Associated Factors with Parenteral Nutrition Associated Cholestasis in Neonates / 소아외과

PURPOSE: Long time total parenteral nutrition (TPN) can induce irreversible liver damage. In this study, we investigated the associated factors of parenteral nutrition associated cholestasis (PNAC) in neonates. METHODS: We retrospectively reviewed 227 neonates (male:female=110:117) those who had received TPN over 2 weeks from March 2010 to February 2014. PNAC was defined as direct bilirubin was higher than 2.0 mg/dL without any cause except TPN. RESULTS: Overall incidence was 28.6%. PNAC was frequently developed in younger gestational age with lower birth weight. Episodes of sepsis, underlying bronchopulmonary dysplasia, history of necrotizing enterocolitis, and experience of gastrointestinal surgery increase the incidence of PNAC. PNAC was directly associated the duration of TPN and long period to full enteral feeding, reaching 60 and 150 mL/kg/day. Overall mortality rate was 9.7%. It was higher in PNAC group despite PNAC was not the primary cause of death. All survivors were recovered from cholestasis with encourage of enteral nutrition. CONCLUSION: PNAC in neonate was associated with younger gestational ages and lower birth weights, duration of TPN, or who experienced sepsis, necrotizing enterocolitis, gastrointestinal surgery or bronchopulmonary dysplasia.

Acute acalculous cholecystitis after laparoscopic appendectomy in a young healthy patient: report of a case

Acute acalculous cholecystitis (AAC) is defined as acute inflammation of the gallbladder in the absence of gallstones. AAC occurs in patients after major surgery and in the presence of serious co-morbidities such as severe trauma, burns, sepsis, prolonged intravenous hyperalimentation and hemodynamic instability. AAC is rare in patients with none of the established risk factors. We present a case of a 38-year-old woman who developed AAC after laparoscopic appendectomy.

Clinicopathologic Features of Papillary Thyroid Carcinoma Coexisting with Hashimoto's Thyroiditis / 대한내분비외과학회지

PURPOSE: Hashimoto's thyroiditis (HT) is an important cause of hypothyroidism caused by autoimmune chronic lymphocytic thyroiditis. In order to attain a better understanding for use in treatment of papillary thyroid carcinoma (PTC) coexisting with HT, we conducted an analysis of the clinicopathologic features, as well as the importance of HT as a prognostic factor. METHODS: In this retrospective study, we analyzed 341 patients who were histopathologically diagnosed with PTC following surgery. RESULTS: PTC coexisting with HT was observed in 19.6% (67 patients) of all PTC patients. A statistically significant gender difference was observed in the group with HT (two male vs. 65 female), with a higher positive rate of anti-thyroglobulin antibody and smaller tumor size, compared to the PTC group without HT. When tumor size increased, a lower coexistence rate of HT was observed. No significant differences were observed in multifocality, cervical lymph node (LN) metastasis, coexistence of benign nodule, and extent of LN dissection. However, frequency of extrathyroidal extension was significantly lower and total thyroidectomy rate was higher in the group with HT. TNM stage and AMES stage were similar in both groups; frequency of high MACIS score showed a significant decrease in the group with HT. The recurrence rate and disease- free survival in patients with PTC were not significantly affected by coexistence of HT. CONCLUSION: We found a significant relationship with gender, extrathyroidal extension, and tumor size in PTC coexisting with HT. However, no significant differences in recurrence rate and disease-free survival were observed between groups. Therefore, coexistence in PTC could not be applicable as a prognostic factor of PTC.

Right Diaphragmatic Rupture after Blunt Trauma: Case Report

Blunt diaphragmatic rupture (BDR) is a relatively rare injury and occurs in 0.8% to 7% of all thorocoabdominal blunt trauma. Especially right diaphragmatic rupture after blunt abdominal trauma is a rarer than left. The diagnosis of BDR can be missed while evaluating the multiple trauma patient. Other severe injuries may mask BDR during the primary resuscitation and survey. We experienced two cases of traumatic rupture of right diaphragm, one diagnosed immediately and the other diagnosed delayed. In this paper we present two cases of traumatic diaphragmatic rupture.

