Selective shunt during carotid endarterectomy using routine awake test with respect to a lower shunt rate / 대한외과학회지

PURPOSE: To evaluate shunt rate and discuss the resultsrelated to selective shunt placement during carotid endarterectomy (CEA) using routine awake test. METHODS: Patients with CEA from 2007 to 2011 were retrospectively reviewed from prospectively collected data. The need for shunt placement was determined by the awake test, based on the alteration in the neurologic examination. We collected data by using the clinical records and imaging studies, and investigated factors related to selective shunt such as collateral circulation and contralateral internal carotid artery (ICA) stenosis. RESULTS: There were 45 CEAs under regional anesthesia with the awake test in 44 patients. The mean age was 61.8 +/- 7.1 years old. There were 82.2% (37/45) of males, and 68.9% (31/45) of symptomatic patients. Selective shunt placement had been performed in only two (4.4%) patients. Among them fewer cases (4%) had severe (stenosis >70%) contralateral ICA lesions, and more cases (91%) of complete morphology of the anterior or posterior circulation in the circle of Willis. There was no perioperative stroke, myocardial infarctionor death, and asymptomatic new brain lesions were detected in 4 patients (9%), including 2 cases of selective shunt placement. CONCLUSION: CEA under routine awake test could besafe and feasible method with low shunt placement rate in selected patients.

Change of Common Iliac Artery after Abdominal Aortic Aneurysm Repair Using a Tube Graft / 대한혈관외과학회지

PURPOSE: It remains controversial whether to use a tube graft or a bifurcated graft during open abdominal aortic aneurysm (AAA) repair, due to the potential for progression or development of a common iliac artery (CIA) aneurysm. This study evaluated the fate of CIA after tubular AAA repair. METHODS: On a retrospective basis, we reviewed 61 patients who underwent open AAA repair with a tube graft, between March 2000 and December 2009. Fifty-seven patients were included in this study; we excluded 4 cases in which the patients died in-hospital. Of those enrolled, 24 patients underwent follow-up computed tomography at least 1-year after surgery. CIAs were categorized into 3 groups: normal (< or =12 mm), ectasia (range, 13 to 18 mm), and aneurysm (range, 19 to 25 mm). The incidence of CIA aneurysm rupture was investigated, and the expansion rate of CIA was calculated. RESULTS: Mean patient age was 64 years and 73% of patients were male. Preoperatively, 8 patients had 2 normal CIAs, 14 patients had one CIA aneurysm at least, 27 patients had one CIA ectasia, and 8 patients were unknown. There was a mean follow-up of 51 months; no deaths were caused by rupture of CIA aneurysm, and no patient underwent invasive treatment for a CIA aneurysm. The mean follow-up for 24 patients with 48 CIAs was 45 months. The mean expansion rate of CIA was 0.5 mm/y. CONCLUSION: AAA repair using a tube graft was a safe and durable procedure. However, a bifurcated graft should be considered when patients are young and there is the expectation of a long life expectancy is anticipated allowing for a CIA expansion rate of 0.5 mm/y.

Early treatment outcome of isolated calf vein thrombosis after total knee arthroplasty / 대한외과학회지

PURPOSE: In contrast to proximal deep vein thrombosis (DVT), the treatment of isolated calf vein thrombosis (ICVT) remains controversial. This study aimed to investigate early treatment outcomes of ICVT after total knee arthroplasty (TKA). METHODS: Medical records of 313 patients who underwent TKA from October 2007 to December 2009 were retrospectively reviewed. A DVT-computed tomography (CT) was performed 7 days after surgery. ICVT was identified in 76 limbs of 73 patients. Of them, follow-up DVT-CT was available in 39 limbs of 37 patients. The patients with ICVTs were categorized into two groups: oral anticoagulation group (group I, 17 patients with 18 limbs) and conservative treatment group (group II, 20 patients with 21 limbs). Group I received an oral vitamin K antagonist for 3 to 6 months following low molecular weight heparin. Change of thrombus extent and development of pulmonary embolism (PE) was assessed in follow-up DVT-CT. RESULTS: Mean age was 68 years and 95% were female. Of 39 limbs with ICVT, 16 (41%) involved major lower leg veins (posterior tibial vein or peroneal vein), 13 (33%) involved muscular veins (soleal vein or gastrocnemius vein) and 10 (26%) involved both. During 1 to 6 months, follow-up DVT-CT revealed complete thrombus resolution in all limbs and there was no proximal propagation of thrombus or PE in both groups. CONCLUSION: There is no evidence of DVT propagation or newly developed PE in the conservative treatment group. This result suggests that anticoagulation therapy for ICVT patients without PE after TKA may not be mandatory.

