Triple-Tissue Sampling during Endoscopic Retrograde Cholangiopancreatography Increases the Overall Diagnostic Sensitivity for Cholangiocarcinoma

BACKGROUND/AIMS: There are several methods for obtaining tissue samples to diagnose malignant biliary strictures during endoscopic retrograde cholangiopancreatography (ERCP). However, each method has only limited sensitivity. This study aimed to evaluate the diagnostic accuracy of a combined triple-tissue sampling (TTS) method (on-site bile aspiration cytology, brush cytology, and forceps biopsy). METHODS: We retrospectively reviewed 168 patients with suspicious malignant biliary strictures who underwent double-tissue sampling (DTS; n=121) or TTS (n=47) via ERCP at our institution from 2004 to 2011. RESULTS: Among the 168 patients reviewed, 117 patients (69.6%) were eventually diagnosed with malignancies. The diagnostic sensitivity for cancer was significantly higher in the TTS group than the DTS group (85.0% vs 64.9%, respectively; p=0.022). Furthermore, the combination of brush cytology and forceps biopsy was superior to the other method combinations in the DTS group. With respect to cancer type (cholangiocarcinoma vs noncholangiocarcinoma), interestingly, the diagnostic sensitivity was higher for cholangiocarcinoma in the TTS group than the DTS group (100% vs 69.4%, respectively; p<0.001) but not for the non-cholangiocarcinoma patients (57.1% vs 57.1%, respectively). CONCLUSIONS: TTS can provide an improved diagnostic accuracy in suspicious malignant biliary strictures, particularly for cholangiocarcinoma.

Immunoglobulin G4-Related Disease Mimicking Unresectable Gallbladder Cancer

Immunoglobulin G4 (IgG4)-related disease is a novel disease entity that can involve diverse organs, causing specific diseases, including autoimmune pancreatitis, sclerosing cholangitis, cholecystitis, inflammatory aortic aneurysm, and inflammatory pseudotumor. IgG4-related disease is characterized by elevated serum IgG4 concentrations, abundant IgG4 lymphoplasmacytic infiltration, and dramatic steroid responses. It is clinically important to differentiate this rare disease from primary sclerosing cholangitis and cholangiocarcinoma, because the treatment and prognosis of these two diseases are completely different. However, the preoperative diagnosis is challenging, and the disease is frequently misdiagnosed. If the serum level of IgG4 is within the normal range, the diagnosis of IgG4-related disease is more difficult. This article reports on a 59-year-old man with IgG4-related disease mimicking unresectable gallbladder cancer with normal serum IgG4 concentrations.

A Case of Shewanella algae Bacteremia Accompanying Cellulitis in Both Legs of a Patient on Hemodialysis: Case Report and Literature Review

We report a fatal case of Shewanella algae bacteremia accompanied by cellulitis in both legs of a chronic renal failure patient who had not been exposed to sea water or raw fish. A 47-year-old male on hemodialysis was admitted to our clinic due to pain in both legs accompanied by a febrile sensation that started 2 days prior to his visit. A blood culture specimen revealed S. algae, a rare human opportunistic pathogen. In spite of early and appropriate antimicrobial treatment, the patient died of septic shock on the second day of his hospital stay. Recently, serious infections caused by Shewanella species have been reported in increasing frequency. Hepatobiliary diseases have been proposed as predisposing factors, not only for infection by this organism, but also for fatality. However, we should be aware of the significance of S. algae in patients with renal insufficiency, especially those on maintenance hemodialysis. Herein, we report our case with review relevant literature.

Use of the pedicled buccal fat pad in the reconstruction of intraoral defects: a report of five cases

The buccal fat pad is specialized fat tissue located anterior to the masseter muscle and deep to the buccinator muscle. Possessing a central body and four processes it provides separation allowing gliding motion between muscles, protects the neurovascular bundles from injuries, and maintains facial convexity. Because of its many advantageous functions, the use of the buccal fat pad during oral and maxillofacial procedures is promoted for the reconstruction of defects secondary to tumor resection, and those defects resulting from oroantral fistula caused by dento-alveolar surgery or trauma. We used the pedicled buccal fat pad in the reconstruction of intraoral defects such as oroantral fistula, maxillary posterior bone loss, or defects resulting from tumor resection. Epithelization of the fat tissue began 1 week after the surgery and demonstrated stable healing without complications over a long-term period. Thus, we highly recommend the use of this procedure.

Evans syndrome following long-standing Hashimoto's thyroiditis and successful treatment with rituximab / 대한혈액학회지

We report a case of a 51-year-old woman with Evans syndrome (autoimmune hemolytic anemia and primary immune thrombocytopenia) and hypothyroidism. She was previously diagnosed with Hashimoto's thyroiditis in 1994 (age, 35) and autoimmune hemolytic anemia (AIHA) 3 years ago. She was treated with oral prednisolone. After a period, in which the anemia waxed and waned, there was an abrupt development of thrombocytopenia (nadir 15x10(9)/L) that coincided with the tapering off of prednisolone after 3 years of administration. Because her thrombocytopenia was refractory to prednisolone, we administered rituximab (375 mg/m2 weekly) for 4 weeks. Two weeks after the completion of the rituximab treatment, her platelet count was up to 92x10(9)/L. No intermittent peaking of thyroid stimulating hormone occurred after rituximab treatment was initiated. Evans syndrome and autoimmune thyroiditis might share common pathophysiological mechanisms. This notion supports the use of rituximab in a patient suffering from these disorders.

