Proximal Junctional Kyphosis in Adult Spinal Deformity: Definition, Classification, Risk Factors, and Prevention Strategies

Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.

Revised Electroencephalography Terminology and Clinical Consideration

Electroencephalography (EEG) has been used for decades to evaluate and assess brain function. It is a useful method to diagnose brain disorders. However, confirmed interpretation of EEG is quite challenging because there is no standardized method for EEG reading and this may lead to interrater variability even among expert electroencephalographers. In this background, uniformly accepted nomenclature for EEG pattern were required to improve interrater agreement and to support communication for EEG research. American Clinical Neurophysiology Society (ACNS) established the standardized critical care EEG terminology since 2012 and has recently published the revised 2021 version of EEG terminology. This review covers new concepts of 2021 ACNS EEG terminology and clinical considerations of various EEG patterns.

Two Focal Seizure in a Patient Caused by Different Mechanism

Poststroke epilepsy is the most common cause of epilepsy in adult. Acute symptomatic seizure is a provoked seizure usually caused by systemic metabolic disorders. If stroke patient has a seizure, it is very important to discriminate whether it is a poststroke epilepsy or provoked seizure. The reason is that there are differences in the approach to treatment and the continuation of antiepileptic drugs. We report a stroke mimic patient who had two different mechanisms of focal seizures.

Clinical and radiographic parameters for patients with adult spinal deformity

Improved medical care and increased life expectancy have led to a focus on the impact of adult spinal deformity (ASD) on health-related quality of life (HRQoL) in the field of the spine. Recently, there has been a paradigm shift in the evaluation and management of ASD regarding the important correlation between sagittal imbalance and clinical outcomes.Current Concepts: Loss of lumbar lordosis is recognized as a key driver of ASD followed by forward-leaning of the trunk, reducing thoracic kyphosis, pelvic retroversion, and knee flexion. Radiological assessment has been critical for evaluating ASD from the anteroposterior and lateral view of the whole spine radiograph. Important parameters include coronal, regional, global, and sagittal spinopelvic parameters. Especially, sagittal spinopelvic parameters significantly correlate with disability and HRQoL in patients with ASD, which can influence the process of decision-making with respect to the choice between conservative treatment and surgery.Discussion and Conclusion: Sagittal imbalance has been recently emphasized in patients with ASD. Therefore, the decision-making of ASD treatment should be focused on restoring harmonious alignment to prevent catastrophic complications and improvement of HRQoL.

Adult Spinal Deformity: Current Concepts and Decision-Making Strategies for Management

Adult spinal deformity (ASD) is characterized by three-dimensional abnormalities of the thoracic or thoracolumbar spine that exerts significant impacts on the health-related quality of life (HRQoL). With the important effects that deformity of the sagittal plane exerts on the HRQoL, there have been paradigm shifts in ASD evaluation and management. Loss of lumbar lordosis is recognized as a key driver of ASD followed by reducing kyphosis, pelvic retroversion, and knee flexion. The Scoliosis Research Society (SRS)– Schwab classification reflects the sagittal spinopelvic parameters that correlate pain and disability in ASD patients. Although the SRS–Schwab classification provides a realignment target framework for surgeons, a structured patient-specific systemic approach is crucial for the process of decision-making. ASD management should be focused on restoring age-specific harmonious alignment and should consider the comorbidities and risk factors of each patient to prevent catastrophic complications and enhance the HRQoL.

Adult Spinal Deformity: Current Concepts and Decision-Making Strategies for Management

Adult spinal deformity (ASD) is characterized by three-dimensional abnormalities of the thoracic or thoracolumbar spine that exerts significant impacts on the health-related quality of life (HRQoL). With the important effects that deformity of the sagittal plane exerts on the HRQoL, there have been paradigm shifts in ASD evaluation and management. Loss of lumbar lordosis is recognized as a key driver of ASD followed by reducing kyphosis, pelvic retroversion, and knee flexion. The Scoliosis Research Society (SRS)– Schwab classification reflects the sagittal spinopelvic parameters that correlate pain and disability in ASD patients. Although the SRS–Schwab classification provides a realignment target framework for surgeons, a structured patient-specific systemic approach is crucial for the process of decision-making. ASD management should be focused on restoring age-specific harmonious alignment and should consider the comorbidities and risk factors of each patient to prevent catastrophic complications and enhance the HRQoL.

