A Xiphoid Elongation Following a Trauma Laparotomy: A Case Report

Xiphoid elongation is a rare phenomenon where the xiphoid process elongates after stimuli such as surgery, physical therapy, or trauma. We report on a 47-year-old male involved in a traffic accident who went into cardiac arrest. He received ongoing cardiopulmonary resuscitation for nine minutes before recovery of cardiac rhythm, and transfer from a local hospital to the trauma center. He received management for hypotensive shock which was temporarily corrected using Resuscitative Endovascular Balloon Occlusion of the Aorta, and underwent trauma laparotomy in which ileocolic artery ligation and a splenectomy were performed. Six months later, the patient reported epigastric discomfort when he bent over. A hard, linear mass was palpated along the upper midline incision scar and a computed tomography scan showed an elongated xiphoid process (10 cm). The patient underwent surgical excision, and electrocauterization of the xiphoid process. This is a rare case of xiphoid elongation following multiple stimuli to the xiphoid process.

The influence of changes in-hospital infection control protocols and cardiopulmonary resuscitation environment to treatment outcomes on out-of-hospital cardiac arrest due to the COVID-19 pandemic: a single center retrospective observational study

Objective@#Coronavirus disease 2019 (COVID-19) pandemic has been affecting the safety of hospital healthcare workers and the outcome of out-of-hospital cardiac arrest patients. This study aimed to analyze the influence of the changes inhospital infection control protocols (ICP) and cardiopulmonary resuscitation (CPR) environment on the treatment outcomes of out-of-hospital cardiac arrest patients. @*Methods@#The medical records of patients who visited the emergency room were retrospectively reviewed for the period from March 13, 2019 to March 13, 2021. Patient data were analyzed before and after March 13, 2020, when the “in-hospital CPR guidelines related to COVID-19 infection” was recommended by the Korean Society of Emergency Medicine. We performed a comparison and analysis of the first epinephrine administration time and the intubation time with other CPR-related factors in both groups. The in-hospital return of spontaneous circulation (ROSC) and the over 24-hour survival rate were defined as treatment outcomes. @*Results@#A total number of 453 patients were included in the study. After ICP, the in-hospital ROSC was increased (29.8% vs. 42.1%, P=0.006), whereas the over 24-hour survival rate was decreased (67.2% vs. 40.6%, P=0.001). The time intervals from the hospital visit to the first epinephrine administration—1.0 (0-1.0) vs. 1.0 (0-2.0), P=0.007—and tracheal intubation—1.0 (0-1.0) vs. 1.0 (1.0-2.8), P<0.001—were statistically significantly higher than those before ICP application. In our multivariable analysis, the ICP application and pre-hospital emergency medical service (EMS) response time were factors associated with the treatment outcome. @*Conclusion@#After the application of the ICP, both the first epinephrine administration time and the tracheal intubation time from the patient’s hospital visit were prolonged. The application of ICP and the delayed EMS response time were factors associated with the treatment outcome.

Effect of bupivacaine on postoperative pain and analgesics use after single-incision laparoscopic appendectomy: double-blind randomized study

PURPOSE: Local anesthetics can decrease postoperative pain after appendectomy. This study sought to verify the efficacy of bupivacaine on postoperative pain and analgesics use after single-incision laparoscopic appendectomy (SILA).METHODS: Between March 2014 and October 2015, 68 patients with appendicitis agreed to participate in this study. After general anesthesia, patients were randomized to bupivacaine or control (normal saline) groups. The assigned drugs were infiltrated into subcutaneous tissue and deep into anterior rectus fascia. Postoperative analgesics use and pain scores were recorded using visual analogue scale (VAS) by investigators at 1, 8, and 24 hours and on day 7. All surgeons, investigators and patients were blinded to group allocation.RESULTS: Thirty patients were allocated into the control group and 37 patients into bupivacaine group (one patient withdrew consent before starting anesthesia). Seven from the control group and 4 from the bupivacaine group were excluded. Thus, 23 patients in the control group and 33 in the bupivacaine group completed the study. Preoperative demographics and operative findings were similar. Postoperative pain and analgesics use were not different between the 2 groups. Subgroup analysis determined that VAS pain score at 24 hours was significantly lower in the bupivacaine group (2.1) than in the control group (3.8, P = 0.007) when surgery exceeded 40 minutes. During immediate postoperative period, bupivacaine group needed less opioids (9.1 mg) than control (10.4 mg).CONCLUSION: Bupivacaine did not decrease pain and analgesics use. When surgery exceeded 40 minutes, bupivacaine use might be associated with less pain and less analgesics use.

