Predictors for Amputation in Patients with Diabetic Foot Wound

PURPOSE: Diabetic foot wound (DFW) is known as a major contributor of nontraumatic lower extremity amputation. We aimed to evaluate overall amputation rates and risk factors for amputation in patients with DFW. MATERIALS AND METHODS: From January 2014 to December 2017, 141 patients with DFW were enrolled. We determined rates and risk factors of major amputation in DFW and in DFW with peripheral arterial occlusive disease (PAOD). In addition, we investigated rates and predictors for amputation in diabetic foot ulcer (DFU). RESULTS: The overall rate of major amputation was 26.2% in patients with DFW. Among 141 DFWs, 76 patients (53.9%) had PAOD and 29 patients (38.2%) of 76 DFWs with PAOD underwent major amputation. Wound state according to Wagner classification, congestive heart failure, leukocytosis, dementia, and PAOD were the significant risk factors for major amputation. In DFW with PAOD, Wagner classification grades and leukocytosis were the predictors for major amputation. In addition, amputation was performed for 28 patients (38.4%) while major amputation was performed for 5 patients (6.8%) of 73 DFUs. Only the presence of osteomyelitis (OM) showed significant difference for amputation in DFU. CONCLUSION: This study represented that approximately a quarter of DFWs underwent major amputation. Moreover, over half of DFW patients had PAOD and about 38.2% of them underwent major amputation. Wound state and PAOD was major predictors for major amputation in DFW. Systemic factors, such as CHF, leukocytosis, and dementia were identified as risk factors for major amputation. In terms of DFU, 38.4% underwent amputation and the presence of OM was a determinant for amputation.

Amyand Hernia: Sonographic and CT Appearances

Herniation of the appendix into an inguinal canal is known as an Amyand hernia. Due to its nonspecific symptoms, clinical diagnosis is extremely difficult, and an accurate preoperative diagnosis of Amyand hernia with ultrasound (US) and CT is rarely reported. Herein, we reported a typical case of Amyand hernia in a 74-year-old male in which the correct diagnosis was made using inguinal US and contrast-enhanced abdominopelvic CT. US and CT findings of Amyand hernia showed a target-like tubular structure within the inguinal canal.

Adrenal Mass as Initial Presentation of Metastatic Hepatocellular Carcinoma: A Case Report

Metastases from hepatocellular carcinoma (HCC) can be found in the multiple organs including adrenal gland. But adrenal metastasis of HCC without obvious hepatic lesion is very rare. We report CT and MR findings of a patient who presented with adrenal metastasis as the first clinical manifestation of HCC. Signal intensity and enhancement pattern of adrenal metastastic mass of HCC were similar to those of HCC on MRI.

Klebsiella Pneumoniae Multi-organ Abscesses not Accompanied by Liver Abscesses: A Case Report

A Klebsiella pneumoniae infection has a tendency to spread to multiple organs. It is most commonly seen in patients with liver abscesses, but infection in more than three organs without liver abscesses is unusual. We report one case of a K. pneumoniae infection that presented acute pyelonephritis with left perirenal, anterior pararenal, left psoas, and prostate abscesses without liver abscesses in a diabetic patient. With effective antibiotics and ultrasound-guided percutaneous drainage, the patient recovered without significant sequelae.

Two Consecutive Cases of Ampulla of Vater Cancer Combined with Annular Pancreas and Unusual Anatomic Variation

Annular pancreas is a rare congenital anomaly that consists of a ring of pancreatic tissue partially or completely encircling the descending portion of the duodenum. Coexisting ampullary carcinoma in annular pancreas combined with anomaly of hepatic artery or bile duct are thought to be extremely rare. Two consecutive cases of ampullary carcinoma in annular pancreas with bile duct or hepatic artery anomaly are described. In addition, English literature reports of coexisting ampullary carcinoma in annular pancreas are summarized. Clinical symptoms of the two patients were jaundice and abdominal discomfort. The two ampullary cancers were early adenocarcinomas in the ampulla of Vater that were curatively treated by pylorus preserving pancreaticoduodenectomy. Ampullary carcinoma associated with annular pancreas is rare. Its combination with an additional biliary or hepatic artery anomaly make our cases extremely unique. Certain aberrant events in the overall stages of the development of the liver, bile duct, and pancreas may have occurred in these patients. Surgeons need to note preoperatively these possible associated anatomic variations.