Clinicopathological Feature and Recurrence Pattern of Triple Negative Breast Cancer

PURPOSE: Triple-negative breast cancers (TNBC; estrogene receptor-negative, progesterone receptor-negative, and human epidermal growth factor receptor-2-negative) are very aggressive tumors with high risk of recurrence and poor prognosis. We have compared the clinical characteristics, recurrence rate and pattern between TNBC and nonTNBC. METHODS: A study was done among 879 patients who were diagnosed with breast cancer and received surgery from January 1999 to December, 2005 at Kyungpook National University Hospital. Medical records and pathological reports were reviewed. TNBC was defined as ER(-), PR(-), HER2(-). NonTNBC was defined as having any one of them positive. RESULTS: Of the 879 patients, 81 (9.2%) cases were TNBC. As compared with nonTNBC, TNBC had no significant difference in age of diagnosis (P=0.478), tumor size (P=0.961), axillary lymph node metastasis (P=0.398), stage (P=0.341), histological type (P=0.550), operation method (P=0.053) and chemotherapy (P=0.971). In histological classification TNBC had significantly a high histologic grade, compared to nonTNBC (P<0.001). The median follow-up period was 53 months. There have been 56 local recurrences, 70 distant metastases, 10 distant metastasis with local recurrence and 66 deaths. There was no significant difference in recurrence rate and mortality rate between the two groups. But, average time to recurrence was significantly shorter in TNBC than nonTNBC. CONCLUSION: TNBC had shorter time interval to recurrence compared to nonTNBC and had higher histological grade (mostly grade 3). Therefore, in TNBC, careful treatment and follow-up are important. Further long-term investigations with larger groups of patients will be necessary.

Expanded Criteria for Living Donor Liver Transplantation in Patients with Advanced Hepatocellular Carcinoma

PURPOSE: The purpose of this study was to evaluate the possibility of expanding the indication for living donor liver transplantation (LDLT) for treatment of hepatocellular carcinoma (HCC), beyond the Milan criteria without compromising patient survival. METHODS: This was a retrospective study of 5patients (36.4%) that had undergone LDLT, beyond the Milan criteria, among 143 patients with HCC. The study was conducted in patients treated by the Department of Surgery, Catholic University of Korea from Oct 2000 to May 2008. We evaluated the survival curve, prognostic factors for survival and compared survival between our new criteria and Milan criteria. RESULTS: The 5 year patient survival and disease free survival rate in patients treated with LDLT beyond the Milan criteria were 50.2% and 61.9%, respectively. The prognostic factors affecting disease free survival and patient survival included serum AFP level, tumor size, vascular invasion, and tumor cell differentiation on univariate analysis. In multivariate analysis, AFP (200 ng/mL), tumor size (7 cm) and vascular invasion had significant influence on survival and disease free survival. According to our new criteria (size <7 cm, AFP <200 ng/ mL), 88.1% of our patients were included compare to the 63.6% that would have been if limited to the Milan criteria. With both factors met, the survival was comparable to the survival of Milan criteria (63.7% on our criteria and 78.2% on Milan criteria at 5 years) (P =0.103). CONCLUSION: A tumor size <7 cm and an AFP < 200 ng/mL appear to be useful cut-off values, beyond that criteria required by Milan. An analysis according to our criteria showed an acceptable survival outcome. Further verification of these findings by a large volume or prospective study is required for widespread adoption of our new criteria.

