Résumé
PURPOSE: Surgeons may be uncertain about the optimal timing of appendectomy to decrease complications, especially for complicated appendicitis. The aim of the study was to compare clinical outcomes between early and late surgery for complicated appendicitis. METHODS: A prospectively maintained database of complicated appendicitis was queried. Elective interval surgery (EIS) group and early surgery (ES) were matched with propensity score and marked with a prefix ‘p.’ Patient characteristics and surgical outcomes were compared. RESULTS: The propensity score-matched EIS group had a lower chance to underwent ileo-cecectomy or right hemicolectomy (1.5% vs. 6.9%, P = 0.031), a tendency of lower rate of postoperative complication (6.9% vs. 13.7%, P = 0.067), a lower rate of wound infection (1.5% vs. 8.4%, P = 0.010), and shorter postoperative hospital stay (3.72 days vs. 5.82 days, P < 0.001) than the propensity score-matched ES group. Multivariate analysis showed that delayed surgery for more than 48 hours or urgent surgery due to failure of EIS and open conversion were independent risk factors for postoperative complications (P = 0.001 and P = 0.025, respectively). In subgroup analysis, high American Society of Anesthesiologists physical status classification and distant abscess or generalized ascites in initial CT increased the risk of failure of EIS. CONCLUSION: EIS can be a useful option for selected adult patients with complicated appendicitis.
Sujets)
Adulte , Humains , Abcès , Appendicectomie , Appendicite , Ascites , Classification , Durée du séjour , Analyse multifactorielle , Complications postopératoires , Score de propension , Études prospectives , Facteurs de risque , Chirurgiens , Infection de plaieRésumé
PURPOSE: Laparoscopic adhesiolysis is increasingly used to treat patients with small bowel obstruction (SBO), however, its safety of laparoscopic surgery(LS) with bowel resection in SBO is unclear. The purpose of the present study was to compare the perioperative outcomes of LS with those of open surgery (OS) for SBO and to evaluate the risk factors of 30-day postoperative morbidity and recurrence. METHODS: We retrospectively reviewed medical records of patients who had been diagnosed with SBO and underwent surgery at four Hallym-University-affiliated hospitals between January 2013 and December 2016. The rates of 30-day postoperative complications and recurrence were compared between groups using univariate and multivariate analysis. Propensity score matching was performed to compare the outcome. RESULTS: A total of 117 patients with SBO were included in the present study, of which 86 underwent OS and 31 underwent LS. Time to water intake, time to soft diet, and postoperative hospital stay were significantly shorter in the LS group (p=0.002, 0.003, and 0.027, respectively). The complication (p=0.249) and recurrence rate (p=0.679) were similar between the two group. Propensity score matching analysis demonstrated that laparoscopic surgery showed quicker recovery and similar complication and recurrence rate. In multivariate analysis, LS was not associated with either complications (p=0.806) or recurrence (p=0.956). CONCLUSION: LS is associated with several perioperative advantages for the treatment of SBO without affecting the risk of 30-day postoperative complications or recurrence. Therefore LS can be a safe and feasible option for treating SBO.
Sujets)
Humains , Régime alimentaire , Consommation de boisson , Laparoscopie , Durée du séjour , Dossiers médicaux , Analyse multifactorielle , Complications postopératoires , Score de propension , Récidive , Études rétrospectives , Facteurs de risqueRésumé
Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.
Sujets)
Adulte , Animaux , Femelle , Humains , Rats , Artère carotide externe , Déglutition , Endoscopie , Perforation de l'oesophage , Oesophage , Études de suivi , Lambeaux tissulaires libres , Enrouement , Jéjunum , Veines jugulaires , Artère mésentérique supérieure , Microchirurgie , Lésions du nerf laryngé récurrent , Rupture , Emphysème sous-cutané , Chirurgiens , Thyroïdectomie , Transplants , Veines , Paralysie des cordes vocalesRésumé
In colorectal carcinoma, poorly differentiated clusters (PDCs) are a poor prognostic indicator and show morphological continuity and behavioral similarities to micropapillary patterns (MPPs) as well as tumor buds (TBs). Epithelial-mesenchymal transition (EMT) and inhibition of cancer-stromal interactions may contribute to the development of PDCs. To clarify the biological nature of PDCs, we examined immunohistochemical stainings for β-catenin, Ki-67, E-cadherin, epithelial cell adhesion molecule (EpCAM), MUC1, and epithelial membrane antigen (EMA), which are associated with EMT and cancer-stromal interactions. The expression frequencies and patterns of PDCs, TBs, and differentiated neoplastic glands from the tumor center (TC) were compared. In the study group (117 cases), the nuclear β-catenin staining index was higher in PDCs (37.3%) and TBs (43.3%) than in neoplastic glands from TC (8.9%, P < 0.001). The mean Ki-67 labeling index in TC was 71.5%, whereas it was decreased in PDCs (31.2%) and TBs (10.2%, P < 0.001). E-cadherin and EpCAM displayed a tendency to be found along the cell membrane in TC samples (91.5% and 92.3%, respectively), whereas they showed loss of membranous staining in PDC (44.4% and 36.8%, respectively) and TB samples (60.7% and 68.4%, respectively). An inside-out pattern for MUC1 and EMA was frequently observed in PDC (48.7% and 45.3%, respectively) and TB samples (46.2% and 45.3%, respectively), but not in TC samples. Our data demonstrate that there is a pathogenetic overlap among PDCs, TBs, and MPPs and suggest that they might represent sequential growth patterns that branch from common biological processes such as dedifferentiation and alteration in cancer-stromal interactions.
