First Experience of Single-Port Robotic Areolar Approach Thyroidectomy

Objectives@#. Numerous minimally invasive thyroidectomy techniques have been developed and are actively utilized in hospitals around the globe. Herein, we describe a recently developed minimally invasive thyroidectomy technique that employs the da Vinci SP, and we present the preliminary clinical outcomes of single-port robotic areolar thyroidectomy (SPRA). @*Methods@#. A 3-cm semi-circular incision on the right areola and a small 8-mm incision on the left areola were created. Using hydro-dissection and an advanced bipolar device, a subcutaneous skin flap was created, extending from the areola to the thyroid cartilage. The da Vinci SP was then inserted through the incision in the right areola. Between December 2022 and March 2023, 21 SPRA procedures were conducted. Patients’ medical records and surgical videos were subsequently reviewed. @*Results@#. Lobectomy was performed in 17 patients, isthmectomy in 2 patients, and total thyroidectomy in 2 patients. The mean flap time was 14.9±4.2 minutes and the console time was 62.4±17.1 minutes. The mean tumor size was 0.89± 0.65 cm and the number of retrieved lymph nodes was 3.94±3.98 (range, 0–12). There were no observed instances of vocal cord palsy or hypoparathyroidism. @*Conclusion@#. We successfully developed and performed the novel SPRA for the first time worldwide. Unlike other robotic surgery methods, SPRA is less invasive and leaves no visible scars. This technique employs a sophisticated single-port robotic device. However, to assess the efficacy of this method, we need to analyze more cases and conduct comparative studies in the near future.

Initial Experience With Robotic Modified Radical Neck Dissection Using the da Vinci Xi System Through the Bilateral Axillo-Breast Approach

Objectives@#. The bilateral axillo-breast approach (BABA) to robotic thyroidectomy has been extended to modified radical neck dissection (MRND). This study assessed outcomes in patients who underwent robotic MRND through BABA using the da Vinci Xi system. @*Methods@#. The medical records of 40 patients who underwent total thyroidectomy, bilateral central neck dissection, and MRND from September 2018 to March 2020 were reviewed retrospectively, including 12 who underwent robotic surgery and 28 who underwent open surgery. All operations were performed by a single endocrine surgeon. @*Results@#. The operation time was significantly longer in the robotic group than in the open group (277.08±32.64 vs. 191.43± 60.43 minutes, respectively, P<0.01), but the number of retrieved lymph nodes did not differ significantly (32.58± 9.31 vs. 34.54±10.90, respectively, P=0.569). The incidence of transient hypoparathyroidism was significantly lower in the robotic group (16.7% [2/12] vs. 53.6% [15/28], P=0.041). The mean hospital stay was shorter (3.92±0.90 vs. 4.71±1.63 days) and the pain score on the first postoperative day was lower (2.92±0.29 vs. 3.18±0.67) in the robotic group. Six of the 12 patients (50%) in the robotic group had stimulated thyroglobulin levels <1.0 ng/mL. @*Conclusion@#. Robotic MRND through BABA has several advantages, including excellent cosmetic outcomes and a lower incidence of transient hypoparathyroidism than is the case for open MRND. Robotic MRND through BABA may be a promising surgical approach compared with conventional open MRND.

The association of the serum levels of myostatin, follistatin, and interleukin-6 with sarcopenia, and their impacts on survival in patients with hepatocellular carcinoma