Malignant Fibrous Histiocytoma Originating in the Short-term after Excision

MFH is rare with just a few thousand cases diagnosed each year. We report a case of right flank malignant fibrous histiocytoma (MFH) in the short-term after tumor excision. A 47-year-old woman visited hospital after being diagnosed with MFH. Resection margin was positive, so we planned for wide excision. While awaiting surgery, 1.5 cm sized new mass occurred adjacent to the incision site. The patient underwent wide excision. Postoperative pathologic findings observed a 1.0 cm diameter mass with infiltrative borders in the subcutaneous fat. It was composed of spindle or epithelial cell showing severe polymorphism. Many mitotic cells were observed including atypia. In immunohistochemical study, tumor cells were negative for smooth muscle actin, desmin, myoglobin, S100, cytokeratin, and positive for CD68, and thus diagnosed as pleomorphic MFH. With the purpose of improving local tumor control, radiation therapy was performed after wide excision.

Treatment of Ongoing Bleeding after a Damage Control Laparotomy for a Pelvic Bone Fracture: Arterial Embolization: A Case Report

Massive bleeding due to traumatic pelvic bone fracture is a leading cause of death. Thus, several methods to control bleeding have been attempted, but none of these has yet been clearly established. After an automobile accident, a 34-year-old motorist was admitted to the Emergency Department for right hip,leg and abdominal pain. Because the patient's pressure remained consistently low and pelvic bone fracture and abdominal bleeding were found on radiologic examination, an explorative laparotomy was performed. After pelvic packing and bleeding control, bleeding still continued, so Angiography was performed, and arterial embolization for bleeding was performed.

Serious Bleeding Complication Due to the Use of Low-molecular-weight heparin to treat a Traumatic Patient with Acute Renal Failure

Trauma is an important risk factor for a pulmonary thromboembolism, and anticoagulation is essential to prevent deep vein thrombosis (DVT) in patients with trauma. Low-molecular-weight heparin (LMWH) is excreted in the kidney; therefore, using LMWH in patients with renal insufficiency may increase the risk of bleeding complication. The following case describes a 55-year-old traffic accident victim who had massive bleeding and underwent a laparotomy for bleeding control. The patient had acute renal failure, and enoxaparin was administered for the prophylaxis of DVT. Although the patient suffered from serious complications such as pericardial hematoma, the patient recovered without sequellae and was discharged at day 84.

Treatment of Ongoing Bleeding after a Damage Control Laparotomy for a Pelvic Bone Fracture: Arterial Embolization: A Case Report

Massive bleeding due to traumatic pelvic bone fracture is a leading cause of death. Thus, several methods to control bleeding have been attempted, but none of these has yet been clearly established. After an automobile accident, a 34-year-old motorist was admitted to the Emergency Department for right hip,leg and abdominal pain. Because the patient's pressure remained consistently low and pelvic bone fracture and abdominal bleeding were found on radiologic examination, an explorative laparotomy was performed. After pelvic packing and bleeding control, bleeding still continued, so Angiography was performed, and arterial embolization for bleeding was performed.

Serious Bleeding Complication Due to the Use of Low-molecular-weight heparin to treat a Traumatic Patient with Acute Renal Failure

Trauma is an important risk factor for a pulmonary thromboembolism, and anticoagulation is essential to prevent deep vein thrombosis (DVT) in patients with trauma. Low-molecular-weight heparin (LMWH) is excreted in the kidney; therefore, using LMWH in patients with renal insufficiency may increase the risk of bleeding complication. The following case describes a 55-year-old traffic accident victim who had massive bleeding and underwent a laparotomy for bleeding control. The patient had acute renal failure, and enoxaparin was administered for the prophylaxis of DVT. Although the patient suffered from serious complications such as pericardial hematoma, the patient recovered without sequellae and was discharged at day 84.

Cox-2 Expression in Malignant Breast Tumors

PURPOSE: Cox-2 expression in breast carcinoma has been reported to be related to angiogenesis, lymph node metastasis and Her-2 expression. The aim of this study is to evaluate the clinicopathologic significance of Cox-2 expression in the invasive ductal carcinomas (IDC) and intraductal carcinomas (DCIS) of the breast. METHODS: The materials were 353 IDC cases and 82 DCIS cases. Immunohistochemical stain for Cox-2 was interpreted as 1+ (weak & focal) and 2+ (diffuse), and the relationships between Cox-2 and ER, PR, Her-2, p53, Ki-67 and bcl-2 expressions were analyzed. RESULTS: There was no significant difference of Cox-2 expression between IDC (148/353, 41.9%) and DCIS (38/82, 46.3%). Cox-2 (2+) expression was more frequent in low grade than intermediate and high grade IDC, but the difference was not significant statistically (P=0.0833), and there were no significant differences of Cox-2 expression according to age, tumor size, nuclear grade, lymph node metastasis in IDC and DCIS cases. In IDC cases, Cox-2 (1+ and 2+) expression showed positive relationships with p53 (+) and more than 10% of Ki-67 labeling index (P=0.0029, P=0.0015), and revealed tendencies of positive relationships with ER (+) and bcl-2 (+) (P=0.0750, P=0.0776). However, no significant relationship between Cox-2 and Her-2 expressions was recognized. In DCIS cases, Cox-2 (2+) expression rate was increased in cases showing negative for Her-2 (P=0.0092) and positive for bcl-2 (P=0.0486). CONCLUSION: Cox-2 expression seems to be involved in the development of breast carcinomas, but not related to the invasiveness. Cox-2 expression, especially 2+, in the DCIS cases suggest a possibility of less aggressive biological behavior.