The Risk Factors for Extrahepatic Recurrence after Curative Resection of Hepatocellular Carcinoma

PURPOSE: A few studies have been reported on extrahepatic metastasis after curative resection for hepatocellular carcinoma (HCC). We investigated the patterns of extrahepatic recurrence and we identified the risk factors for extrahepatic recurrence after curative resection for HCC. METHODS: We retrospectively reviewed 587 patients who underwent surgical resection with a curative aim from January 1998 to December 2007 in the Yonsei University Health Care System. Among the 571 patients, 291 (51.0%) patients developed recurrence. Sixty five patients initially presented with extrahaptic recurrence. The patients with extrahepatic recurrence were divided into Group A (peritoneal recurrence) and Group B (non-peritoneal extrahepatic recurrence). RESULTS: Group A had higher rates of intraoperative bleeding>1,500 ml and perioperative transfusion too. On the multivariate analysis, perioperative transfusion, satellite nodule and the tumor size were the independent risk factors for Group A. The Edmondson-Steiner grade, satellite nodule and the tumor size were the independent risk factors for Group B. The 1, 3 and 5-year overall survival rates after curative resection for the patients with extrahepatic recurence were 83.1%, 48.9% and 27.4%, respectively. The recurrence patterns and treatment modalities did not affect the overall survival after treatment for extrahepatic recurrence. CONCLUSION: A perioperative transfusion was found to be a different risk factor for peritoneal recurrence, as compared to those risk factors for non-peritoneal extrahepatic recurrence. Therefore, efforts by physicians to decrease intraoperative bleeding may prevent peritoneal recurrence after performing curative resection for HCC.

Renal Carcinoma Cell Metastasis into Pancreas : A Single Center Experience

INTRODUCTION: Renal cell carcinoma (RCC) is a relative rare tumor, accounting for approximately 3% of adult malignancies. Renal cell carcinoma has a high metastatic potential and is renowned for its ability to spread to almost any organ of the body. Pancreas is a rare site for metastasis from other primary cancers. Moreover, pancreatic metastasis is difficult to differentiate and may be misdiagnosed as a primary pancreatic cancer. The aim of this study was to review our cases of renal cell carcinoma that had metastasized to the pancreas after radical nephrectomy. METHODS: We did a retrospective review of the records of 4 patients with pathologically confirmed RCC that had metastasized to the pancreas after radical nephrectomy. RESULTS: Our group of 4 patients consisted of 2 men and 2 women. Their average age was 58.7 years (+/- 10.51 years). The locations within the pancreas were the head, in 2 (50.0%) and the body/tail in 2 (50.0%) patients. The pancreatic metastases were treated by pancreaticoduodenectomy in 2 patients, and by distal pancreatectomy in 2 patients. Median survival duration was 109.0 (+/- 67.3 months) "Median" is associated with an interquartile range (25% to 75%). The number 67.3 appears to be a standard deviation which is associated with the "mean". CONCLUSIONS: RCC is an unpredictable tumor that may result in a late metastasis even from an early stage. Aggressive surgical management of pancreatic lesions offers a chance of long-term survival.