Background/Aims@#The role of serum myokine levels in sarcopenia and the outcome of hepatocellular carcinoma (HCC) patients are not clear. This study investigated the serum levels of myostatin, follistatin, and interleukin-6 (IL-6) in HCC patients and their association with sarcopenia and survival. @*Methods@#Using prospectively collected pretreatment samples from 238 HCC patients in a hospital from 2012 to 2015, the serum levels of 3 myokines were determined and compared to 50 samples from age and sex-matched healthy controls. Sarcopenia was evaluated using the psoas muscle index (PMI) measured at the third lumbar level in the computed tomography, and clinical data were collected until 2017. @*Results@#The median levels of the 3 myokines for the male and female HCC patients were as follow: myostatin (3,979.3 and 2,976.3 pg/mL), follistatin (2,118.5 and 2,174.6 pg/mL), and IL-6 (2.5 and 2.7 pg/mL), respectively. Those in the HCC patients were all significantly higher than in the healthy controls. In the HCC patient, the median PMI was 4.43 (males) and 2.17 cm2/m2 (females) with a sarcopenic prevalence of 56.4%. The serum levels of myostatin, IL-6 and follistatin in the HCC patients showed a positive, negative, and no correlation with PMI, respectively. The serum follistatin level was an independent factor for poor survival in HCC patients. @*Conclusions@#The serum levels of myostatin, follistatin, and IL-6 and their correlation with sarcopenia and survival were presented in HCC patients for the first time. The role of the serum follistatin level as a poor prognostic biomarker warrants further study.

Pneumocephalus following fluoroscopy-guided lumbar epidural injection in elderly patients: two cases report and a review of Korean literatures - Two cases report -

Background@#Pneumocephalus can originate from accidental dural puncture while performing epidural block using the loss-of-resistance (LOR) technique with an air-filled syringe. Case: We present two cases of pneumocephalus after lumbar epidural block under fluoroscopy for pain control in elderly patients. @*Conclusions@#Lumbar epidural block should be performed under fluoroscopic guidance in elderly patients with severe lesions. The physician should be aware of the increased possibility of a dural puncture occurring due to anatomical changes in older patients. The use of saline is recommended for the LOR technique. A contrast injection should be used together with the LOR technique to locate the epidural space. If a dural puncture occur, the patient should be carefully monitored to determine whether pneumocephalus has developed.

Low concentration continuous femoral nerve block improves analgesia and functional outcomes after total knee arthroplasty in spinal anesthesia

BACKGROUND: Total knee arthroplasty (TKA) is associated with severe pain postoperatively. Femoral nerve block is commonly used for pain control after TKA. This study investigated whether continuous femoral nerve block (CFNB) can improve postoperative analgesia and functional outcome as compared to intravenous patient controlled analgesia (PCA) in patients with TKA. METHODS: We reviewed the electronic medical records of patients who underwent TKA with spinal anesthesia between March 2014 and February 2015. In Group IV, postoperative pain was managed by IV-PCA. Group CFNB received CFNB-PCA via a device. Thirty patients were enrolled per group. Patient outcomes were assessed by analgesia, functional outcomes, and health-related quality of life factors. RESULTS: Additional analgesics and additional nerve block for adequate pain control were significantly more frequent in the IV than CFNB group (P = 0.015 and P = 0.012, respectively). Range of motion up to 105 degrees was prolonged in the IV group than CFNB group (P = 0.013). EuroQol five dimensions score was improved in the CFNB group than IV group postoperative 3 weeks (P = 0.003). The incidence of transfusion due to postoperative bleeding was significantly frequent in the IV group than CFNB group (P = 0.042). CONCLUSIONS: Postoperative low concentration continuous femoral nerve block for analgesia after TKA improves analgesia, functional outcomes, and incidence of transfusion without falling risk.

Estimation of the effect-site equilibration rate constant using the time-to-peak effect of muscle relaxants measured by train-of-four stimulation during general anesthesia induction / 대한마취과학회지

BACKGROUND: The concept of the effect-site concentration of anesthetic agents is important. The effect compartment model can be explained using the concepts of effect-site concentration and effect-site equilibration rate constant (k e0). This study confirms that the time-to-peak effect (tpe ) can be measured easily in clinical practice by applying a priming dose and train-of-four (TOF) during general anesthesia induction, and k e0 can be calculated from the tpe of the four muscle relaxants that are commonly used in general anesthesia. METHODS: Eighty patients who received general anesthesia were divided into the succinylcholine, rocuronium, atracurium, or vecuronium groups. Priming doses of muscle relaxants were administered. The effects of muscle relaxants were quantified by recording the twitch response of the adductor pollicis muscle after stimulating the ulnar nerve. The tpe was measured at the lowest TOF value. k e0 was calculated from the measured tpe . RESULTS: The k e0 values of the succinylcholine, rocuronium, atracurium, and vecuronium groups were 0.076 (0.030)/min, 0.228 (0.122)/min, 0.062 (0.011)/min, and 0.077 (0.019)/min, respectively. CONCLUSIONS: It is possible to estimate k e0 from the tpe of muscle relaxants using a priming dose and TOF during general anesthesia induction.