Clinical Outcome of Pretransplant Renal Dysfunction in Adult Living Donor Liver Transplantation / 대한이식학회지

BACKGROUND: The aim of this study is to analyze the clinical significance of preoperative renal dysfunction in patients with living donor liver transplant (LDLT). METHODS: We analyzed data collected retrospectively from 327 consecutive LDLT performed at Department of Surgery, Catholic University of Korea from Jan. 2000 to Dec. 2007. Based on creatinine clearance rate (CCR) calculated before LDLT, the patients were classified in three groups: normal renal function(CCR > or =70 ml/min, 273 patients, 83.5%), mild renal dysfunction (CCR or =40 ml/min, 38 patients, 11.6%) and severe renal dysfunction (CCR1.5 mg/dl) was up to 46.2%. Even in patient with normal renal function, the incidence of postoperative hemodialysis and renal dysfunction 3 months postoperatively was about 5%. Multivariate analysis showed that preoperative serum creatinine, MELD score and postoperative diabetes predicted postoperative renal dysfunction. There was no statistical difference in survival curve between normal and mild renal dysfunction group but the patient with severe renal dysfunction showed worse survival compare with other groups (P < 0.001). CONCLUSIONS: Our data suggested that the patient with preoperative severe renal dysfunction have had poor recovery of renal dysfunction and high incidence of hemodialysis postoperatively and showed worse survival rate after transplantation.

Steatotic Graft for Liver Transplantation / 대한이식학회지

It is common practice to reject potential grafts with fatty change over 30%. We report a case of successful liver transplant using a graft with 70% fatty liver. The patient was a 53 year old male with alcoholic liver cirrhosis who had received endoscopic varix ligation (EVL) for esophageal varix bleeding 4 months ago. He presented with esophageal varix bleeding and drowsy mentality, and was admitted to the ICU via the emergency room. He received EVL again. Preoperative total bilirubin was 11.4 mg/dl, prothrombin time was 40%. The donor was a 50 year old male with diabetes. Liver biopsy showed 70% fatty liver. The operation took 10 hours, and there was no intraoperative complication. Sixteen days after the operation, liver enzymes were normal but total bilirubin was elevated up to 10.26 mg/dl. Liver biopsy was done. Biopsy showed almost no fatty liver but it showed moderate rejection, so steroid recycling was done. Total bilirubin decreased steadily. But 38 days after the operation, ascites increased, and follow-up liver biopsy again showed almost no fatty change but showed severe rejection. Steroid pulse therapy was done, and after pulse therapy the amount of ascites decreased, and the patient was discharged 56 days after the transplantation in tolerable condition. Brain death donor liver grafts with severe fatty liver increase the risk of post transplant complications such as renal failure. But since severe fatty liver does not always cause primary nonfunction, it may be considered as transplant grafts in selected cases.

Clinical Significance of Tumor Size in Patients with Hepatocellular Carcinoma

PURPOSE: The aim of this study is to evaluate the significance of tumor size as a predictor of biological tumor behavior and to get some information to decide on the proper operative modality by assessing the survival rate for HCC patients. METHODS: Between January 1995 and September 2006, 278 patients with hepatocellular carcinoma (HCC) underwent liver surgery at our hospital. Of the 278 cases, 176 cases (63.3%) underwent liver resection and 102 cases (36.4%) underwent liver transplantation (LT). All the patients were divided into 4 groups according to their tumor size; 10 cm. We analyzed the pathologic outcomes, survival rates and the outcome of each operative modality, as related to the tumor size. RESULTS: The incidence of vascular invasion increased with the tumor size ( 10 cm: 50.0%)(P<0.005). For the less than 2 cm sized tumor group, the Edmonson-Steiner (E-S) grade III or IV was present in 40.7% of the patients, as compared with 78.9% in the group of patients with a tumor larger than 10 cm (P=0.005). The patients with a larger tumor showed a poorer survival rate. Liver transplantation showed the longer disease free survival compared to liver resection, though there was no significant benefit in the survival rate. Patients with a small sized tumor showed a better outcome when they underwent liver transplantation and patients with a large sized tumor did better when they underwent liver resection. CONCLUSION: Tumor size can be used as a preoperative predictor of the pathologic outcome when considering that the larger size of tumor the patients had, the more prevalent was vascular invasion, the tumor cell grade was more advanced and the survival rate was poorer. For patients with small sized HCC, liver transplantation can be considered the appropriate treatment modality.

