Influence of Insurance Status on Survival of Surgically Treated Esophageal Cancer Patients / 대한소화기학회지

BACKGROUND/AIMS: Socioecomomic factor is an important determinant of access to healthcare and is one of the potential causes of disparities in esophageal cancer care outcomes. The aim of the study was to clarify the association between National health Insurance status (health insurance vs. medicare) as a socioeconomic factor and survival of patients with esophageal cancer who underwent surgical resection. METHODS: Among the 66 patients who underwent surgical resection for esophageal cancer between January 2006 and December 2017, 17 patients (25.8%) were in the medicare group. The data were analyzed to identify clinical manifestations and to compare surgical and oncologic outcomes between the groups. RESULTS: There was no significant difference in the distribution of sex (p=0.13), age (p=0.24), and pathologic stage (p=0.61) between the groups. The length of median hospital stay was significantly shorter in the healthy insurance group (18 days vs. 25 days, p=0.04). In the medicare group, postoperative mortality rates and incidence of postoperative complication were non-significantly higher (11.8% vs. 6.1%, p=0.45, 64.7% vs. 46.7%, p=0.21, respectively). However, pulmonary complication rates, including pneumonia, acute respiratory distress syndorme, and prolonged air leakage was significantly higher in the medicare group (47.1% vs. 18.4%, p=0.02). Five-year disease free survival rate was not different between the two groups (61.0% vs. 54.5%, p=0.68); the 5-year overall survival rate was significantly lower in the medicare group (27.7% vs. 53.7%, p=0.03). CONCLUSIONS: The medicare status of National health insurance could have a negative influence on the overall survival in patients with esophageal cancer who underwent surgery.

Successful desensitization of pemetrexed-induced anaphylaxis in a patient with malignant mesothelioma

No abstract available.

Successful desensitization of pemetrexed-induced anaphylaxis in a patient with malignant mesothelioma

No abstract available.

Early Experiences with the Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm

BACKGROUND: The aim of this study was to report our early experiences with the endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAAs), which are a rare and life-threatening condition. METHODS: Among 42 patients who underwent thoracic endovascular aortic repair (TEVAR) between October 2010 and September 2015, five patients (11.9%) suffered an rDTAA. RESULTS: The mean age was 72.4±5.1 years, and all patients were male. Hemoptysis and hemothorax were present in three (60%) and two (40%) patients, respectively. Hypovolemic shock was noted in three patients who underwent emergency operations. A hybrid operation was performed in three patients. The mean operative time was 269.8±72.3 minutes. The mean total length of aortic coverage was 186.0±49.2 mm. No 30-day mortality occurred. Stroke, delirium, and atrial fibrillation were observed in one patient each. Paraplegia did not occur. Endoleak was found in two patients (40%), one of whom underwent an early and successful reintervention. During the mean follow-up period of 16.8±14.8 months, two patients died; one cause of death was a persistent type 1 endoleak and the other cause was unknown. CONCLUSION: TEVAR for rDTAA was associated with favorable early mortality and morbidity outcomes. However, early reintervention should be considered if persistent endoleak occurs.

Postoperative Life-Threatening Recurrent Ventricular Arrhythmia Triggered by the Swan-Ganz Catheter in a Patient Undergoing Off-Pump Coronary Artery Bypass Surgery

Recurrent ventricular arrhythmia can be fatal and cause serious complications, particularly when it is caused immediately after an operation. Incorrect placement of a Swan-Ganz catheter can trigger life-threatening ventricular arrhythmia, but even intensive care specialists tend to miss this fact. Here, we report a case of recurrent ventricular arrhythmia causing a severe hemodynamic compromise; the arrhythmia was induced by a severely angulated Swan-Ganz catheter. The recurrent ventricular arrhythmia was not controlled by any measures including repositioning of the catheter, until the complete removal of the Swan-Ganz catheter. It is necessary to keep in mind that the position of the pulmonary artery catheter should be promptly checked if there is intractable recurrent ventricular arrhythmia.

