Spontaneous Hemoperitoneum in Patients Taking Anticoagulants

PURPOSE: Spontaneous hemoperitoneum is not a common disease but may cause a fatal outcome. Warfarin is a coumarin anticoagulant, used widely for therapeutic and prophylactic anticoagulation. Although, it is considered a life saving medicine, it is associated with significant adverse effects including intraabdominal bleeding. Literatures about spontaneous hemoperitoneum in patients taking anticoagulants have been reported, but until now there have not been a definite establishment in diagnostic criteria and treatment strategy. METHODS: Among 209 patients who were diagnosed hemoperitoneum from Jan 2005 through May 2009, we identified 9 patients with spontaneous hemoperitoneum without any trauma history or solid organ abnormalities. All 9 patients were taking warfarin for various durations. Initially, we evaluated vital signs, laboratory, CT findings, and clinical course, retrospectively. In addition, we analyzed risk factors potentiating the pharmacologic effect of anticoagulants. RESULTS: One of the most prominent features in this study is that all patients showed prolonged international normalized ratio (6.36~15.11). One patient received an exploratory laparotomy for hemoperitoneum secondary to warfarin, presenting as a localized peritonitis in the right lower quadrant of the abdomen. Mean hospital stay was 15.2 days. Five patients were transfused with packed red blood cells (500~1,000 ml) and fresh frozen plasma (300~900 ml). All patients were discharged without any mortality. CONCLUSION: It is important to identify and confirm the factors that can potentiate the pharmacologic effect of anticoagulants, when acute abdomen is suspected in patients taking anticoagulants. If the patients are hemodynamically stable, they can be treated without surgical intervention.

The Prognostic Factors and Severity Index in Fournier's Gangrene

PURPOSE: Fournier's disease is polymicrobial necrotizing fasciitis of the perineal, perianal, or genital areas. The objective of this study was to investigate patients with Fournier's gangrene and to determine risk factors that affect mortality. METHODS: This study was a retrospective clinical study. Clinical presentations and outcomes of surgical treatments were evaluated in 27 patients with Fournier's gangrene that were treated in a single institution from January 2000 to March 2009. RESULTS: The mean age of patients was 52.8+/-14.4 yr, and the male-to-female ratio was 25:2. Among the predisposing factors, diabetes mellitus was the most common (n=8, 29.6%). The most common infection source was anorectal (n=16, 59.3%). Sepsis on admission was detected in 16 cases (59.3%). Four patients died during treatment, for an overall mortality of 14.8%. A logistic regression test showed a Fournier's gangrene severity index greater than 9 and sepsis on admission to be prognostic factors. CONCLUSION: The mortality rate was higher in patients with sepsis on admission and with a Fournier's gangrene severity index greater than nine.

Traumatic Pericardial Rupture: A Case Report

Pericardial rupture due to blunt trauma is very rare, but can lead to serious complications. It occurs mainly on the left, is found incidentally during surgery, and is seldom discovered radiologically unless accompanied by cardiac herniation. The following case describes a 53-year-old traffic-accident victim who received emergency pericardial repair and bleeding control via an exploratory thoracotomy and an exploratory laparatomy. The patient was discharged without any complication and remained healthy at six month after injury.

The Early Experience of Laparoscopic Sigmoid Colon and Rectal Cancer Resection

PURPOSE: The aim of this study is to assess the pathologic surgical outcome and short-term outcome of a laparoscopic colorectal resection at an early time on the learning curve in comparison with open surgery. METHODS: Retrospectively collected data were obtained on 49 patients who underrent a laparoscopic sigmoid colon and rectal cancer resection between May 2001 and January 2006. The compared factors were the clinicopathologic characteristics, the operation time, the postoperative recovery, and complications. RESULTS: There were no significant differences in age, sex, TNM stage, and tumor size between the laparoscopic and open-surgery groups. The operation time was significantly longer in the laparoscopic group (291.4 vs. 201.9 min P < 0.001). In the view point of postoperative recovery, the laparoscopic group showed a significant advantage in the passage of flatus. There were no significant differences in harvested LNs, proximal margin, and distal margin between the two groups. The complication rate was not significantly different, but anastomotic leakage was higher in the laparoscopic group (16.7% vs. 2%, P=0.02). CONCLUSIONS: There were no significant differences in harvested LNs, proximal margin, and distal margin between the two groups, but anastomotic leakage was higher in the laparoscopic group.

