors for conversion (P = 0.010, P = 0.019 and P < 0.001). In multivariate analysis, pathology (acute cholecystitis or GB empyema) was significant risk factors for conversion to CLC in SILC (P < 0.001). CONCLUSION: Although SILC is a feasible method for most patients with benign GB disease, CLC has to be considered in patients with acute cholecystitis or GB empyema because it is likely to result in inadequate visualization of the Calot's triangle and greater bleeding risk.

Risk factors for prolonged operative time in single-incision laparoscopic cholecystectomy

PURPOSE: We performed 3-channel single incision laparoscopic cholecystectomy (SILC) in earlier period of this study and modified our method to 4-channel SILC using a snake retractor for better operative field in later period. This study has been designed to evaluate the risk factors for prolonged operative time in SILC. METHODS: From April 2010 to August 2014, 323 cases of 3-channel SILC (Konyang standard method [KSM] group) and 399 cases of 4-channel SILC (modified KSM [mKSM] group) using a snake retractor were performed. RESULTS: The clinical characteristics were not significantly different between KSM and mKSM group except preoperative percutaneous transhepatic gallbladder drainage (PTGBD) treatment (9.6% vs. 16.5%, P 30 kg/m2 as well as the 4-channel SILC. CONCLUSION: Among patients with these risk factors, conventional laparoscopic cholecystectomy could be considered as well although SILC might be safe and feasible modality for benign gallbladder disease.

Comparison of the Clinical Outcomes between Anti-thymocyte Globulin and Basiliximab Induction Therapy in Deceased Donor Kidney Transplantation: Single Center Experience / 대한이식학회지

BACKGROUND: The aim of this study is to evaluate the clinical outcomes between anti-thymocyte globulin (ATG) and basiliximab induction in deceased donor kidney transplantation (DDKT). METHODS: Between May 2006 and February 2015, 40 patients underwent DDKT at our institution. Three cases (7.5%) of them were lost during the following-up schedule. In this study, ATG induction criteria were donor age >50 years old or donor creatinine level >1.3 mg/dL except hepatitis B virus positive and hepatitis C virus positive recipients. Recipients were divided into two groups: the ATG group (n=20) and the basiliximab group (n=17). RESULTS: The 1-year patient survival in the ATG group was 89.4% compared to 93.8% in the basiliximab group (P=0.989). Graft survival for a 1 year in the ATG and the basiliximab group was 89.1% and 93.8%, respectively (P=0.967). Incidences of acute rejection episodes were more prevalent in the basiliximab group (15.0% vs. 29.4%, P=0.428). The glomerular filtration rate level by period of recipients was not different in both group (12th month, 64.60+/-16.17 mg/dL vs. 68.51+/-18.60 mg/dL, P=0.544). The overall complications during the follow-up were not significantly different in both groups (90.0% vs. 76.5%, P=0.383). CONCLUSIONS: The results showed that there was no difference in the patient survival and graft survival between induction of ATG and basiliximab of the DDKT were not different. Therefore, use of both induction agents led to a good patient and graft survival and ATG might be a safe and preferable agent for relatively poor renal function of donor in kidney transplantation.

Single incision laparoscopic cholecystectomy using Konyang Standard Method

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is a minimally invasive surgery that is growing rapidly among surgical procedures. However, there is no standard method for SILC. Therefore, we evaluated the adequacy and feasibility of SILC using Konyang Standard Method. METHODS: We retrospectively reviewed our series of 307 SILCs performed between April 2010 and August 2012. Initially we excluded the patients who were more than 70 years old, had cardiologic or pulmonologic problems and complications of acute cholecystitis. After 50 cases, we did not apply the exclusion criteria. We performed SILC by Konyang Standard Method using three-trocar single port (hand-made) and long articulated instruments. RESULTS: Three hundred and seven patients underwent SILC. Male were 131 patients and female were 176 patients. Mean age was 51.6 +/- 13.7 years old and mean body mass index was 24.8 +/- 3.6 kg/m2. Ninety-three patients had histories of previous abdominal operation. Patient's pathologies included: chronic cholecystitis (247 cases), acute cholecystitis (30 cases), gall bladder (GB) polyps (24 cases), and GB empyema (6 cases). Mean operating time was 53.1 +/- 25.4 minutes and mean hospital stay was 2.9 +/- 3.4 days. There were four cases of 3-4 ports conversion due to cystic artery bleeding. Complications occurred in 5 cases including wound infection (2 cases), bile duct injury (1 case), duodenal perforation (1 case), and umbilical hernia (1 case). CONCLUSION: SILC using Konyang Standard Method is safe and feasible. Therefore, our standard procedure can be applied to almost all benign GB disease.