The Effects of Obesity on Laparoscopy-Assisted Distal Gastrectomy and Conventional Open Gastrectomy in Patients with Early Gastric Cancer

PURPOSE: The aim of this study was to assess the short-term results of conventional open distal gastrectomy (ODG) and laparoscopy-assisted distal gastrectomy (LADG) in obese patients with early gastric cancer. METHODS: This study included 28 consecutive patients who underwent LADG and 33 patients who underwent ODG for early gastric cancer. The patients were divided into two groups: obese (body mass index, BMI> or =25) and non-obese (BMI<25). Patient characteristics, operative details, and postoperative outcomes were analyzed and compared between the two groups. RESULTS: The operation time was longer in LADG patients than in ODG patients. In the LADG group, the high BMI subset required significantly longer operative time than the low BMI subset. The number of retrieved lymph nodes, average perioperative hemoglobin concentration, serum albumin, first flatus, and postoperative WBC count were similar between the two groups. Regarding ODG patients, the mean perioperative decrease in hemoglobin concentration was significantly greater in the high BMI subset. The difference in operative time between the ODG/high BMI subset and the ODG/low BMI subset was not statistically significant. CONCLUSION: Obesity has differing effects on LADG and on ODG, and this should be considered when deciding what procedure to utilize in patients with early gastric cancer. Further research is needed to better elucidate the relationship between obesity and gastrectomy for early gastric cancer.

Clinical Significance of Serum Carcinoembryonic Antigen (CEA) Level at Diagnosis of Liver Metastases in Patients with Colorectal Cancer

PURPOSE: In numerous clinical trials to stratify prognosis of patients with liver metastases (LM) from colorectal cancer (CRC), the clinical value of serum carcinoembryonic antigen (CEA) levels at diagnosis of LM has not been fully investigated in these group. The aim of this study is to explore the relation of CEA to characteristics of LM and to analyze prognostic value of this widely used tool. METHODS: We retrospectively analyzed clinical data of 143 LM patients who were performed surgical intervention or non-surgical intervention. The cohort was divided into two groups; normal CEA group (NCEAG, or =5 ng/ml, n=102). We examined correlation between serum CEA at diagnosis of LM and other clinicopathologic factors and performed univariate and multivariate analyses to determine the clinical impact of this marker on survival. RESULTS: Compared to ECEAG, the characteristics of LM of NCEAG was associated with unilobar distribution of LM (P=0.003), less metastases (P<0.001), less rate of synchronocity (P=0.008) and more surgical intervention of hepatic deposits (P<0.001). The 5-year survival rate for NCEAG was better than ECEAG (P=0.031). Multivariate analysis revealed that the presence of lymphatic duct invasion, no performance of chemotherapy, bilobar distribution of LM, and treatment of non-surgical intervention had a significant effect on survival. CEA elevation was identified as independently associated with bilobar distribution and non-surgical intervention of LM. CONCLUSIONS: Although CEA level is not a independent prognostic factor in this study, the clinical characteristics identified in this study and correlation to non surgical intervention of LM may help better patient selection in the management of CRC LM patients.

Peutz-Jeghers Syndrome Associated with Jejuno- jenunal Intussusception

Peutz-Jeghers syndrome (PJS) is a rare hereditary disease where the clinical manifestations are multiple harmatomatous gastrointestinal polyps and pigmentations of the skin. A harmatomatous polyp can develop at any part of the gastrointestinal tract, and the proximal small bowel is frequently involved. Intestinal obstruction, bleeding and intussusception, caused by GI polyps have been reported, which often require repeated surgery. A female patient presented with suffering of abdominal pain for two days duration. The patient was diagnosed with intussusception, and a resection and anastomosis of the small bowel was performed. The patient was treated for 15 days, and was discharged from the hospital without any particular complications. We report this case with a review of the literature.