Changes of the Lipoprotein Profiles with Time after Discontinuation of Statin Therapy

BACKGROUND AND OBJECTIVES: Some patients stop statin therapy in spite of their doctors' advice. This study was designed to assess the pattern of lipoprotein profile changes and clinical characteristics of the patients who discontinued statin therapy. SUBJECTS AND METHODS: 69 patients (male 42.0%) were enrolled. The clinical characteristics and laboratory data on the lipoprotein levels were obtained from the medical records. RESULTS: The coexistence of diabetes mellitus (DM) was seen in 28% of the patients, hypertension was noted in 72% and coronary artery disease (CAD) was noted in 42%. The average lipoprotein levels during statin therapy were total cholesterol (TC)=163.8 mg/dL, triglycerides (TG)=174.3 mg/dL, high-density lipoprotein cholesterol (HDL-C)=34.8 mg/dL and low-density lipoprotein cholesterol (LDL-C)=94.2 mg/dL. LDL-C level increased by 44.9% at 2-3 months after ceasing statin therapy and by 54.6% at 4-6 months after ceasing statin therapy (p<0.01). The changes of the lipoprotein levels from baseline to 2-3 months and 4-6 months after discontinuation were +22.6% and +30.0% for the TC level, +20.8% and +24.0% for the TG level, and 0.06% and -0.65% for the HDL-C level respectively (p<0.01 for TC and TG, p=not significant (NS) for HDL-C). The achievement rate of target LDL-C level as suggested by the Adult Treatment Panel III (ATP III) of National Cholesterol Education Program (NCEP) was decreased 62.7% at 2-3 months and then it was decreased to 61.8% at 4-6 months after statin discontinuation. DM and CAD were more frequent in the patients who did not achieve the target LDL-C level even with life style modification. CONCLUSION: After statin discontinuation, TC and LDL-C were increased within 3 months. DM and CAD were highly prevalent in patients who didn't achieve their treatment goal.

Rectal Temperature Maintenance Using a Heat Exchanger of Cardioplegic System in Cardiopulmonary Bypass Model for Rats / 대한흉부외과학회지

BACKGROUND: Small animal cardiopulmonary bypass (CPB) model would be a valuable tool for investigating pathophysiological and therapeutic strategies on bypass. The main advantages of a small animal model include the reduced cost and time, and the fact that it does not require a full scale operating environment. However the rat CPB models have a number of technical limitations. Effective maintenance and control of core temperature by a heat exchanger is among them. The purpose of this study is to comfirm the effect of rectal temperature maintenance using a heat exchanger of cardioplegia system in cardiopulmonary bypass model for rats. MATERIAL AND METHOD: The miniature circuit consisted of a reservoir, heat exchanger, membrane oxygenator, roller pump, and static priming volume was 40 cc. Ten male Sprague-Dawley rats (mean weight 530 gram) were divided into two groups, and heat exchanger (HE) group was subjected to CPB with HE from a cardioplegia system, and control group was subjected to CPB with warm water circulating around the reservoir. Partial CPB was conducted at a flow rate of 40 mg/kg/min for 20 min after venous cannulation (via the internal juglar vein) and arterial cannulation (via the femoral artery). Rectal temperature were measured after anesthetic induction, after cannulation, 5, 10, 15, 20 min after CPB. Arterial blood gas with hematocrit was also analysed, 5 and 15 min after CPB. RESULT: Rectal temperature change differed between the two groups (p<0.01). The temperatures of HE group were well maintained during CPB, whereas control group was under progressive hypothermia. Rectal temperature 20 min after CPB was 36.16+/-0.32 degrees C in the HE group and 34.22+/-0.36 degrees C in the control group. CONCLUSION: We comfirmed the effect of rectal temperature maintenance using a heat exchanger of cardioplegia system in cardiopulmonary bypass model for rats. This model would be a valuable tool for further use in hypothermic CPB experiment in rats.

