Effect of Nalbuphin Dosage and Incision Length of Abdominal Wall on Return of Bowel Function after Colectomy

PURPOSE: Nalbuphin has definitive advantages over the more commonly used narcotic analgesic:a ceiling respiratory depression, little effect on the cardiovascular system and a lower incidence of nausea and vomiting. The use of a small incision results in early return of bowel function and shortening of hospital stay. Narcotic use has been felt to be proportional to the length of the abdominal incision. The aim of this study was to determine whether return of bowel function after colectomy in the postoperative period and incision length were directly proportional to the narcotics. METHODS: 38 patients undergoing colon and rectal resection for benign and malignant colorectal disease between July 2000 and April 2001 participated in this study. Nalbuphin and ketorolac was administered continually by patient controlled analgesia for 48 hours. Additional nalbuphin was used for further pain control. Patients were followed for return of bowel function as measured by first audible bowel sounds, first passage of flatus and first defecation. RESULTS: There was a significant correlation between the amount of total nalbuphin administered and return of bowel function as measured by bowel sound (r=0.89; P=0.01), time to first passage of flatus (r=0.76; P=0.01), and time to first defecation (r=0.58; P=0.05). Incision length did not show any correlation with either nalbuphin use or return of bowel function. CONCLUSIONS: There is no apparent benefit for lesser incision length. Return of bowel function is influenced by use of postoperative nalbuphin. So adequate sized abdominal incision is needed and lesser use of narcotics is more beneficial for the return of bowel function.

Study of the Cellular Immune Response according to Hemodialysis Duration in Chronic Renal Failure Patients

BACKGROUND: In order to evaluate the effects of the duration of hemodialysis on cell mediated immunity, we studied cellular immune responses in vitro in 12 patients on chronic hemodialysis and in 6 healthy volunteers with normal kidney function. METHODS: The patients on maintenance hemodialysis were divided into two subgroups according to the duration of the hemodialysis: Group 1 (within 5 years, n=6) and Group 2 (>5 yr and < or =10 yr, n=6). Group 3 include the normal control (n=6). The peripheral blood lymphocytes of each group were cultured in RPMI medium 1640 without/or with 3 microgram of phytohemagglutinin (=PHA) for 7 days. RESULTS: CD4 /CD8 ratio at 48hours was totally comparable between the uremic patients (Group 1 and Group 2) and the controls (Group 3). The proportions of CD25 T lymphocytes after 48 hours culture were abnormally high: 7.1+/-0.5% and 7.0+/-1.3% in the uremic patients as compared to 2.5+/-0.6 in the normal controls at the basal state and 66.7+/-2.6% and 68.8+/-1.9% in the uremic patients as compared to 78.3+/-4.6% in the normal controls at the PHA-stimulated condition. The spontaneous production of IL-2 (mean pg SEM) was significantly lower in hemodialized patients (Group 1: 34.5+/-6.0 pg/ml, Group 2: 33.8+/-6.2 pg/ml) as compared to the normal patients (Group 3: 58.8+/-10.4 pg/ml). The PHA stimulated IL-2 production was also significantly reduced in the hemodialized patients (Group 1: 53.2+/- 13.3 pg/ml, Group: 53.0+/-10.3 pg/ml) as compared to the normal patients (Group 3: 150.0+/-24.5 pg/ml). The mean proliferative response to PHA at each point in the hemodialized patients were significantly lower than those of the controls. CONCLUSIONS: These data show that there is no significant correlation between the level of the cell mediated immune response and the duration of hemodialysis. Several defects in the cell mediated immune response associated with uremia might start at an early phase of the hemodialysis.

Prognostic Significance of Occult Lymph Node Metastases in Breast Cancer / 대한암학회지

PURPOSE: About 20% to 30% of patients with node-negative breast cancer die of systemic metastases in 10 years after surgery. This may be due to either early occult systemic spread before node metastasis or occult lymph node metastasis (OLNM) which is undectected by routine pathologic evaluation. The purpose of this study was to assess the incidence and its prognostic significance of OLNM in breast cancer. MATERIALS AND METHODS: Paraffin blocks of axillary lymph nodes from 50 patients with invasive breast carcinoma initially diagnosed as node-negative by routine histological examination were evaluated. All nodes were serially sectioned by 40 pm thickness interval, followed by hematoxylin-eosin (H-E) staining and cytokeratin immunohistochemical staining. RESULTS: OLNM were detected in 6 patients (12%) by immunohistochemical method; in 3 of these 6 patients, it were also detectable by serial sectioning and H-E staining. OLNM correlated with the primary tumor size (r=0.43, p <0.05). During mean follow- up of 57 months, there were 4 systemic recurrences and one death. Of 6 patients with OLNM, 2 had multiple systemic recurrences (33.3%). Of 44 patients without OLNM, in contrast, only 3 had systemic recurrences (6.8%). Five year disease-free survival rates of patients with and without OLNM were 66.7% and 93.0%, respectively (p=0.087). CONCLUSION: These results suggest that about 10% of patients with "node-negative" breast cancer have OLNM, and the presence of OLNM may have marginal prognostic significance. Serial sectioning and cytokeratin immunohistochemical staining of axillary lymph nodes should be considered as a part of the routine histologic examination especially in the patients with a large primary tumor.