Spontaneous Disappearance of Microcalcifications in Breast Papillary Carcinoma: Case Report

Spontaneous disappearance of breast calcification has rarely been reported. The majority of cases of spontaneously resolving calcifications have been concerned with benign processes. We report here on breast papillary carcinoma that showed spontaneously resolving microcalcifications without newly developed parenchymal changes on the follow-up mammogram.

Loop Colostomy with Not Everted Fashion for Rectal Cancer

PURPOSE: An anastomotic leak after resection of rectal cancer is a omnious complication. The diverting stoma is performed to avoid this serious complication. However, a diverting stoma and a stoma reversal are associated with significant morbidity and a small mortality. As stoma-related complications are associated with a delay of adjuvant therapy for advanced rectal cancer, minimal stoma-related morbidity is mandatory for rectal cancer patients. A safe and simple dissection of the stoma is known to be associated with less morbidity at stoma closure. Since in a loop colostomy of a not everted fashion, it is easy to construct and dissect the peristomal site at colostomy reversal, this study evaluated the usefulness of a protective loop colostomy of a not everted fashion in rectal cancer. METHODS: We reviewed the clinical records of 71 cases of loop colostomy closure for rectal cancer between January 1996 and December 2004. The clinical data, including indications for the stoma, the clinicopathologic features of the patients and their general conditions, the data for patients receiving adjuvant therapy, stoma-related morbidity, stoma-closure-related morbidity, and perioperative data were examined. RESULTS: Indications for stoma creation are the discretion of the surgeon (n=22), poor bowel preparation (n=21), unstable anastomosis (n=16), bowel obstruction (n=6), and anastomotic leakage (n=6). The stoma-related morbidity rate for a non-eversion colostomy was 5.6%. Morbidity events were peristomal erythema (n=2), prolapse (n=1), and parastomal hernia (n=1) requiring surgery. The stoma-closure-related morbidity rates was 9.9%. In the 45 patients undergoing adjuvant therapy, colostomy closure was performed during adjuvant therapy in 39 patients. Major complications, such as anastomotic leakage or abscess following reversal of the non-eversion colostomy, occurred in 1 of the 71 patients (1.4%). The average operating time and the blood loss for clostomy closure were 89.5 minutes and 202.3 ml, respectively. A simple closure of the loop colostomy was performed in 51 patients (71.8%). CONCLUSIONS: Based on our results, a non-eversion colostomy may be considered due to the ease of construction and reversal if a temporary diverting stoma for rectal cancer is indicated.

Collision Tumor in the Gastric Stump after Radical Subtotal Gastrectomy

Collision tumors is rare entities in which two distinct primary tumors develop in contiguity. They may arise as independent tumors in the same organ or in adjacent organs. The occurrence of a collision tumor in the stomach, consisting of adenocarcinoma and neuroendocrine tumor, is extremely rare. We report a case of a patient, who had undergone a radical subtotal gastrectomy for gastric cancer 3 year earlier, and an ulcerating tumor of the gastric stump had developed. A total resection of the remnant stomach was performed, and the pathological examination revealed a collision tumor consisting of an adenocarcinoma and a neuroendocrine tumor. The coexistence of both adenocarcinoma and neuroendocrine tumor of the gastric stump has never been reported. The authors present this case and a review of the relevant literature.

Radical Subtotal Gastrectomy in Early Gastric Cancer Patient with Situs Inversus Totalis

Situs inversus totalis is a complete mirror image of the thoracic and abdominal viscera. There are many cases of malignant neoplasms being found in patients with situs inversus totalis. We report a case of situs inversus totalis with an early gastric cancer. The patient was a 50-year-old woman who presented with epigastric discomfort with a one-month duration. The chest X-ray showed dextrocardia and the abdomen CT revealed situs inversus totalis with wall thickening of the gastric antrum. The resected specimen showed a 2 cm sized eroded lesion in the antrum. Histologically, gastric cancer was diagnosed as a well differentiated tubular adenocarcinoma that was confined to the mucosal layer. The patient was treated successfully with a radical subtotal gastrectomy, even though situs inversus totalis was not familiar to the surgeon.