Unintentional lumbar facet joint injection guided by fluoroscopy during interlaminar epidural steroid injection: a retrospective analysis

BACKGROUND: An epidural steroid injection (ESI) is a commonly administered procedure in pain clinics. An unintentional lumbar facet joint injection during interlaminar ESI was reported in a previous study, but there has not been much research on the characteristics of an unintentional lumbar facet joint injection. This study illustrated the imaging features of an unintentional lumbar facet joint injection during an interlaminar ESI and analyzed characteristics of patients who underwent this injection. METHODS: From December 2015 to May 2017, we performed 662 lumbar ESIs and we identified 24 cases (21 patients) that underwent a lumbar facet joint injection. We gathered data contrast pattern, needle approach levels and directions, injected facet joint levels and directions, presence of lumbar spine disease as seen on magnetic resonance images (MRI), and histories of lumbar spine surgeries. RESULTS: The contrast pattern in the facet joint has a sigmoid or ovoid contrast pattern confined to the vicinity of the facet joint. The incidence of unintentional lumbar facet joint injection was 3.6%. The mean age was 68.47 years. Among these 21 patients, 14 (66.7%) were injected in the facet joint ipsilaterally to the needle approach. Among the 20 patients who received MRI, all (100%) had central stenosis and 15 patients (75%) had severe stenosis. CONCLUSIONS: When the operator performs an interlaminar ESI on patients with central spinal stenosis, the contrast pattern on the fluoroscopy during interlaminar ESI should be carefully examined to distinguish between the epidural space and facet joint.

Persistent α-Fetoprotein Elevation in Healthy Adults and Mutational Analysis of α-Fetoprotein Promoter, Enhancer, and Silencer Regions

BACKGROUND/AIMS: α-Fetoprotein (AFP) is normally 1 year, and 20 controls with low AFP levels (<0.61 to 2.9 ng/mL) were included in the study. AFP levels were collected from the families of two of the patients. We sequenced five regions that are critical for AFP expression: a promoter, two enhancers, and two silencers. RESULTS: One of the two cases in which family information was represented is the first case of hereditary persistence of AFP in South Korea. Mutations related to AFP overexpression were not found in the transcription regulatory regions among the four patients. CONCLUSIONS: Persistent AFP elevation is a heterogeneous condition with or without a hereditary pattern and may be caused by factors outside of transcription regulatory region changes. Further research on the mechanism of AFP elevation is needed.

Difficult endotracheal intubation secondary to tracheal deviation and stenosis in a patient with severe kyphoscoliosis: a case report / 대한마취과학회지

We report on a case of difficult endotracheal intubation in a patient with marked tracheal deviation at an angle of 90 degrees combined with stenosis due to kyphoscoliosis with vertebral body fusion. After induction of general anesthesia, a proper laryngeal view was easily obtained using a videolaryngoscope. But a tracheal tube could not be advanced more than 3 cm beyond the vocal cords due to resistance, despite various attempts, including the use of small size tubes, full rotation of the tube tip, and fiberoptic bronchoscopy. Ultimately, the airway was successfully secured by placing a tube tip above the area of resistance and by additionally packing saline-soaked gauzes around the tracheal inlet to minimize gas leakage and to fasten the tube in the trachea.