The Usefulness of Salvage Transplantation in Patients with Hepatocellular Carcinoma / 대한이식학회지

PURPOSE: The treatment of choice for hepatocellular carcinoma (HCC) is either surgical resection or liver transplantation. Liver transplantation has the advantage of treating both the tumor and cirrhosis at the same time. However, due to the shortage of donors the availability of this treatment modality is limited. When recurrence is found after liver resection, liver transplantation (salvage transplantation) is an alternative treatment option, as well as in cases with hepatic failure after resection. We carried out this study to evaluate the usefulness of salvage transplantation in these cases. METHODS: From October 2000 to September 2007, among 305 patients who underwent living donor liver transplantation at Kangnam St. Mary Hospital, 119 underwent liver transplantation for HCC. Among them, 102 patients received a primary liver transplantation (PT) and 17 salvage liver transplantation (ST). Among those who underwent a ST, 7 had a major liver resection and 10 had a minor resection, prior to the transplantation. During the ST, all patients received right lobe grafts from living donors. Preoperative and postoperative clinical data were analyzed, as well as survival and disease free survival between the PT and ST groups. RESULTS: There were 5 cases (4.9%) of perioperative mortality in the PT group and 3 cases (17.7%) in the ST group; this difference was without statistical significance. The transfusion requirement for red blood cells was greater in the ST group; but this difference did not reach statistical significance (13.5+/-8.5 units in PT vs. 17.9+/-8.5 units in ST). In addition, there were no significant differences in the recipient operation time (640+/-111 mins in PT vs. 751+/-145 mins in ST), postoperative complication rate (32.3 % in PT vs. 58.8% in ST), reoperation rate (7.8 % in PT vs. 5.9% in ST), and postoperative hospital stay (30.9+/-9.9 days in PT vs. 29.2+/-11.5 days in ST). Furthermore, the 3- and 5-year intention to treat overall survival rate (70.0%, 65.1% in PT vs. 82.4%, 76.0% in ST) were not significantly different. CONCLUSION: The overall survival and disease free survival rates after ST were similar to those after PT. Salvage transplantation, therefore, may be a useful rescue therapy for patients that develop disease recurrence or deterioration of liver function after liver resection for HCC.

Living-Donor Liver Transplantation with Transient Portacaval Shunt and Splenectomy in a Patient with Small-for-Size Graft and Bleeding Gastric Fundal Varices: A Case Report / 대한이식학회지

Excessive portal venous inflow has been known as a determining factor for hepatic injury in small-for-size graft in living-donor liver transplantation. Partial diversion of portal inflow to the systemic circulation by portacaval shunt has been reported as a promising treatment modality to prevent patient from small-for-size graft syndrome. In addition, splenectomy itself is not only a method to decrease portal flow, but also a treatment for the gastric fundal variceal bleeding. We performed living-donor liver transplantation with transient portacaval shunt and splenectomy due to small-for-size graft in a 50 year-old male suffering from hepatitis B virus related liver cirrhosis with bleeding gastric fundal varices, not amenable to control endoscopically. The donor was patient's wife and a graft to recipient body weight ratio (GRWR) was 0.64. During surgery, left portal vein was used for temporary portacaval shunt and the right portal vein was anatomosed to the graft portal vein. After all vascular anastomoses completed, an endoloop (OpenLoop(R), SJM, Paju, Korea) was placed around portacaval shunt without tightening, and the knot pusher was brought out through abdominal wall introduced in a silastic drain tube. Concomitant splenectomy was performed. Twenty-four hours after transplantation, the loop placed around portacaval shunt was tightened as a bedside procedure. The recipient had an uneventful postoperative course and was discharged with normal graft function 26 days after transplantation. Living-donor liver transplantation with transient portacaval shunt and splenectomy could be an acceptable surgical treatment strategy for patients with end-stage liver disease with small-for-size graft and bleeding gastric fundal varices.