Neurovascular Compression Confirmed by 3D T2-Weighted Volume Isotropic Turbo Spin-Echo Acquisition Sequence in Trigeminal Neuralgia

No abstract available.

Surgical Strategy for T2 Gallbladder Cancer: Nationwide Multicenter Survey in Korea

BACKGROUND: Although all guidelines suggest that T2 gallbladder (GB) cancer should be treated by extended cholecystectomy (ECx), high-level scientific evidence is lacking because there has been no randomized controlled trial on GB cancer. METHODS: A nationwide multicenter study between 2000 and 2009 from 14 university hospitals enrolled a total of 410 patients with T2 GB cancer. The clinicopathologic findings and long-term follow-up results were analyzed after consensus meeting of Korean Pancreas Surgery Club. RESULTS: The 5-year cumulative survival rate (5YSR) for the patients who underwent curative resection was 61.2%. ECx group showed significantly better 5YSR than simple cholecystectomy (SCx) group (65.4% vs. 54.0%, P = 0.016). For N0 patients, there was no significant difference in 5YSR between SCx and ECx groups (68.7% vs. 73.6%, P = 0.173). Systemic recurrence was more common than locoregional recurrence (78.5% vs. 21.5%). Elevation of cancer antigen 19-9 level preoperatively and lymph node (LN) metastasis were significantly poor prognostic factors in a multivariate analysis. CONCLUSION: ECx including wedge resection of GB bed should be recommended for T2 GB cancer. Because systemic recurrence was more common and recurrence occurred more frequently in patients with LN metastasis, postoperative adjuvant therapy should be considered especially for the patients with LN metastasis.

Sinus Tract Formation with Chronic Inflammatory Cystic Mass after Beta Tricalcium Phosphate Insertion

Beta tricalcium phosphate (β-TCP) is one of allogenic bone substitute which is known to have interconnected pores that draws cell and nutrients for bone generation. It has been resulted in good outcomes for bone defect coverage or augmentation. However, several studies have also reported negative outcomes and associated complications including unexpected formation of cystic mass, continuous pain and secretion. We present the case of a 36-year-old man with a right cheek cystic mass who had a history of right zygomaticomaxillary (ZM) complex fracture and surgical correction with β-TCP powder insertion to ZM bone defect. Excisional biopsy under local anesthesia revealed calcified mass in a sinus tract which was found to be connected to the ZM bone defect site in postoperative computed tomography image. Further excision under general anesthesia was performed to remove the sinus tract and fine granules which filled the original defect site. Pathologic report revealed bony spicules and calcification materials with chronic foreign body reaction. Postoperative complications and recurrence were not reported.

Sinus Tract Formation with Chronic Inflammatory Cystic Mass after Beta Tricalcium Phosphate Insertion

Beta tricalcium phosphate (β-TCP) is one of allogenic bone substitute which is known to have interconnected pores that draws cell and nutrients for bone generation. It has been resulted in good outcomes for bone defect coverage or augmentation. However, several studies have also reported negative outcomes and associated complications including unexpected formation of cystic mass, continuous pain and secretion. We present the case of a 36-year-old man with a right cheek cystic mass who had a history of right zygomaticomaxillary (ZM) complex fracture and surgical correction with β-TCP powder insertion to ZM bone defect. Excisional biopsy under local anesthesia revealed calcified mass in a sinus tract which was found to be connected to the ZM bone defect site in postoperative computed tomography image. Further excision under general anesthesia was performed to remove the sinus tract and fine granules which filled the original defect site. Pathologic report revealed bony spicules and calcification materials with chronic foreign body reaction. Postoperative complications and recurrence were not reported.

Multiple Epidermal Cysts in the Volar Skin of the Thumb

No abstract available.

Systemic metastasis of hepatocellular carcinoma responsive to multidisciplinary treatment including debulking surgery

The lung, followed by regional lymph node and bone, is the most common site for extrahepatic metastasis of hepatocellular carcinoma (HCC). Metastatic skin lesion of HCC is rare, and it is a sign of poor prognosis, indicating the strong possibility of metastases in other regions of the body. We report the case of a 52-year-old male with multiple metastases, including skin metastasis of HCC, which were treated with multidisciplinary therapy.