Dissecting Aneurysm Originating in the Abdominal Aorta: A case report

Although almost all cases of spontaneous aortic dissection originate in the thoracic aorta, dissections limited to the abdominal aorta occur very rarely. According to the previous literatures, localized abdominal aortic dissections account for 1~4% of all aortic dissections. The predisposing factors of spontaneous abdominal aortic dissection are similar to those of thoracic aortic dissection. Many patients have a history of hypertension and the incidence appears to be greater in patients with congenital heart diseases, pregnancy or Marfan's syndrome. And it occurs 3 times more frequently in men than in women. Histologically, atherosclerosis is the most common finding. In many cases, presenting symptoms and signs are not specific, so that this disease entity can be overlooked at bedsides. In our case, the patient was a 76-year-old man who had a vague periumbilical pain occurred one day before. He had no trauma history nor other illness. Abdomino-pelvic CT showed 4x7 cm sized dilatation of abdominal aorta from below the renal arteries to just above the aortic bifurcation site and compatible with aortic dissecting aneurysm. We performed aneurysmectomy and restored arterial continuity with an aorto-bifemoral bypass using dacron. The patient's postoperative course was relatively uneventful and he remains well one year after operation. In conclusion, because of its rarity and nonspecific symptoms and signs, spontaneous aortic dissection confined to the abdominal aorta may be misdiagnosed by physicians. And usually, untreated aortic dissections have a lethal course. So, more accurate diagnostic approaches and optimal managements are needed for good outcome.

Clinical Review of Acute Arterial Occlusive Disease in Lower Extremities

Despite various methods of treating acute lower limb ischemia, the reported mortality continues to be in the 10% to 30% range. To evaluate the results according to etiology, location, time interval before starting treatment of acute lower extremities occlusive lesion, this study was done for 38 patients with acute arterial occlusive disease. The causes of acute lower limb occlusion were embolism (n=18, 47.4%) and thrombosis (n=20, 52.6%). The mortality rate was 11.1% (2/18) in embolism and 10% (2/20) in thrombosis. All the patients with embolic occlusion were treated by thromboembolectomy with Fogarty catheter, and thrombotic occlusive lesion were treated by intraarterial thrombolytic therapy only (n=3), followed by corrective procedure such as PTA only for short iliac arterial lesion (n=1), PTA and stent for long iliac arterial lesion (n=5), bypass operation (n=5). The amputation rate was higher (p,24 hr, 7/20, 35.0%) than in shorter duration (<24 hr, 1/18, 5.6%), and in multiple lesion (7/13, 53.7%) than single lesion (1/25, 10.0%). Even though advanced therapeutic modality for acute lower limb occlusive disease, mortality is still high, and limb salvage is dependent on various factors such as status of patients, etiology and number of lesion site, time interval before starting treatment.

Safety of Early Postoperative Feeding after Elective Colorectal Surgery

Introduction: Several investigators demonstrated that routine nasogastric decompression after abdominal surgery was unnecessary and can be safely eliminated. Some authors suggested that early feeding could be tolerated by the majority of patients after elective colorectal surgery. PURPOSE: The aim of our study was to prospectively assess the safety and tolerability of early oral feeding after colorectal surgery. METHODS: This trial included 69 patients who underwent an colon or rectal operation between April 1997 and August 1998. Patients were randomized after the operative procedure into one of two groups. Group 1: early oral feeding-all patents received a clear liquid diet on the first postoperative day followed by a regular diet as tolerated. Group 2: delayed feeding-all patients were treated in the traditional way with feeding only after the resolution of their postoperative ileus. Both groups had intraoperative nasogastric tubes that were removed at the end of surgery. The patients were monitored for vomiting, nasogastric tube reinsertion, time of regular diet consumption, complication, and length of hospitalization. The nasogastric tube was reinserted if two or more episodes of vomiting of more than 100 ml occurred in the absence of bowel movement. RESULTS: Sixty-nine consecutive patients were studied, 34 patients in group 1 (12 males and 22 females, mean age 58.1+/-12.7), and 35 patients in group 2 (16 males and 19 females, mean age 58.5+/-12.7). Significant differences were not noted in age and type of procedures. No significant differences were seen in rates of vomiting and overall complications. However, early feeding group well tolerated a regular diet (postoperative period to take regular diet of group 1: 5.4+/-4.0 days, group 2 : 8.1+/-4.6 days, p=0.013), and were discharged from hospital significantly earlier than the delayed feeding group(group 1: 14.0+/-5.1 days, group 2: 19.1+/-8.6 days, p=0.004). CONCLUSION: Early feeding after colorectal surgery is successfully tolerated by the majority of patients and led to earlier hospital discharge.