The Effect of Old Age on the Development of Postoperative Complication in Surgery for Gastric Carcinoma

PURPOSE: Despite the fact that the number of elderly in the population has increased due to the improvement in medical skills and equipment and an increased interest in health, there is a view common among patients, guardians, and even the surgeons that the prognosis after surgery in the elderly is not optimistic. We examined the effect of old age on the prognosis after surgery in patients who were to undergo surgery after being diagnosed with gastric cancer. The effect of old age on the development of postoperative complications was evaluated. METHOD: Five hundred and seventy three patients, who underwent surgery for gastric cancer from January 1994 to December 1998 at Wonju Christian Hospital under Yonsei University Wonju College of Medicine, were analyzed retrospectively. The patients were divided into those older and younger 70 years of age. The presence of an underlying disease, the physical condition according to ASA(American Society of Anesthesiologist) classification, the extent of the resection, the TNM stage according to the AJCC (American Joint Committee on Cancer), and the operation time were examined. The effects of age on the postoperative complications in the study and control groups were also evaluated. RESULTS: Among the 573 patients, 515 were under 70 years and 58 were older than 70. Those older than 70 years, showed significant differences with physical condition (P<0.001), the presence of an underlying disease (P=0.043), M stage of TNM staging (P=0.001), hospital days (P<0.001), and operation time (P=0.026). CONCLUSION: Age itself did not correlate with the development of postoperative complications (P=0.193). The presence of an underlying disease affected the development of postoperative complications regardless of age or gender. Therefore, surgery can be performed safely when the patient's condition is evaluated thoroughly before surgery and the operation is carried out as scheduled.

The Clinical Value of Venography Prior to Arteriovenous Fistula Creation

PURPOSE: Maturation failure after arteriovenous fistula (AVF) creation is a major problem that determines the early success of a fistula for hemodialysis. Therefore the pre-operative evaluation of venous status is widely recommended for obtaining a favorable AVF result. To assess the effectiveness and significance of venography as a pre-operative vein evaluation mode, we compared the short-term and long-term results of AVF according to the performance of pre-operative venography. METHOD: Two hundred forty patients who underwent AVF from March 2002 to May 2004 were enrolled in this study. We performed pre-operative venography on selected patients with equivocal physical findings such as small vein, interrupted venous drainage and arm edema. The clinical manifestations and AVF results such as the early failure rate and patency rate by performance of venography were reviewed retrospectively. RESULT: Pre-operative venography was performed in 86 patients (35.8%). The mean age, proportion of female gender and prevalence of diabetes was significantly higher in the venography group compared to the non-venography group. Among the 86 cases of venography, 53 cases (61.6%) contained one or more abnormal venous findings. Small or turbulent veins at the planned operation site were found in 36 cases (41.9%), thrombosis or sclerotic change of veins were found in 8 cases, disappearance of veins were found in 8 cases and stenosis of the central vein was found in one case. We changed the planned AVFs according to the venography findings in 43 cases (50.0%). For this reason, the proportion of upper fistulas and graft fistula was significantly increased in the venography group. The fistula maturation failure rate in the venography group was 5.8% (5/86), which was significantly lower than that of the non-venography group. The one-year and two-year patency rate of the venography group were 86.8% and 83.5% respectively, which was also significantly higher than those rates of the non-venography group (74.9% and 73.4%, for one-year and two-year patency rate, respectively)(P=0.03). CONCLUSION: The selective application of venography for pre-operative venous mapping is valuable for the selection of the type of AVF, and it produces good results with a superior maturation rate and patency rate.