The risk factors of early recurrence after hepatectomy in hepatocellular carcinoma

PURPOSE: Early recurrence after hepatectomy is a well-known poor prognostic factor in patients with hepatocellular carcinoma. This study was undertaken to identify the risk factors of early recurrence in patients with hepatocellular carcinoma after hepatectomy. METHODS: One hundred and sixty-seven patients that underwent hepatectomy for hepatocellular carcinoma from January 2005 to December 2010 were enrolled. The numbers of patients with or without early recurrence group were 40 and 127, respectively. Clinico-pathologic factors were retrospectively analyzed. RESULTS: Potential risk factors were classified as host, tumor, or surgical factors. Of the host factors examined, lobular hepatitis activity was found to be a significant risk factor of early recurrence, and of the tumor factors, infiltrative type of gross appearance, level of preoperative AFP and worst Edmondson-Steiner grade were significant. CONCLUSION: The present study shows that an infiltrative gross appearance, a high preoperative AFP level, high lobular hepatitis activity, and a poor Edmondson-Steiner grade are independent risk factors of early recurrence. Accordingly, patients with these risk factors should be followed closely after hepatectomy.

Rationale and surgical technique of laparoscopic left lateral sectionectomy using endoscopic staples

PURPOSE: Laparoscopic left lateral sectionectomy (LLLS) has been widely accepted due to benefits of minimally invasive surgery. Some surgeons prefer to isolate glissonian pedicles to segments II and III and to control individual pedicles with surgical clips, whereas opt like to control glissonian pedicles simultaneously using endoscopic stapling devices. The aim of this study was to find the rationale of LLLS using endoscopic staples. METHODS: We retrospectively analyzed and compared the clinical outcomes (operation time, drainage length, transfusion, hospital stay, and complication rate) of 35 patients that underwent LLLS between April 2004 and February 2012. Patients were dichotomized by surgical technique based on whether glissonian pedicles were isolated and controlled (the individual group, n = 21) or controlled using endoscopic staples at once (the batch group, n = 14). RESULTS: Mean operation time was 265.3 +/- 21.3 minutes (mean +/- standard deviation) in the individual group and 170 +/- 22.9 minutes in the batch group. Operation time in the batch group was significantly shorter than the individual group (P = 0.007). Mean drainage length was 4.8 +/- 1.6 and 2.6 +/- 1.5 days in the individual and the batch group. There was significantly shorter in the batch group, also (P = 0.006). No transfusion was required in the batch group, but 4 patients in the individual group needed transfusion. Mean hospital stay was 10.7 +/- 1.1 and 9.4 +/- 0.8 days in the individual and the batch groups (P = 0.460). There were no significant complications or mortality in both groups. CONCLUSION: LLLS using endoscopic staples (batch group) was found to be an easier and safer technique without morbidity or mortality.

The comparison of oncologic and clinical outcomes of laparoscopic liver resection for hepatocellular carcinoma

PURPOSE: We evaluate the operative outcome and oncologic outcome of laparoscopic liver resection for hepatocellular carcinoma (HCC), and compare with open liver resection. METHODS: From January 2004 to December 2012, clinical data of 70 patients who underwent laparoscopic liver resection for HCC (laparoscopic liver resection group, lapa-group) were collected and analyzed retrospectively. Control group (open liver resection group, open-group) were retrospectively matched, and compared with lapa-group. RESULTS: Laparoscopic major liver resections were performed in 4 patients. Laparoscopic anatomical resections and nonanatomical resections were performed in 39 patients, and 31 patients, respectively. Mean operative time was shorter in lapa-group (215.5 +/- 121.84 minutes vs. 282.30 +/- 80.34 minutes, P = 0.001), mean intraoperative transfusion rate and total amount were small in lapa-group (24.28%, 148.57 +/- 3,354.98 mL vs. 40.78%, 311.71 +/- 477.01 mL). Open conversion occurred in 6 patients (8.57%) because of bleeding, inadequate resection, invisible mass on intraoperative ultrasonography, and tumor rupture. In lapa-group and open-group, 3-year disease-free survival rates were 58.3% +/- 0.08%, and 62.6% +/- 0.06%, respectively (P = 0.773). In lapa-group and open-group 3-year overall survival rates were 65.3% +/- 0.8%, and 65.7% +/- 0.6%, respectively (P = 0.610). CONCLUSION: Laparoscopic liver resection for HCC is feasible and safe in a large number of patients, with reasonable operative and oncologic results.