Sujets)
Adénocarcinome , Phénomènes biologiques , Cadhérines , Membrane cellulaire , Tumeurs colorectales , Cellules épithéliales , Transition épithélio-mésenchymateuse , Mucine-1Résumé
No abstract available.
Sujets)
Humains , Colectomie , Côlon , Tumeurs du côlon , EndoprothèsesRésumé
Differentiation-based histologic grading of colorectal carcinoma (CRC) is widely used, but its clinical impact is limited by insufficient prognostic value, interobserver disagreement, and the difficulty of its application to CRC with specific histologic types such as mucinous and medullary carcinoma. A recently proposed novel grading system based on quantifying poorly differentiated clusters (PDCs) claims to have the advantages of reproducibility and improved prognostic value, and might apply to heterogeneous CRC. We aimed to validate the clinicopathologic significance of the PDCs-based grading system and to determine the relationship between this grading system and microsatellite instability (MSI). Two hundred and one patients who had undergone radical surgery were reviewed. Based on the number of PDCs, 85, 58, and 58 tumors were classified as grade (G) 1 (42.3%), G2 (28.9%), and G3 (28.9%), respectively. PDCs-based grade was significantly associated with T, N, and M stages; lymphovascular invasion; conventional histologic grade; and frequent tumor budding (all P <0.001). In multivariate analysis, PDCs-based grade was found to be an independent prognostic factor for disease-free survival (P = 0.022; hazard ratio, 3.709 [G2], 7.461 [G3]). G3 CRC significantly correlated with high MSI (MSI-H) compared to G1 and G2 (P = 0.002; odds ratio, 5.750). In conclusion, this novel grading would provide valuable prognostic information to a greater number of patients and would require continued verification. PDCs-based grading is feasible for CRCs with heterogeneous morphology, and we propose that the association between G3 and MSI-H be further evaluated in different histological subtypes of CRC.
Sujets)
Femelle , Humains , Mâle , Adulte d'âge moyen , Tumeurs colorectales/génétique , Survie sans rechute , Métastase lymphatique/anatomopathologie , Instabilité des microsatellites , Grading des tumeurs/méthodes , Charge tumorale/physiologieRésumé
PURPOSE: We applied a long Roux-en-Y (RY) gastrojejunostomy (bypassed jejunum over 100 cm) as a reconstruction method for diabetes control to gastric cancer patients with type 2 diabetes and body mass index (BMI) < 35 kg/m2. The effect of this procedure on diabetes control was assessed. METHODS: We prospectively performed modified RY gastrojejunostmy after curative radical distal gastrectomy. Thirty patients had completed a 1-year follow-up. Patients were followed concerning their diabetic status. The factors included in the investigation were length of bypassed jejunum, BMI and its reduction ratio, glycated hemoglobin (HbA1c), fasting blood glucose, and duration of diabetes. Diabetic status after surgery was assessed in three categories: remission, improvement, and stationary. In evaluation of surgical effects on diabetes control, remission and improvement groups were regarded as effective groups, while stationary was regarded as an ineffective group. RESULTS: At postoperative one year, statistical significance was observed in the mean BMI and HbA1c. Diabetes control was achieved in 50% of the patients (remission, 30%; improvement, 20%). BMI reduction ratio, preoperative HbA1c, and duration of diabetes were correlated to the status of type 2 diabetes mellitus. The preoperative HbA1c was the most influential predictor in diabetic control. CONCLUSION: The effect of long RY gastrojejunostomy after gastrectomy for diabetes control could be contentious but an applicable reconstruction method for diabetes control in gastric cancer patients with type 2 diabetes and BMI < 35 kg/m2. Diabetes remission is expected to be higher in patients with greater BMI reduction, short duration of diabetes, and lower preoperative HbA1c.