Ultrasound Guided Low Approach Interscalene Brachial Plexus Block for Upper Limb Surgery

BACKGROUND: The interscalene brachial plexus block is widely used for pain control and anesthetic purposes during shoulder arthroscopic surgeries and surgeries of the upper extremities. However, it is known that interscalene brachial plexus block is not appropriate for upper limb surgeries because it does not affect the lower trunk (C8-T1, ulnar nerve) of the brachial plexus. METHODS: A low approach, ultrasound-guided interscalene brachial plexus block (LISB) was performed on twenty-eight patients undergoing surgery of the upper extremities. The patients were assessed five minutes and fifteen minutes after the block for the degree of block in each nerve and muscle as well as for any complications. RESULTS: At five minutes and fifteen minutes after the performance of the block, the degree of the block in the ulnar nerve was found to be 2.8 +/- 2.6 and 1.1 +/- 1.8, respectively, based on a ten-point scale. Motor block occurred in the median nerve after fifteen minutes in 26 of the 28 patients (92.8%), and in all of the other three nerves in all 28 patients. None of the patients received additional analgesics, and none experienced complications. CONCLUSIONS: The present study confirmed the achievement of an appropriate sensory and motor block in the upper extremities, including the ulnar nerve, fifteen minutes after LISB, with no complications.

The Influence of Genotype Polymorphism on Morphine Analgesic Effect for Postoperative Pain in Children

BACKGROUND: Although opioids are the most commonly used medications to control postoperative pain in children, the analgesic effects could have a large inter-individual variability according to genotypes. The aim of this study was to investigate the association between single nucleotide polymorphisms and the analgesic effect of morphine for postoperative pain in children. METHODS: A prospective study was conducted in 88 healthy children undergoing tonsillectomy, who received morphine during the operation. The postoperative pain score, frequency of rescue analgesics, and side effects of morphine were assessed in the post-anesthesia care unit. The children were genotyped for OPRM1 A118G, ABCB1 C3435T, and COMT Val158Met. RESULTS: Children with at least one G allele for OPRM1 (AG/GG) had higher postoperative pain scores compared with those with the AA genotype at the time of discharge from the post-anesthesia care unit (P = 0.025). Other recovery profiles were not significantly different between the two groups. There was no significant relationship between genotypes and postoperative pain scores in analysis of ABCB1 and COMT polymorphisms. CONCLUSIONS: Genetic polymorphism at OPRM1 A118G, but not at ABCB1 C3435T and COMT Val158Met, influences the analgesic effect of morphine for immediate acute postoperative pain in children.

Postoperative Quality of Life after Total Gastrectomy Compared with Partial Gastrectomy: Longitudinal Evaluation by European Organization for Research and Treatment of Cancer-OG25 and STO22

PURPOSE: The European Organization for Research and Treatment of Cancer quality-of-life questionnaire-OG25 was developed to evaluate the quality of life in patients with stomach and esophageal cancer. The following are included in the OG25 but not in the STO22: odynophagia, choked when swallowing, weight loss, trouble eating with others, trouble swallowing saliva, trouble talking, and trouble with coughing. In this study, we evaluated the quality of life of gastrectomized patients using both, the OG25 and the STO22. MATERIALS AND METHODS: A total of 138 patients with partial gastrectomy (PG) (distal gastrectomy=91; pylorus-preserving gastrectomy= 47) and 44 patients with total gastrectomy (TG) were prospectively evaluated. Body weight and scores from the OG25 and STO22 were evaluated preoperatively and at 3 weeks, 3 months, and 6 months after surgery. RESULTS: Patients with TG had significant weight loss compared to patients with PG. At 3 months, TG was associated with worse scores for dysphagia, eating, odynophagia, trouble eating with others, trouble with taste, and weight loss on the OG25. TG was also associated with dysphagia, eating restrictions, and anxiety on the STO22. The OG25 helped differentiate between the groups with respect to weight loss, odynophagia, choked when swallowing, and trouble eating with others. The OG25 scores changed over time and were significantly different. CONCLUSIONS: The OG25 is a more sensitive and useful scale than the STO22 for evaluating the quality of life of gastrectomized patients, especially those with total gastrectomy.