Fine Needle Aspiration Cytology of Hepatic Hydatid Cyst: A Case Study

Hydatid cysts (echinococcosis) are caused by an infestation with larval tapeworms of the genus Echinococcus. The disease is extensively distributed worldwide, and it has been rarely reported in Korea. We describe the cytologic features of a case of hepatic hydatid cyst in a 28-year-old male. Computed tomography revealed a cystic mass in the right lobe of the liver. A right hemihepatectomy was performed. The aspirated fluid from the hepatic cystic mass was clear. The smears showed protoscolices, hooklets, and a laminated membrane.

Single center experience of laparoscopic hepatectomy: the comparison of perioperative outcomes between early and late period

BACKGROUNDS/AIMS: The aim of this study is to clarify the safety and feasibility of laparoscopic hepatectomy, through comparing the early and late periods of perioperative outcomes. METHODS: We retrospectively analyzed 138 patients who underwent laparoscopic hepatectomy from January 2003 to June 2011, at Yeungnam University Hospital. We divided the total patients to early period (from January 2003 to February 2007, n=49) and late period (from March 2007 to June 2011, n=89) groups and compared the perioperative outcomes including the mean operation time, intra-operative blood loss, postoperative hospital stay, intensive care unit (ICU) stay, and duration of liver function test (LFT) normalization. RESULTS: The mean operation time was 308 minutes (range: 140-510) in the early group and 193 minutes (range: 40-350) in the late period group (p<0.001). The mean intraoperative blood loss was 171 ml (range: 50-1,200) in the early and 44 ml (range: 0-400) in the late group (p=0.005). The postoperative hospital stay was 9.7 days (range: 4-31) in the early and 6.8 days (range: 2-9) in the late period (p<0.001). The ICU stay hour was 21.6 hours (range: 0-120) in the early and 2.8 hour (range: 0-24) in the late period (p<0.001). The duration of LFT normalization was 5.7 days (range: 0-39) in the early and 2.1 days (range: 0-20) in the late period (p=0.003). The perioperative outcomes in the late period were better than the early period, which showed a statistically significant difference. CONCLUSIONS: Laparoscopic hepatectomy is feasible and can be safely performed in selected patients but requires a long experience in open liver resection and mastery of laparoscopic surgical skills.

Laparoscopic liver resection for malignant liver tumors, why not more? / 대한외과학회지

PURPOSE: The precise role of laparoscopic liver resection in liver malignancies remains controversial despite an increasing number of publications that have used the laparoscopic resection of benign liver tumors. This study was performed to assess the feasibility, safety, and outcome of laparoscopic liver resection for malignant liver tumors. METHODS: This study is a retrospective review of the profiles, pathology, surgery and outcome performed on 61 patients who had undergone laparoscopic liver resection for liver malignancies between January 2004 and March 2011. RESULTS: Among the 61 patients, 34 patients had hepatocellular carcinoma (HCC), 24 patients had liver metastasis. The mean tumor size was 2.8 +/- 2.0 cm (mean +/- standard deviation). Tumors located at Couinaud segment number 2 to 8. The resection included 36 anatomical resections, 25 wedge resections. The mean surgical time was 209.7 +/- 108.9 minutes. There was one operation that resulted in death. Postoperative complications occurred in 9 patients (14%). There were 2 conversions to laparotomy (3%). The mean postoperative hospital stay was 9.0 +/- 4.4 days. Blood transfusion was needed in 11 patients (18%). The mean surgical margin was 1.3 +/- 1.2 cm. The mean follow-up period was 18.1 +/- 11.1 months. The three-year overall survival rate was 87% for patients with HCC and 95% for patients having liver metastases from colorectal cancer. CONCLUSION: Even though laparoscopic liver resection requires a learning curve, it produced acceptable outcomes even in patients who had a malignant liver tumor. This study provides evidence to support further investigation and the establishment of laparoscopic liver resection for malignant liver tumors.

Current Status of Laparoscopic Liver Resection in Korea

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.