Laparoscopic appendectomy under spinal anesthesia with dexmedetomidine infusion / 대한마취과학회지

BACKGROUND: Laparoscopic appendectomy (LA) is rarely performed under regional anesthesia because of pneumoperitoneum-related problems. We expected that dexmedetomidine would compensate for the problems arising from spinal anesthesia alone. Thus, we performed a feasibility study of spinal anesthesia with intravenous dexmedetomidine infusion. METHODS: Twenty-six patients undergoing LA received spinal anesthesia with intravenous dexmedetomidine infusion. During surgery, the patient's pain or discomfort was controlled by supplemental fentanyl or ketamine injection, and all adverse effects were evaluated. RESULTS: No patient required conversion to general anesthesia, and all operations were completed laparoscopically without conversion to open surgery. Seventeen (65.4%) patients required supplemental injection of fentanyl or ketamine. Bradycardia occurred in seven (26.9%) patients. CONCLUSIONS: Spinal anesthesia with dexmedetomidine infusion may be feasible for LA. However, additional analgesia, sedation, and careful attention to the potential development of bradycardia are needed for a successful anesthetic outcome.

Laparoscopic appendectomy under spinal anesthesia with dexmedetomidine infusion / 대한마취과학회지

BACKGROUND: Laparoscopic appendectomy (LA) is rarely performed under regional anesthesia because of pneumoperitoneum-related problems. We expected that dexmedetomidine would compensate for the problems arising from spinal anesthesia alone. Thus, we performed a feasibility study of spinal anesthesia with intravenous dexmedetomidine infusion. METHODS: Twenty-six patients undergoing LA received spinal anesthesia with intravenous dexmedetomidine infusion. During surgery, the patient's pain or discomfort was controlled by supplemental fentanyl or ketamine injection, and all adverse effects were evaluated. RESULTS: No patient required conversion to general anesthesia, and all operations were completed laparoscopically without conversion to open surgery. Seventeen (65.4%) patients required supplemental injection of fentanyl or ketamine. Bradycardia occurred in seven (26.9%) patients. CONCLUSIONS: Spinal anesthesia with dexmedetomidine infusion may be feasible for LA. However, additional analgesia, sedation, and careful attention to the potential development of bradycardia are needed for a successful anesthetic outcome.

Improvement of Hypoxemia by Inhaled Nitric Oxide Gas Therapy in Potential Deceased Donor / 대한이식학회지

Potential diseased donors manifest altered physiological changes associated with pulmonary edema, profound hemodynamic and metabolic abnormalities. These derangements may be more significant after apnea tests which result in severe hypoxemia and cardiovascular complications. Nitric oxide (NO) inhalation therapy can be applied following apnea tests in the brain-dead donor whose ventilator support has been maintained with high positive end-expiratory pressure. Inhalation of NO gas causes selective dilation of blood vessels in only those lung segments that are actively participating in gas exchange (oxygen and carbon dioxide) at the alveolar capillary level. In other words, this increases the blood flow to areas of the lung where oxygen is being provided and thus improves oxygen levels in the body. We report on the case of a 14-year-old organ donor with inhaled NO therapy after apnea testing. The duration of NO inhalation therapy was 14 hours. This deceased donor, who suffered with severe hypoxemia and hemodynamic instability after apnea tests, improved after NO gas therapy and adequate vasoactive drugs. NO gas therapy will be helpful for improving oxygen delivery to pulmonary vessels. Two kidneys and one liver were successfully retrieved from donors. These recipients had well preserved function of allografts. Therefore, NO inhalation can be helpful in improvement of hypoxemia and increasing organ availability in deceased organ donors.

Four-channel single incision laparoscopic cholecystectomy using a snake retractor: comparison between 3- and 4-channel SILC 4-channel single incision cholecystectomy

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is a widely used method of performing cholecystectomy. A common technique used in SILC is a 3-channel method. However, exposure of Calot's triangle is limited in conventional 3-channel SILC. Therefore, we herein report the adequacy and feasibility of 4-channel SILC using a snake retractor. METHODS: Four hundred and fifteen SILC cases were performed between April 2010 and February 2013. We performed 326 SILC cases between April 2010 and September 2012 using the 3-channel method. We introduced a snake retractor for liver traction in October 2012, and 89 cases of 4-channel SILC using snake retractor have been performed since. RESULTS: Thirty patients (9.2%) in the 3-channel SILC group, and 23 patients (25.8%) in the 4-channel SILC group, were treated with percutaneous transhepatic gallbladder drainage insertion because of acute inflammation of the gallbladder (GB) before operation (P < 0.001). The mean operating time was 53.0 +/- 25.8 minutes in the 3-channel SILC group and 51.9 +/- 18.6 minutes in the 4-channel SILC group (P = 0.709). In the 3-channel SILC group, mean hospital stay was 3.0 +/- 3.3 days whereas it was 2.6 +/- 0.9 days in the 4-channel SILC group (P = 0.043). There were a total 9 cases (2.1%) of additional port usages, 6 cases (1.8%) in the 3-channel SILC group and 3 cases (3.4%) in the 4-channel SILC group (P = 0.411), due to cystic artery bleeding and bile leakage from gallbladder bed, but there were no open conversions. CONCLUSION: Benign diseases of the GB can be operated on using SILC with the 4-channel method using a snake retractor.