Living-Donor Liver Transplantation with Renoportal Anastomosis using an Interposition Polytetrafluoroethylene Graft for a Patient with Large Spontaneous Splenorenal Shunt: A Case Report / 대한이식학회지

Adequate portal perfusion is essential in liver transplantation. End-stage liver disease is often accompanied by a large spontaneous splenorenal shunt and poor portal flow. To secure an adequate portal perfusion of the graft, collaterals including splenorenal shunt should be interrupted during liver transplantation. However, this procedure is usually too demanding because of massive bleeding, as well as time-consuming. As in living-donor liver transplantation size-matched liver graft and vascular grafts are not always available, an alternative must be sought. We performed living-donor liver transplantation with renoportal anastomosis in a 52 year-old male with a large spontaneous splenorenal shunt. During surgery, left renal vein was divided at the caval junction and the distal stump was end-to-end anastomosed to the graft portal vein using 16 mm interposition polytetrafluoroethylene graft without ligation of collaterals. The initial postoperative course of this patient was uneventful. However, on postoperative day 6 and 12 perihepatic hematoma evacuation and portal vein graft thrombectomy were performed respectively. Since then, adequate portal blood flow and patency of the interposition polytetrafluoroethylene graft was maintained throughout the postoperative period. The patient was discharged with normal graft function 10 weeks after transplantation. Renoportal anastomosis using an interposition polytetrafluoroethylene graft in living-donor liver transplantation could be an acceptable alternative for patients with end-stage liver disease with a large spontaneous splenorenal shunt.

Treatment of Polytetrafluoroethylene Hemoaccess Infections

PURPOSE: Infection of PTFE hemoaccess is the gravest complication associated with these devices. Infection most commonly results in premature access failure. Other potential complications of graft infections include: bleeding, systemic sepsis, limb ischemia from interruption of the arterial supply, bacterial endocarditis, or even death. This study was undertaken to evaluate the major pathogen and the appropriate treatment modality, according to the time of the infection occurrence. METHODS: Between February 1996 and May 2002, sixty PTFE hemoaccess infections were treated by the same surgeon at Soonchunhyang University Hospital. All the patients' records were retrospectively reviewed. RESULTS: Four cases developed a PTFE hemoaccess infection within one month of their construction, and were treated with the total removal and new access formation of the contralateral arm. The other fifty-six cases occurred after one month; twenty-six were treated with the removal and new access formation, eighteen with segmental resection and interposition, seven with incision and drainage, and five with antibiotics only. In the four cases that developed within one month, two developed infectious complications and one died. Whereas, in the fifty-six cases that developed after one month, five cases developed infectious complications and four died. Twenty-four cases of thirty nine graft infections with being checked culture test for bacteria were due to Staphylococcus aureus, with sensitivity to vancomycin. CONCLUSION: The managements of the PTFE hemoaccess infections were influenced by the time the infection occurred. Graft infections that occur within one month should be treated aggressively, with total removal. Infections that occur after one month could be selected for a salvage operation. The causative organism of a graft infection is Staphylococcus aureus, and vancomycin is the drug of choice.

Primary Hepatic Malignant Fibrous Histiocytoma

Malignant fibrous histiocytoma (MFH) is a common sarcoma of the soft tissue, usually occurring in the extremities and less commonly in the retroperitoneal space, the abdominal cavity, or other site such as the skin or the head and neck resion. However, MFH of the liver is quite a rare neoplasm. This tumor has five distinct histological subtypes: storiform pleomorphic, myxoid, giant cells, inflammatory and angiomatoid. Recently, we experienced a case of primary MFH in a surgically removed liver. This case is reported with a review of the literature.