Tumor Necrosis Factor-alpha-308G/A Promoter Polymorphism is Associated with the Severity of Gastric Carcinomas

PURPOSE: The pro-inflammatory cytokine, tumor necrosis factor-alpha (TNF-alpha), is a central mediator of the immune response involved in a wide range of immuno-inflammatory and infectious diseases. There is increasing evidence that TNF-alpha may promote the development and spread of the cancer. Polymorphisms in the TNF-alpha promoter have been related to TNF-alpha production. Therefore, we investigated the potential association of TNF-alpha genotypes with gastric cancer in the Korean population. METHODS: The study included 66 patients with gastric adenoma, 75 patients with gastric carcinoma, and 551 healthy controls. The -308 and -238 polymorphisms in the TNF-alpha promoter were analyzed by PCR- restriction fragment length polymorphism (RFLP). Distributions of TNF-alpha promoter polymorphisms were compared between groups by chi2 test. P values smaller than 0.05 were considered to be significant. RESULTS: The proportion of individuals carrying the TNF-alpha -308A allele was higher in the carcinoma group compared to controls and adenomas, but the differences were not significant (P=0.124). However, the TNF-alpha -308A allele was significantly associated with advanced gastric carcinoma (P=0.026), serosa invasion (P=0.004), neural invasion (P= 0.021), and lymph node metastasis (P=0.005). On the other hand, the TNF-alpha -238G/A polymorphism was not associated with the development of gastric adenoma and carcinoma and the severity of gastric carcinoma. CONCLUSION: These results suggest that the TNF-alpha -308A allele is associated with the severity of gastric carcinoma in terms of invasion and metastasis in the Korean population. Therefore, TNF-alpha promoter polymorphism could be used as a predictive marker of the severity of gastric carcinoma.

A Case of Strangulated Intussusception Caused by the Small Intestinal Lipoma in Adult / 대한소화기내시경학회지

An intussusception in adulthood is an unusual cause of bowel obstruction. It accounts for up to 5% of all intussusception. Approximately 90% of cases are secondary to a definite lesion such as malignancy or lipoma. Most patients are asymptomatic and the lesion is often detected incidentally at colonoscopy, operation and autopsy. Strangulated intussuscetion is a rare case and also requires emergency operation. A 32-year-old woman visited our emergency room because of severe epigastric pain. Abdominal CT revealed a low density mass in bowel loop and distended small bowel loops filled with fluid. Colonoscopic finding showed huge purple-colored coil-spring lesion in the ascending colon. From this findings, we diagnosed a strangulated intussusception. Surgically removed specimen revealed a small intestinal lipoma.

Bacterial Translocation and Prognosis of Critically Ill Patients

PURPOSE: To identify Bacterial translocation (BT) from the gut to the blood in the critically ill patients by using the polymerase chain reaction (PCR) to confirm the sensitivity of PCR in the detection of intestinal bacterial deoxyribonucleic acid (DNA) in human blood. Further, to determine the relationship between the identification of BT and the prognosis of these patients. METHODS: The oligonucleotide primers used to amplify bacterial DNA from whole blood were the beta-galactosidase (BG) gene of E. coli, DNA coding for 16S ribosomal RNA (16S rRNA), and the glutamine synthase gene of Bacteroides fragilis (BFR). DNA was extracted from the blood of 45 cases of critically ill patients and 10 controls. PCR techniques were used to amplify the genes from E. coli, Bacteroides fragilis, and a region of 16S ribosomal RNA found in many gram-negative and positive bacteria. RESULTS: Bacterial DNA genes were not detected in any of the controls, but were found all in 6 cases of patients with positive blood cultures. Of the 39 cases with no growth in their blood culture, 11 cases in BG and BFR, and 13 cases in 16S rRNA had positive findings in bacterial DNA PCR. Fifteen cases (33%) in BG, 19 cases (42%) in BFR, and 16 cases (35.5%) in 16S rRNA of the critically ill patients had detectable bacterial DNA in their blood. Of those with a positive PCR, MOF developed in 11 cases (57.9%) and of these, 10 subsequently died of MOF. One case (3.8%) in the negative PCR was developed and died of MOF. Patients having positive translocated bacterial DNA had a worse prognosis than the group with a negative DNA. CONCLUSION: In order to confirm BT, the PCR method for detecting bacterial DNA in the blood of critically ill patients is more sensitive than blood cultures. BT from the gut can be a major factor in the development of multiple organ failures in critically ill patients. Therefore, early detection of BT with PCR can play a major role in the treatment of critically ill patients.