Clinical Usefulness of Preoperative and Postoperative CA-19-9 Antigen in Pancreatic and Bile Duct Neoplasms

PURPOSE: The CA-19-9 antigen is a commonly used tumor marker for pancreatic and bile duct neoplasms. It is well known that the CA-19-9 antigen is a good predictor of resectability, prognosis and recurrence. The aim of this study was to evaluate the efficacy of the CA-19-9 antigen as preoperative resectability and postoperative recurrence markers in pancreatic and bile duct neoplasms. METHODS: Between February 1995 and June 2001, 234 patients, with pancreatic and bile duct neoplasms, at the Department of Surgery, Samsung Medical Center, were followed up with the CA-19-9 antigen, both preoperatively and postoperatively. The ROC curve was used to analyze the relationship between a radical resection and the preoperative CA-19-9 antigen. During the postoperative follow- up, 124 patients that had radical resections, and postoperative follow-up for the CA-19-9 antigen, were studied for this relationship using Chi-square tests. RESULTS: The cut-off values in the pancreatic (P=0.527) and bile duct (P=0.688) neoplasms were 325.50 U/ml and 58.35 U/ml, respectively, using the ROC curve for the relationship between a radical resection and the preoperative CA-19-9 antigen, although the result was statistically insignificant. From the 124 patients used for the statistical analysis, 64 had a recurrence, of which 57 showed an increase in the CA-19-9 antigen, with the 7 showing no elevation. 60 patients had no recurrence, of which 28 showed an increase in the CA-19-9 antigen. The elevation of the CA-19-9 antigen was analyzed between the recurrence and no recurrence groups using Chi-square tests, which revealed a statistical significance (P<0.001). CONCLUSION: In patients with pancreatic and bile duct neoplasms, the CA-19-9 antigen could not predict the preoperatie resectability, but was a clinically effective follow-up marker for a recurrence.

Comparative Analysis of alpha-STAT and pH-STAT Strategies During Deep Hypothermic Circulatory Arrest in the Young Pig / 대한흉부외과학회지

INTRODUCTION: The most dramatic application of hypothermia in cardiac surgery is in deep hypothermic circulatory arrest (DHCA). Because man in natural circumstances is never exposed to this extreme hypothermic condition, one of the controversial aspects of clinical hypothermia is appropriate acid-base management (alpha-stat versus pH-stat). This study aims to compare alpha-stat with pH-stat for: (1) brain cooling and re-warming speed during hypothermia induction and re-warming by cardiopulmonary bypass (CPB); (2) cerebral perfusion, metabolism, and their coupling; and (3) the extent of development of cerebral edema after circulatory arrest, in young pigs. MATERIALS AND METHODS: Fourteen young pigs were assigned to one of two strategies of gas manipulation. Cerebral blood flow was measured with a cerebral venous outflow technique. After a median sternotomy, CPB was established. Core cooling was initiated and continued until nasopHaryngeal temperature fell below 20degree C. The flow rate was set at 2,500 ml/min. Once their temperatures were below 20degree C, the animals were subjected to DHCA for 40 mins. During cooling, acid-base balance was maintained according to either alpha-STAT or pH-STAT strategies. After DHCA, the body was re-warmed to normal body temperature. The animals were then sacrificed, and their brains measured for edema. Cerebral perfusion and metabolism were measured before the onset of CPB, before cooling, before DHCA, 15 mins after re-warming, and upon completion of re-warming. RESULTS AND CONCLUSION: Cooling time was significantly shorter with alpha-stat than with pH-stat strategy, while there were no significant differences in rewarming time between the two groups. Nosignificant differences were found in cerebral blood flow, metabolic rate, or flow/ metabolic rate ratio between two groups. Temperature-related differences were significant in cerebral blood flow, metabolic rate, and flow/metabolic rate ratio within each group. Brain water content showed no significant differences between two groups.