Acute Physiology and Chronic Health Evaluation II Score and Sequential Organ Failure Assessment Score as Predictors for Severe Trauma Patients in the Intensive Care Unit / 대한구급학회지

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). METHODS: We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. RESULTS: The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. CONCLUSIONS: In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

Acute Physiology and Chronic Health Evaluation II Score and Sequential Organ Failure Assessment Score as Predictors for Severe Trauma Patients in the Intensive Care Unit / 대한중환자의학회지

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). METHODS: We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. RESULTS: The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. CONCLUSIONS: In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

Acute Care Surgery Model for Emergency Cholecystectomy

PURPOSE: Acute care surgery (ACS) models have evolved worldwide over the last decade. However, South Korea has an established trauma system and does not consider the ACS model. This study compares the management and outcome of emergency cholecystectomy in the ACS model to those of traditional on-call attending surgeon model for emergency surgery. METHODS: Retrospectively collected data for patients who underwent emergency cholecystectomy from May 2013 to January 2015 was analyzed to compare data from a traditional on-call system (OCS) and ACS. RESULTS: One hundred and twenty-four patients were enrolled in the study (62 patients ACS vs. 62 patients OCS). Hospital stay (days) (ACS=4.29±2.49 vs. OCS=4.82±4.48, p=0.46) and stay in emergency room (minutes) (ACS=213.10±113.99 vs. OCS=241.10±150.73, p=0.20) did not differ significantly between groups. Operation time (minutes) was significantly shorter in the ACS than OCS group (389.97±215.21 vs. 566.35±290.14, p<0.001). Other clinical variables (sex, open-conversion rate, whether the operation was performed at night/holiday, intensive care unit admission rate) did not differ between groups. There was no mortality and readmission. CONCLUSION: The implementation of the ACS led to shorter operation time and no increase of postoperative mortality and complication.

Effect of triclosan-coated sutures on surgical site infection after gastric cancer surgery via midline laparotomy

PURPOSE: Surgical site infection (SSI) after open abdominal surgery is still a frequently reported nosocomial infection. To reduce the incidence of SSI, triclosan-coated sutures with antiseptic activity (Vicryl Plus) were developed. The aim of this study was to analyze the effect of Vicryl Plus on SSI after gastric cancer surgery via midline laparotomy. METHODS: A total of 916 patients who underwent gastric cancer surgery at Samsung Medical Center between December 2009 and September 2011 were prospectively collected. We examined the occurrence of SSI (primary endpoint), assessments of wound healing (secondary endpoint). They were evaluated postoperatively on days 3, 7, and 30. RESULTS: Of the 916 patients, 122 were excluded postoperatively by screening (out of the study protocol, adverse events, etc.). The remaining 794 patients were enrolled and monitored postoperatively. The cumulative SSI incidence was 11 cases (1.39%; 95% confidence interval [CI], 0.77-2.50) on day 30. Seromas were most frequently detected in wound healing assessments, with a cumulative incidence of 147 cases (18.51%; 95% CI, 15.98-21.39) on day 30. CONCLUSION: The use of triclosan-coated sutures (Vicryl Plus) for abdominal wall closure can reduce the number of SSIs in gastric cancer surgery.

Evaluation of Risk Factors and In-hospital Mortality of Postintubation Hypotension in the Emergency Department

PURPOSE: Arterial hypotension is a recognized complication of emergency intubation, whereas there have been contradicting opinions regarding postintubation hypotension. The aim of this study was to determine the incidence, related factors, and impact on patient outcomes associated with postintubation hypotension (PIH) in intubations performed in the emergency department. METHODS: A structured chart audit of all consecutive adult patients requiring emergency endotracheal intubations over a two-year period (2011.1.1.~2012.12.31.) was performed retrospectively. Patients older than 20 years who had no systolic blood pressure below 90 mmHg at any time before intubation were included. Patients were analyzed in two groups, those with PIH, defined as any recorded systolic pressure less than 90 mmHg within 60 minutes of intubation, and those with no PIH. The primary outcome was in-hospital mortality. RESULTS: Overall, 186 patients intubated in the emergency department were identified, and 18.4% (34 of 186) developed PIH. Advanced age was an independent factor of developing PIH (OR: 3.4, 95% CI: 1.3-9.0, p=0.02). Patients with PIH had significantly higher in-hospital mortality (53% vs 29%; p=0.01), and multiple logistic regression showed that PIH was an independent predictor of in-hospital mortality (OR: 2.5, 95% CI: 1.1-5.5 p=0.03). CONCLUSION: Postintubation hypotension occurs in 18.3% of hemodynamically stable patients before intubation. PIH is independently associated with in-hospital mortality. Advanced age is an independent predicting factor of PIH.