Ki-67 and VEGF as Possible Prognostic Factors in Radically-resected Ampulla of Vater Cancer

PURPOSE: Ampulla of Vater cancer has a more favorable prognosis and survival than other malignant periampullary tumors. The pathologic staging of ampulla of Vater carcinoma is a key determinant of the patient's prognosis. However, we have often encountered patients in whom the course of their disease differed substantially from what would be predicted based on their clinical staging, which highlights the need to consider additional predictive factors. We applied an immunohistochemical technique to examine the expression of Ki-67 and VEGF in radicallyresected ampulla of Vater carcinomas, and then compared the status of expression with several clinicopathologic factors. METHODS: Sixty-four patients who underwent curative resection for ampulla of Vater cancer between January 1992 and December 2006 at the Yonsei University College of Medicine were reviewed. The relationships between the expression of molecular markers and clinicopathologic factors were determined. RESULTS: There was no relationship between the clinicopathologic characteristics and the expression of molecular markers in patients with ampulla of Vater cancer. Among the clinicopathologic characteristics, lymph node metastasis was identified as an independent factor of survival after curative resection for ampulla of Vater carcinoma. CONCLUSION: Measurement of Ki-67 and VEGF in patients with ampulla of Vater carcinoma may have an important role in identifying the poor prognostic group.

Conventional Angiogram versus Multi-detector Row Helical Computed Tomography Angiogram for Preoperative Diagnostic Imaging in Low Extremity Arterial Surgery

PURPOSE: We performed this study to assess the suitability of conventional angiography (CA) vs. multi-detector row helical CT angiogram (MD-CTA) as a method of preoperative diagnostic imaging for low extremity arterial surgery. METHODS: From February 2004 to September 2006, 23 patients (4 claudicants, 19 limb-threatening ischemia) were studied with CA and MD-CTA preoperatively. The site and degree of stenotic or occlusive lesions in arterial segments from the renal artery to the dorsalis pedis artery were compared with both methods. We also compared the surgical inflow and outflow site changes in preoperative planning based on CA and MD-CTA and the final outcome. Additional diagnostic value and test-related complications were also analyzed. RESULTS: The median age of patients was 68 years old (range: 43~89 years), with a male to female ratio of 1.3:1. Twenty-three patients had CA after an MD-CTA scan. One hundred fifty lesions were detected in these patients. The total ratio of consistency for occlusion in CA vs. MD-CTA was 69.6%. Three patients received amputation treatment and eleven patients received a bypass operation. The agreement between the preoperative plan based on MD-CTA and the final operation was 100%, even in critical limb ischemia. There were no serious complications related to the tests. CONCLUSION: These findings suggest that MD-CTA is an adequate preoperative imaging study of infrainguinal arterial surgery and may be substituted for conventional angiography without any serious complications.

Initial Experience with Laparoscopic and DaVinci Robotic-assisted Liver Resection

PURPOSE: Although laparoscopic surgery has become more popular, its technical difficulties have limited the applications of this technique to liver surgery. We report here on our experience with liver resection with perfoming laparoscopic assisted and DaVinci robot assisted hepatectomy. METHODS: We retrospectively evaluated 40 patients who underwent laparoscopic assisted and DaVinci robotic assisted hepatectomy at the Yonsei University Health System from January 2002 to January 2008. RESULTS: Thirty patients (75%) had malignancy and ten patients (15%) had benign disease. We performed Lt. hepatectomy (7.5%), wedge resection (17.5%), segmentectomy (30%) and Lt. lateral segmentectomy (45%). The rate of conversion to laparotomy was due to intraoperative bleeding was 10%. The complication and mortality rates were 7.5% and 0%, respectively CONCLUSION: Laparoscopic and DaVinci robot hepatectomy showed a reduced time to oral intake, a shortened hospital stay and a smaller incisional scar compared to open surgery. So, laparoscopic and DaVinci robot hepatectomy should be performed in selected patients as the postoperative status of the patients is better than that with performing open hepatectomy.

Aggressive Angiomyxoma in Female Pelvic Cavity: A Case Report

Aggressive angiomyxoma is a rare neoplasm occurring in the female pelvic cavity or perineum, and tends torecur. The radiographic findings of angiomyxoma have not been previously reported in Korea ; we describe a case ofaggressive angiomyxoma in the female pelvic cavity, with emphasis on the pathologic and radiologic findings, andreview the literature.