Clinical Features of Hospitalized Patients with Community Acquired Pneumonia during 2009 Influenza A (H1N1) Pandemic / 대한구급학회지

BACKGROUND: A new influenza A(H1N1) virus emerged and spread globally in 2009, and the rapid progression of pneumonia often required ICU care. We describe the cause analysis and clinical aspects of community acquired pneumonia during the period of the pandemic H1N1 influenza A. METHODS: We reviewed the medical records of 48 adult cases of community acquired pneumonia in which patients were admitted to a public health hospital in Seoul from August to November in 2009. The patients had confirmed H1N1 influenza A based on RT-PCR assay. RESULTS: Thirteen cases of the 48 (27.1%) were 2009 H1N1 RT-PCR positive patients and three (6.3%) of these cases were mixed viral and bacterial pneumonia patients. The mean age was younger and the PSI score was lower in H1N1 patients. Chest radiographic findings of ground glass opacity and interstitial marking were remarkable in H1N1 patients. Major complication events with ICU care or death occurred in 23.1% of the H1N1 positive group and 48.6% of the H1N1 negative group (p=0.202). The major complication group of H1N1 patients had a higher PSI score, lower platelet count, higher CRP and higher mixed bacterial co-infection. CONCLUSIONS: If patients were younger and showed a radiologic finding of interstitial marking or ground glass opacity, we could consider H1N1 influenza as the cause of community acquired pneumonia. A high PSI score, thrombocytopenia, increased CRP and bacterial co-infection were predictable factors of major complication.

Portal and Mesenteric Venous Thrombosis Complicating Endoscopic Injection Sclerotherapy / 대한소화기내시경학회지

Endoscopic injection sclerotherapy is an effective and relatively safe modality for controlling bleeding esophageal varices. Injection of sclerosant causes acute mural thrombosis with a necroinflammatory response and subsequent sclerosis in the venous system of the distal esophagus. A few cases of mesenteric venous thrombosis with small bowel infarction after sclerotherapy have been reported, and most of which were fatal. The association between mesenteric venous thrombosis and sclerotherapy has been strongly suggested, but this still remains unproved. We report here on a case of mesenteric venous thrombosis with small bowel infarction that developed after endoscopic injection sclerotherapy.

The Clinical Implication of MAGE Gene Detection in Bronchial Washing Fluid in Routine Practice / 결핵및호흡기질환

BACKGROUND: Melanoma antigen genes (MAGE) are expressed in many human malignant cells and are silent in normal tissues other than in testis and in placenta. But MAGE expression in benign lung diseases, such as pulmonary tuberculosis or cases with severe inflammation, needs further evaluation to overcome false-positive findings. We evaluated detection rates of the melanoma antigen genes (MAGE) RT-nested PCR in bronchoscopic washing samples from patients with benign lung disease, as well as in patients with malignancies. METHODS: Bronchial washing fluid from 122 patients was used for cytological examination and MAGE gene detection using RT-nested-PCR of common A1-6 mRNA. We compared the results from the RT-nested PCR and the pathologic or bacteriologic diagnosis. We also analyzed the expression rate and false positive rate of MAGE gene. RESULTS: Among 122 subjects, lung cancer was diagnosed in 23 patients and benign lung disease was diagnosed in 99 patients. In patients with lung cancer, the positive rate of MAGE expression was 47.8% (11/23) and in benign lung disease group, the expression rate was 14.1% (14/99). Among benign lung disease group, the expression rate of MAGE gene (25.0%) in patients with pulmonary tuberculosis (11/44) was especially high. CONCLUSION: MAGE A1-6 RT-nested PCR of bronchial washing fluid can be used as a complementary method in lung cancer, but that test results in a high false positive rate in tuberculosis patients.

Postoperative orocutaneous fistula closure using a vacuum-assisted closure system: a case report

Fleischmann et al. first described the concept of using sub-atmospheric pressure to treat open or infected wounds in 1993. Since then, Argenta and Morykwas developed subatmospheric, or negative pressure dressings in 1997 as a means of managing complicated wounds. Since its introduction in 1997, the vacuum-assisted closure (VAC) system has been used widely in general plastic surgery, general surgery, and orthopedic surgery to manage complicated wounds of the torso and extremities. However, there is a paucity of literature describing its use in the head and neck region, particularly in oral and maxillofacial surgery. We report a successful case of postoperative orocutaneous fistula closure using a VAC system in a 59-year male with a review of the relevant literature.

Transoral removal of proximal submandibular stone: report of 5 cases and review of the literature

The submandibular gland is the second largest major salivary gland, which secretes 40% of the total daily saliva. Owing to its anatomic characteristics as well as the high viscosity and basicity of the saliva, sialolithiasis is found most commonly in the submandibular gland. Sialolithiasis that cannot be treated by conservative treatment is conventionally removed by an excision of the submandibular gland. Generally, an excision of the submandibular gland is performed via an extra-oral approach but the disadvantages of this treatment include a risk of injuring the facial nerve and scar formation. Case reports have revealed an even less invasive intraoral surgical technique for the removal of sialolith that does not affect the submandibular gland function. The functional recovery of the gland, complications and recurrence rates after surgery with this conservative intraoral procedure were all successful. We report 5 patients from the department of Oral and Maxillofacial Surgery at Dental Hospital, Yonsei University, who had undergone a resection of the sialolith though the intraoral approach with successful results.