Ultrasound-guided superficial cervical plexus block for carotid endarterectomy in a patient with Lemierre syndrome: A case report

A 70-year-old woman with an infectious thrombus in her left internal jugular vein (IJV) underwent carotid endarterectomy for stenosis and a highly movable plaque in her right carotid artery. She had been treated with antibiotics for four weeks before surgery due to Lemierre syndrome, a rare septic thrombophlebitis in the IJV secondary to an oropharyngeal infection. The right IJV was in a two-fold dilated state due to compensation for a thrombotic left IJV. Accordingly, superficial cervical plexus block was performed under ultrasound guidance to ensure safety and accuracy. During surgery, the alertness was maintained and the patient did not complain of pain in the absence of additional analgesics. No block-related complications were encountered. The authors report for the first time their regional anesthetic experiences in a patient with Lemierre syndrome.

Glypican-3 level assessed by the enzyme-linked immunosorbent assay is inferior to alpha-fetoprotein level for hepatocellular carcinoma diagnosis

BACKGROUND/AIMS: Glypican-3 (GPC3) protein is highly expressed in hepatocellular carcinoma (HCC) tissue. It has been suggested as a diagnostic biomarker, but its inconsistent performance means that it requires further assessment. We therefore investigated the diagnostic value of the plasma GPC3 level compared to the alpha-fetoprotein (AFP) level as a diagnostic biomarker of HCC. METHODS: We enrolled 157 consecutive patients with newly diagnosed HCC and 156 patients with liver cirrhosis (LC) as the control group. GPC3 plasma levels were measured using two commercially available enzyme-linked immunosorbent assays (ELISAs, named as Assay 1 and 2), and AFP levels were measured using an enzyme-linked chemiluminescent immunoassay. The diagnostic accuracy was analyzed using the receiver operating characteristics (ROC) curve. RESULTS: Plasma GPC3 levels in HCC patients were very low (0–3.09 ng/mL) in Assay 1, while only 3 of the 157 patients (1.9%) showed detectable GPC3 levels in Assay 2. The median GPC3 level was not significantly elevated in the HCC group (0.80 ng/mL) compared with the LC group (0.60 ng/mL). The area under the ROC curve (AUC) for GPC3 was 0.559 in Assay 1. In contrast, the median AFP level was significantly higher in HCC (27.72 ng/mL) than in LC (4.74 ng/mL), with an AUC of 0.729. CONCLUSION: The plasma level of GPC3 is a poor diagnostic marker for HCC, being far inferior to AFP. The development of a consistent detection system for the blood level of GPC3 is warranted.

A Comparison of Three Methods for Postoperative Pain Control in Patients Undergoing Arthroscopic Shoulder Surgery

BACKGROUND: Arthroscopic shoulder operations (ASS) are often associated with severe postoperative pain. Nerve blocks have been studied for pain in shoulder surgeries. Interscalene brachial plexus blocks (ISB) and an intra-articular injection (IA) have been reported in many studies. The aim of the present study is to evaluate the effect of ISB, a continuous cervical epidural block (CCE) and IA as a means of postoperative pain control and to study the influence of these procedures on postoperative analgesic consumption and after ASS. METHODS: Fifty seven patients who underwent ASS under general anesthesia were randomly assigned to one of three groups: the ISB group (n = 19), the CCE group (n = 19), and the IA group (n = 19). Patients in each group were evaluated on a postoperative numerical rating scale (NRS), their rescue opioid dosage (ROD), and side effects. RESULTS: Postoperative NRSs were found to be higher in the IA group than in the ISB and CCE groups both at rest and on movement. The ROD were 1.6 +/- 2.3, 3.0 +/- 4.9 and 7.1 +/- 7.9 mg morphine equivalent dose in groups CCE, ISB, and IA groups (P = 0.001), respectively, and statistically significant differences were noted between the CCE and IA groups (P = 0.01) but not in between the ISB and CCE groups. CONCLUSIONS: This prospective, randomized study demonstrated that ISB is as effective analgesic technique as a CCE for postoperative pain control in patients undergoing ASS.

A Clinical Experience of Massive Transfusion in a Patient with Cardiac Arrest Resulting from Abdominal Aortic Aneurysm Rupture / 대한수혈학회지

We report on a case of successful management of a patient with abdominal aortic rupture requiring massive blood transfusion during the peri-operative period. The patient had fully recovered 19 days after the operation, through intra-operative cardiac arrest and massive transfusion. We analyze a process of blood transfusion and related complications resulting from massive transfusion in order to establish a treatment for peri-operative patients with hypovolemic shock.