The Influence on the Venous Function of Catheter-Directed Thrombolysis for Deep Vein Thrombosis in Lower Extremity

PURPOSE: Having been disappointed with standard anticoagulation therapy for acute deep vein thrombosis (DVT) in lower extremity, we started catheter-directed thrombolytic therapy. And the aim of this study was to evaluate the effects on venous function of catheter-directed thrombolytic therapy by noninvasive venous tests such as Air plethysmography (APG) and duplex ultrasonography. METHOD: 36 patients with DVT of less than 3 weeks after development into two groups according to treatment modality:Group 1; catheter-directed thrombolysis with Urokinase followed by low-molecular weight heparin (LMWH) and coumadin therapy (n=19, men; 11, women; 8, mean age 47.6 years), Group 2; conventional anticoagulation with LMWH followed by coumadin therapy (n=17; men; 12, women; 5, mean age 47.1 years). The results of lytic therapy were examined by complete phlebography on time of removal of catheter. The location and extent of thrombotic changes were followed-up with duplex scan and venous function was examined with APG. RESULT: Complete clot resolution by lytic therapy was obtained in 12 cases out of 19 cases (63.2%) in Group 1. The residual thrombi at follow-up around 1 year were detected in 4 cases in Group 1, in 11 cases in Group 2. APG parameters that were significantly different (P<0.05) between the two groups were the venous filling index:(Group 1; 1.63+/-1.36 ml/sec, Group 2; 2.66+/-1.58 ml/sec), residual volume fraction (Group 1; 27.54+/-17.40%, Group 2; 49.19+/-20.45%) and outflow fraction (Group 1; 37.79+/-7.05%, Group 2; 32.36+/-6.31 %). The parameters of APG and ultrasonography in Group 1 revealed lesser degree of reflux and smaller amount of residual thrombi. CONCLUSION: Catheter-directed thrombolytic therapy shows better results in complete resolution rate of the acute DVT, reducing remnant thrombi, and preserving venous function such as venous filling index, residual volume fraction and outflow fraction. APG and duplex scanning seem to be useful methods for a complete follow-up evaluation of limbs with DVT.

Long Term Follow-up of Deep Vein Thrombosis in the Lower Extremities

PURPOSE: To learn the long-term prognosis of patients with deep vein thrombosis (DVT), we evaluated the location and extent of thrombotic changes, hemodynamic status and clinical symptoms of patients of more than 12 months after development of acute thrombosis. METHODS: 31 patients (man; 24, female; 7, mean age; 44.7 13.2 years) with phlebograpically documented DVT were followed-up for 13~90 months (mean: 32.6 20.4 months) with Duplex scanning, and photo-plethysmography (PPG), and clinical symptoms. To evaluate the effects of treatment modality, the patients were devided into 3 groups; Group 1 (heparine warfarin, n=17), Group 2 (heparine warfarin catheter directed urokinase, n=10), Group 3 (heparine warfarin systemic urokinase, n=4). But, the size of Group 3 was inappropriate to compare with other groups, we performed analysis of the results of Group 1 and 2. RESULTS: Remained thrombi were detected in 22 patients (70.2%) of 31 patients by Duplex scanning, even 1 year later. Of the 29 patients studied with PPG, 24 patients (83%) revealed valvular incompetence in deep (11 cases, 38%) and superficial venous systems (13 cases, 45%). Thrombolytic rate in Group 2 was much higher than Group 1; complete resolution (40% vs 23%), complete obstruction (0% vs 41%). The statistically significant correlation between resolution degree and symptomatic improvement was shown (p=0.008). CONCLUSION: Residual thrombi and valvular damages after DVT were common. But, thrombolysis by catheter-directed urokinase may be associated with a higher rate of thrombolysis and clinical improvement. Anticoagulation alone may not be a sufficient method for treatment of DVT.