Sujets)
Humains , Anastomose de Roux-en-Y , Chirurgie bariatrique , Glycémie , Indice de masse corporelle , Diabète de type 2 , Jeûne , Études de suivi , Gastrectomie , Dérivation gastrique , Hémoglobine glyquée , Jéjunum , Études prospectives , Tumeurs de l'estomacRésumé
PURPOSE: Ductal carcinoma in situ (DCIS), unlike invasive ductal carcinoma, does not require sentinel lymph node biopsy or axillary lymph node dissection because the possibility of axillary lymph node metastasis is low. However, occasionally, despite preoperative diagnosis of DCIS, invasive ductal carcinoma can be diagnosed by postoperative biopsy. Therefore, a study of the associated risk factors is necessary. METHODS: 198 patients with an initial diagnosis of DCIS, treated between February 2005 and December 2009, were retrospectively analyzed. Associations between clinical and pathologic factors were analyzed for significance using univariate and multivariate analyses. RESULTS: Of the 198 patients, 57 (28.8%) were found to have invasive disease on final pathology. Multivariate analysis revealed 4 independent predictors of invasive cancer upon final pathology: diagnosis by needle biopsy (OR, 3.165; P=0.008), positive p53 on preoperative biopsy (OR, 2.494; P=0.019) DCIS size (>2 cm) on microscopic finding (OR, 2.683; P=0.014), and relatively young age (OR, 0.958, P=0.046). Of the 13 patients with positive axillary lymph nodes, 11 (84.6%) were shown to have invasive cancer on final pathology (P<0.001). CONCLUSION: In cases of preoperative diagnosis based on needle biopsy, positive p53, large tumor, and relatively young age, an SLNB procedure can be considered because in almost 30% of the patients an invasive carcinoma is found after surgery.
Sujets)
Humains , Biopsie , Ponction-biopsie à l'aiguille , Région mammaire , Tumeurs du sein , Carcinome canalaire , Carcinome intracanalaire non infiltrant , Lymphadénectomie , Noeuds lymphatiques , Analyse multifactorielle , Métastase tumorale , Nitriles , Pyréthrines , Études rétrospectives , Facteurs de risque , Biopsie de noeud lymphatique sentinelleRésumé
Malignant fistula of the small bowel to the colon is rare and is most often due to adenocarcinoma. Small bowel lymphoma is unusual, representing less than 1 percent of all gastrointestinal malignancies. We report a case of intestinal lymphoma presenting with diarrhea and abdominal pain. A jejunocolic fistula was discovered during colonoscopy. Celiotomy revealed a large, ulcerated fistula tract between the jejunum and distal transverse colon, and pathology was consistent with peripheral T-cell lymphoma. This is a rare entity in a nonimmunocompromised individual and has not been previously described in Korea.
Sujets)
Douleur abdominale , Adénocarcinome , Côlon , Côlon transverse , Coloscopie , Diarrhée , Fistule , Jéjunum , Corée , Lymphomes , Lymphome T , Lymphome T périphérique , UlcèreRésumé
PURPOSE: Inhalation injury is one of the most severe morbidity and mortality factors in burn patients. The purpose of this study is to analyze the impact of inhalation injury to the prognosis of burn patients and to investigate the relationship between the inhalation injury assessment and the prognosis of patients. METHODS: Bronchoscopy was performed in 170 patients who had the suspicion of inhalation injury and the patients were reviewed retrospectively from January 2008 to December 2009. Mortality was compared between the factors of brochoscopic findings, age, total body surface area (TBSA) burned, carboxyhemoglobin (COHb) level, PaO2/FiO2 (P/F) ratio. RESULTS: Of 170 patients, 28 patients had no inhalation bronchoscopic finding. 109 patients had mild inhalation, 31 patients had moderate inhalation, only 2 patients had severe inhalation findings. The patients of moderate and severe inhalation findings had higher mortality (48.5%) than mild inhalation patients (31.1%). The larger total burnsurface area in inhalation patients, the greater the mortality. When compared to total admitted burn patients during the same period, inhalation patients showed higher mortality in the patients between 10 to 40% total burn surface area. Inhalation patients whose P/F ratio was below 300 showed higher mortality than above 300. But inhalation patients whose COHb level was below 1.5 had no difference in mortality with patients above 1.5. The COHb level and P/F ratio was the statistically different factors between inhalation patients and non-inhalation group in the mortality. CONCLUSION: Bronchoscopic findings, age, TBSA burned, P/F ratio were related with mortality in inhalation patients. When the international standardization of bronchoscopic classification developed, it can be possible to assess the inhalation patients more objectively and that will lead to the advancement in inhalation treatment and research.