Radical resection of intestinal blue rubber bleb nevus syndrome / 대한외과학회지

Blue rubber bleb nevus syndrome (BRBNS) is a rare systemic vascular disorder characterized by multiple venous malformations involving many organs. BRBNS can occur in various organs, but the most frequently involved organs are the skin and gastrointestinal (GI) tract. GI lesions of BRBNS can cause acute or chronic bleeding, and treatment is challenging. Herein, we report a case of GI BRBNS that was successfully treated with a combination of intraoperative endoscopy and radical resection.

Immediately transcripted genes in various hepatic ischemia models / 대한외과학회지

PURPOSE: To elucidate the characteristic gene transcription profiles among various hepatic ischemia conditions, immediately transcribed genes and the degree of ischemic injury were compared among total ischemia (TI), intermittent clamping (IC), and ischemic preconditioning (IPC). METHODS: Sprague-Dawley rats were equally divided into control (C, sham-operated), TI (ischemia for 90 minutes), IC (ischemia for 15 minutes and reperfusion for 5 minutes, repeated six times), and IPC (ischemia for 15 minutes, reperfusion for 5 minutes, and ischemia again for 90 minutes) groups. A cDNA microarray analysis was performed using hepatic tissues obtained by partial hepatectomy after occluding hepatic inflow. RESULTS: The cDNA microarray revealed the following: interleukin (IL)-1beta expression was 2-fold greater in the TI group than in the C group. In the IC group, IL-1alpha/beta expression increased by 2.5-fold, and Na+/K+ ATPase beta1 expression decreased by 2.4-fold. In the IPC group, interferon regulatory factor-1, osteoprotegerin, and retinoblastoma-1 expression increased by approximately 2-fold compared to that in the C group, but the expression of Na+/K+ ATPase beta1 decreased 3-fold. CONCLUSION: The current findings revealed characteristic gene expression profiles under various ischemic conditions. However, additional studies are needed to clarify the mechanism of protection against IPC.

Intra-abdominal bronchogenic cyst: report of five cases

An intra-abdominal bronchogenic cyst (BC) is a very rare congenital anomaly caused by abnormal budding of the developing tracheobronchial tree. Intra-abdominal BCs are reported as retroperitoneal masses in most cases, many of which are located on the left side of the midline, the perigastric area, the left adrenal gland, or the superior body of the pancreas. Intra-abdominal BCs are frequently misdiagnosed due to the rarity, location, and variable cystic content. We report five patients with intra-abdominal BCs who underwent surgery in a single institution.

Synchronous double primary cancers associated with a choledochal cyst and anomalous pancreaticobiliary ductal union / 대한외과학회지

A 60-year-old female was admitted with epigastric pain lasting a month. Preoperative diagnosis was choledochal cyst with anomalous pancreaticobiliaryductal union (APBDU), C-P type. A papillary mass measuring 2.5 x 1.9 cm was found adjacent to the pancreaticocholedochal junction. Gallbladder (GB) cancer was also observed. Pyloric-preserving pancreaticoduodenectomy (PPPD) was performed. The patient received adjuvant chemotherapy/radiation therapy on the tumor bed. The gallbladder cancer showed serosal invasion, while the bile duct cancer extended into the pancreas. Although common bile duct (CBD) cancer lesion showed focally positive for p53 and the gallbladder cancer lesion showed negative for p53, the Ki-67 labeling index of the CBD cancer and GB cancer were about 10% and 30%, respectively. Nine months after curative resection, a stricture on the subhepatic colon developed due to adjuvant radiation therapy. Localized peritoneal seedings were incidentally found during a right hemicolectomy. The patient underwent chemotherapy and had no evidence of tumor recurrence for two years after PPPD.

Acute Lower Gastrointestinal Bleeding from the Appendix Diagnosed by Abdominal Multidetector Computed Tomography: A Case Report and Review of the Literature

Appendiceal bleeding is a kind of lower gastrointestinal bleeding. For treatment, it is essential to identify the location of the lower gastrointestinal tract bleeding. Appendiceal bleeding has some diagnostic difficultie. It is a very rare condition, and colonoscopy shows only the appendiceal orfice. Recently, multidetector computed tomography has increasingly been used in the diagnostic evaluation of most vascular diseases. Herein, we report the case of an appendiceal bleeding diagnosed by using abdominal multidetector computed tomography, and we present a the literature.