Clinicopathological Analysis of Stage IV Gastric Cancer

BACKGROUND: Gastric cancer continues to present a therapeutic challenge because it is one of the most common carcinomas in the world. This study attempted to identify the prognostic effect of gastric resection and to clarify the meaning of distant metastasis in stage IV gastric cancer patients. METHOD: It was a retrospective study using 174 stage IV gastric cancer patient (96 who was operated on and 78 who was not) who were diagnosed during the four years from 1992 to 1996. Several clinicopathologic factors were analyzed to find their prognostic significance for these patient. RESULT: The mean survival duration (MSD) was significantly different according to whether or not an operation was performed, being 18.8 0.6 months for the group that was operated on and 5.4 0.6 months for the group that was not operated on (p=0.0000). With respect to the stage IV patients who was operated on, the MSD was significantly different depending on the Borrman's classification (types 2/3/4 with 11.3 +/- 2.7, 23.0 +/- 2.7, and 8.3 +/- 1.8 months, respectively, p=0.008) as was the presence of distant metastasis (MO/M1 with 24.4 +/- 3.0, 11.5 +/- 1.4 months respectively, p=0.0006). When between curatively and non-curatively resected patients were compared, the MSD was statistically different (18.0 +/- 2.8 and 10.0 +/- 1.5 months, respectively, p=0.0415). In a multivariate survival analysis using Cox's proportional hazard model, Borrman's type and the presence of distant metastasis were clarifed a powerful prognostic factors with ratios of risk of 2.7579 and 1.8825, respectively. CONCLUSION: This study suggests a prognostic benefit for surgery in cases with resectability. Furthermore, we recommend subclassifing stage IV gastric cancer as stage IVa which has no distant metastasis and IVb which has distant metastasis, considering the significant survival difference between these two groups.

A Case of Actinomycosis of the Greater Omentum

Actinomycosis is a chronic suppurative bacterial infection produced by Actinomyces israeli. The three major clinical presentation include the cervicofacial, thoracic, and abdominal regions. Abdominal actinomycosis is a rare entity which presents some difficulty in establishing a correct preoperative diagnosis. The diagnosis is usually based on histologic demonstration of sulfur granules in pus or surgically resected specimen. Recently, authors experienced a case of actinomycosis of the greater omentum in 38-years old woman. The patient underwent surgery under the impression of periappendiceal abscess. A 6cm sized firm mass was noted in the transverse colon. Histologically the mass was composed of fibroinflammatory mass with multiple actinomycosis granules.

A Comparison Between the Three-Trocar Technique and the Four-Trocar Technique in Laparoscopic Cholecystectomy

The laparoscopic cholecystectomy has been clearly established as the gold standard for the surgical treatment of calculous biliary diseases. The currently used most popular technique is the four-trocar technique. This prospective study was designed to examine whether or not three-trocar technique could be chosen as an alternative to the standard four-trocar technique. Prospective data were collected on 98 patients undergoing a laparoscopic cholecystectomy at Wonkwang University Hospital from December 1995 to July 1996. We excluded 40 cases of acute cholecystitis which under went an operative cholangiogram with conversion to the four-trocar method as unfit for this study. We evaluated all associated clinical factors for the three-trocar technique (28 cases); and the four-trocar technique (30 cases), and we analysed the operating time, the intraoperative gallbladder perforation, postoperative complications, the postoperative hospital stay, and the duration for compliants of pain. Between the two techniques, there were no significant differences in the operating times, the postoperative complications, the postopeative hospital stays, and the durations for complaint of pain. However, intraoperative gallbladder perforation more frequently developed in the three-trocar technique than in the four-trocar technique (4 cases versus 1 case, P=0.02). However, gallbladder perforation didn't cause a prolonged operating time; or any other postoperative complication. In our series, the three-trocar technique had results similar to those of the four trocar technique. Morever, the three trocar technique was more economical and had cosmetic advantages. We conclud that a qualified laparoscopic surgeon can choose the three-trocar technique as an alternative to the four-trocar technique.