Ultrasound-guided femoral and popliteal sciatic nerve blocks for below knee surgery in patients with severe cardiac disease / 대한마취과학회지

No abstract available.

Prevalence and Predictors of Postoperative Complications in Patients Older Than 80 Years

BACKGROUND: The number of elderly patients undergoing surgery is steadily growing. Therefore, this study was designed to determine the prevalence and predictors of postoperative complications in patients older than 80 years. METHODS: The medical records of 532 patients above 80 years in age who underwent elective or emergent noncardiac surgery between June 2011 and May 2013 were reviewed retrospectively. Preoperative concomitant disease, operation site, anesthetic technique, and postoperative complications were analyzed. RESULTS: A total of 81.4% of the patients had pre-existing concomitant diseases, while 22.9% had severe systemic diseases. The incidence of severe complications within the first month after operation was 4.1%, and the in-hospital mortality rate was 1.3%. Among the severe postoperative complications, respiratory and cardiovascular complications were commonly observed. In multivariate logistic regression analysis, the predictors of postoperative severe complications included American Society of Anesthesiologists physical status classification of 3 or greater (odds ratio [OR], 5.271; 95% confidence interval [CI], 2.019-13.758; p=0.001), neurosurgery (OR, 23.132; 95% CI, 2.528-211.707; p=0.005) and duration of operation (OR, 1.006; 95% CI, 1.001-1.012; p=0.027). CONCLUSION: Proper preoperative evaluation and appropriate treatment for age-related concomitant diseases are suggested for patients older than 80 years in order to reduce postoperative complications. After operation, the respiratory and cardiovascular systems should be carefully monitored.

Anatomic Variations of Cervical and High Thoracic Ligamentum Flavum / 대한통증학회지

BACKGROUND: Epidural blocks are widely used for the management of acute and chronic pain. The technique of loss of resistance is frequently adopted to determine the epidural space. A discontinuity of the ligamentum flavum may increase the risk of failure to identify the epidural space. The purpose of this study was to investigate the anatomic variations of the cervical and high thoracic ligamentum flavum in embalmed cadavers. METHODS: Vertebral column specimens of 15 human cadavers were obtained. After vertebral arches were detached from pedicles, the dural sac and epidural connective tissue were removed. The ligamentum flavum from C3 to T6 was directly examined anteriorly. RESULTS: The incidence of midline gaps in the ligamentum flavum was 87%-100% between C3 and T2. The incidence decreased below this level and was the lowest at T4-T5 (8%). Among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. CONCLUSIONS: The cervical and high thoracic ligamentum flavum frequently has midline intervals with various features, especially in the caudal portion of the intervertebral space. Therefore, the ligamentum flavum is not always reliable as a perceptible barrier to identify the epidural space at these vertebral levels. Additionally, it may be more useful to insert the needle into the cephalic portion of the intervertebral space than in the caudal portion.

Analysis of Transfusion of Packed RBC in Elderly Patients Over 75 Years in Bipolar Hemiarthroplasty / 대한수혈학회지

BACKGROUND: Bipolar hip hemiarthroplasty (BH) was known to require a large amount of transfusion. And, patients who underwent BH were extreme old age and had underlying medical diseases such as hypertension and diabetes mellitus. The aim of this study was to evaluate packed RBC (Red blood cell) transfusion and pre- and intraoperative variables during BH in elderly patients over 75 years in one university hospital. METHODS: A total of 36 patients who underwent BH from September 2013 to August 2014 in our hospital were evaluated through a retrospective study using computerized medical records and archived documents. RESULTS: Average age of patients was 81.5+/-5.3 years and packed RBC transfusion was performed in 41.6% of all enrolled patients. There was no significant difference in age, weight, height, and time of operation between transfused patients and non-transfused patients. Intraoperative volume of packed RBC transfusion was 0.6 (minimum value: 0, maximum value: 4) units. CONCLUSION: Preparation of blood components such as packed RBC is required in elderly patients over 75 years who were planned BH.