Autologous Arteriovenous Fistula Formation with Basilic Vein Transposition of Forearm

PURPOSE: Arteriovenous fistulas (AVF) are crucial for hemodialysis in patients with end stage renal disease. However, the lack of suitable forearm cephalic veins has led the surgeons to perform alternative procedures, such as transposition of basilic vein or prosthetic A-V graft. To increase the use of the autologous vein in AVF, we tried a technique of basilic venous transposition of the forearm. METHOD: From 2005.1.1 to 2006.6.30, Six patients had AVFs created with a transposed basilic vein of the forearm. We estimated postoperative clinical outcomes such as primary patency rate and operative complications. RESULT: Three of six patients were male and the mean age was 66.2 yr. Two patients were having their first AVF operation, and the others were having their second AVF operation. The mean follow-up period was 14.8 months. Early graft failure was occurred in one (16.7%). The 1-year primary and secondary patency rates were 66.7%, 83.3%, respectively. CONCLUSION: Autologous AVF formation with basilic vein transposition of the forearm was a feasible surgical technique by increasing the chances autologous AVF formation, this procedure could save the vessels on the upper arm for later AVF creation, and so it avoids using artificial grafts. However, this technique needs further study of more detailed clinical outcomes in large series including the long term patency rate, surgical complications, and comparative results to other AVF formation techniques.

Autologous Arteriovenous Fistula Formation with Basilic Vein Transposition of Forearm

PURPOSE: Arteriovenous fistulas (AVF) are crucial for hemodialysis in patients with end stage renal disease. However, the lack of suitable forearm cephalic veins has led the surgeons to perform alternative procedures, such as transposition of basilic vein or prosthetic A-V graft. To increase the use of the autologous vein in AVF, we tried a technique of basilic venous transposition of the forearm. METHOD: From 2005.1.1 to 2006.6.30, Six patients had AVFs created with a transposed basilic vein of the forearm. We estimated postoperative clinical outcomes such as primary patency rate and operative complications. RESULT: Three of six patients were male and the mean age was 66.2 yr. Two patients were having their first AVF operation, and the others were having their second AVF operation. The mean follow-up period was 14.8 months. Early graft failure was occurred in one (16.7%). The 1-year primary and secondary patency rates were 66.7%, 83.3%, respectively. CONCLUSION: Autologous AVF formation with basilic vein transposition of the forearm was a feasible surgical technique by increasing the chances autologous AVF formation, this procedure could save the vessels on the upper arm for later AVF creation, and so it avoids using artificial grafts. However, this technique needs further study of more detailed clinical outcomes in large series including the long term patency rate, surgical complications, and comparative results to other AVF formation techniques.

Transilluminated Powered Phlebectomy under Local Anesthesia

PURPOSE: Transilluminated powered phlebectomy (TIPP) has emerged as a very attractive surgical procedure for varicose vein because of it's many advantages. However, it also has some problems such as hematoma, and skin perforation, and needs general or spinal anesthesia and hospitalization. To overcome these shortcomings, we performed TIPP under only local anesthesia using the tumescent method. METHOD: Eleven (12 limbs) patients were operated and we prospectively estimated the operative complication, pain, duration of hospital stay, side effects and amounts of lidocaine. Lidocaine was infiltrated for groin dissection, and tumescent anesthesia was used on the calf area for TIPP. Great saphenous veins were stripped in 9 limbs, and closed suction drains were inserted in the calf area in 11 limbs. We calculated the amounts of lidocaine, according to the unit area of TIPP, body weight, and body surface area. RESULT: The mean age of the 11 patients was 55.4+/-10.7 years, and 3 patients (27.3%) had risk factors for general anesthesia. Mean operation time was 54.9+/-9.2 minutes, the number of incisions including groin was 4.7+/-0.6, and the area of TIPP was 272.6+/-85.3 cm2. The total lidocaine used was 495.4+/-167.5 mg (1.45 mg/cm2, 8.3 mg/kg, 302.1 mg/BSA m2). Except 2 patients (16.6%) who complained of mild pain and 2 of hematoma (16.6%), there were no side effects of lidocaine or operative complication. Mean hospital stay was 5.8+/-1.4 hours. CONCLUSION: TIPP under local anesthesia might be a relative safe method, and it could reduce the risks and complications of general or spinal anesthesia, hospital stay, and hesitancy to operation.