Impact of the Pattern of Acute Rejection Episodes on Graft Survival / 대한이식학회지

The major reason for the chronic graft loss is chronic rejection. The only predictive factor for chronic rejection is a prior acute rejection episode resulting in a poorer long-term outcome. Also the number of acute rejection episodes is a strong predictor of long-term allograft failure. This study evaluated the impact of a first acute rejection episode and the severity of the rejection and the number of acute rejection episodes on allograft survival. Total of 136 renal transplant were performed between August 1987 to January 1996 at Wonkwang university hospital, and we studied 108 renal transplants that were followed for a minimum of 1.5 years. Acute allograft rejection was mainly diagnosed by clinical evaluation and laboratory data. Transplant patients were divided into three groups according to the time to the first acute rejection; no rejection (group I, n=44); acute rejection during the first 6 months (group II, n=42), acute rejection after 6 months (group III, n=22) and divided into four groups according to the number of acute rejection episodes; no rejection (Group A, n=44), one time (Group B, n=24), two times (Group C, n=23), and more than three times (Group D, n=17). Five-year allograft survival rate for group I-III was 96.4%, 82.7%, 58.5%, respectively (p<0.05 for each comparison to group I). Later acute rejection episodes were associated with worse response to rejection therapy and Group III had higher serum creatinine concentration after rejection therapy than Group II (2.46 1.13 mg/dl vs 1.19 0.7 mg/dl, p<0.05). Five-year allograft survival rate for group A-D was 93.4%, 73.2%, 57.4%, 74.5%, respectively, Group A shows higher graft survival rate, but there was not significant difference in long-term allograft survival among Group B-D. We conclude that late occurrence of a first acute rejection portends a worse prognosis for long-term allograft survival and decreases response to rejection therapy and results in poor graft function. Prevention of later rejection may require a broader focus, with additional efforts directed at improving patient compliance and renal allograft monitoring.

Reversible Acute Nephrotoxicity in Sandimmun Neoral(R) Treated Kidney Transplants / 대한이식학회지

Cyclosporine(CsA) has been used a prime immunosuppressive drug since Calne et al reported the excellent results of cyclosporin in renal transplantation, 1978. But many adverse effects has been reported, one of them, nephrotoxicity is a well-known adverse effect which is developed in high CsA blood level. When previously used Sandimmun was used in the field of various kinds of organ transplantation, there were many difficulties to keep optimal, consistent and stable CsA blood level because of the nature of lipophilic characteristics of drug, wide interpersonal and even intrapersonal variability of its dose and blood concentration. So, there has been the possibility of adverse effects caused by overdosage and rejection phenomenon caused by low dosage. The objective of this study is to assess the significance of drug dosage and CsA blood level in patients developed nephrotoxicity when Sandimmun Neoral was used as a major immunosupressive drug. From January 1995 to September 1996, a total of 21 renal transplant patients from Wonkwang University Hospital entered in this study. We retrospectively analysed CsA dosage, CsA blood level and serum creatinine concentration at postoperative 1, 3, 6, 12 months. These patient were divided into 3 groups according to occurrence of acute rejection and nephrotoxicity. The group A has no nephrotoxicity and no rejection(n=7), the group B has nephrotoxcity only(n=6) and the group C has acute rejection and nephrotoxicity(n=8). There is statistical significance at postoperative 1 month of drug dosage between groups, 10.0+/-2.18, 12.9+/-1.40, 10.5+/-2.01 mg/kg, respectively (p=0.035). Mean CsA blood trough level(ng/ml) in Group A are 427.2+/-73.73, 301.0+/-43.94, 224.8+/-48.39, 175.8+/-46.09 ng/ml at postoperative 1, 3, 6, 12 months, respectively; in Group B, 684.5+/-162.08, 409.5+/-60.67, 278.5+/-27.34, 169.1+/-37.87 ng/ml; in Group C, 484.3+/-131.99, 372.7+/-46.95, 270.8+/-61.17, 188.3+/-48.35 ng/ml. Statistical significance was shown in CsA at postoperative 1, 3 months (P=0.005, P=0.043). Mean serum creatinine concentration(mg/dl) in Group A are 1.3+/-0.20, 1.4+/-0.25, 1.3+/-0.22, 1.4+/-0.20 mg/dl at postoperative 1, 3, 6, 12 months, respectively; in Group 2, 1.7+/-0.24, 2.2+/-0.31, 1.7+/-0.37, 1.5+/-0.31 mg/dl; in Group C, 1.6+/-0.40, 2.8+/-0.38, 2.2+/-0.56, 1.9+/-0.19 mg/dl. Statistical significance in serum creatinine concentration was shown between groups at all index time(P=0.05, P=0.001, P=0.002, P=0.001). Nephrotoxic groups(B,C) regained the serum creatinine concentrations close to basal level according to lowering dosage, but it usually took 5~6 months. This article shows that nephrotoxicity caused by CsA peaked around 3 months and it lasted several months even after adequate dosage adjustment and blood trough level. For the best renal function and avoiding nephrotoxicity, adequate dose adjustment based on the whole blood trough level is needed.