Influence of Anatomy, Associated Anomalies, Age, and Surgical Methods on the Surgical Results of Aortic Coarctation / 대한흉부외과학회지

One hundred forty-four patients underwent operation for coarctation of the aorta at Seoul National University Children's Hospital between June 1986 and Decembsr 1995. Age ranged 0.1 to 191 months. Of these 78.5%(113) were infants. We classified the patients in terms of the anatomic location of coarctatiln and the associatCd anomalies(I[40]= primary coarctation, II[74]=isthmic hypoplasia, lII[30]=tubular hypoplasia involving transverse arch, A[63]=with ventricular septal defect, B[28]=with other major cardiac defects). Subcalvian flap coarctoplasty(60), resection and anastomosis(44), extended aortoplasty(26), and onlay patch(14) were used as surgical methods. Overall operative mortality was 16.0(23/144)%. The hospital mortality was significantly higher in patheints with type III, subtype B, younger age(under 3 months), extended aortoplasty(p<0.01). However, one-stage total repair in patients with subtype A or B were not found to be a predictor of hospital death. Restenosis had occured in 18 patients among 121 survivals(14.9%). The mean follow-up period was 29.1+/-28.8(0~129.2) months. Preoperative, immediate postoperative(within 3 months after operation) and postoperative(later than 6 months after operation) echocardiographic data on the dimensions of ascending aorta(AA), transverse arch(TA), an4 aortic isthmus(Al) were available in 77 patients(I=20, II=42, III= 15). Preoperative and postoperative aortic isthmus(All) and tra sverse arch indices(TAI), defined as TA/AA and AI/AA respectively, were compared. Immediate postoperative All in type I, II and TAI in type III were significantly smaller in stenotic than non-stenotic group suggesting incomplete relieves of stenotic segment Younger age, subclavian coarctoplasty in patient under 3 months of age were round to be the risk factors for restenosis in this series. In conclusion, We found that aortic arch index and transverse arch index can be a useful tool to figure out the anatomic and clinical characteristics of the patients with aortic coarctation, and that anatomy, associated anomalies, age, and surgical methods may influence the surgical outcome of the coarctation repair.

Steroid Effect on the Brain Protection During Open Heart Surgery Using Hypothermic Circulatory Arrest in the Rabbit Cardiopulmonary bypass Model / 대한흉부외과학회지

INTRODUCTION: The use of rabbits as a cardiopulmonary bypass(CPB) animal model is extremely difficult mainly due to technical problems. On the other hand, deep hypothermic circulatory arrest(CA) is used to facilitate surgical repair in a variety of cardiac diseases. Although steroids are generally known to be effective in the treatment of cerebral edema, the protective effects of steroids on the brain during CA are not conclusively established. Objectives of this study are twofold: the establishment of CPB technique in rabbits and the evaluation of preventive effect of steroid on the development of brain edema during CA. MATERIAL AND METHODS: Fifteen New Zealand white rabbits(average body weight 3.5kg) were divided into three experimental groups; control CA group(n=5), CA with Trendelenberg position group(n=5), and CA with Trendelenberg position + steroid(methylprednisolone 30 mg/kg) administration group(n=5). After anesthetic induction and tracheostomy, a median sternotomy was performed. An aortic cannula(3.3mm) and a venous ncannula(14 Fr) were inserted, respectively in the ascending aorta and the right atrium. The CPB circuit consisted of a roller pump and a bubble oxygenator. Priming volume of the circuit was approximately 450ml with 120~150ml of blood. CPB was initiated at a flow rate of 80~85ml/kg/min. Ten min after the start of CPB, CA was established with duration of 40min at 20 degrees C of rectal temperature. After CA, CPB was restarted with 20min period of rewarming. Ten min after weaning, the animal was sacrificed. One-to-2g portions of the following tissues were rapidly dissected and water contents were examined and compared among groups: brain, cervical spinal cord, kidney, duodenum, lung, heart, liver, spleen, pancreas, stomach. Statistical significances were analyzed by Kruskal-Wallis nonparametric test. RESULTS: CPB with CA was successfully performed in all cases. Flow rate of 60-100 ml/kg/min was able to be maintained throughout CPB. During CPB, no significant metabolic acidosis was detected and aortic pressure ranged between 35-55 mmHg. After weaning from CPB, all hearts resumed normal beating spontaneously. There were no statistically significant differences in the water contents of tissues including brain among the three experimental groups. CONCLUSION: These results indicate (1) CPB can be reliably administered in rabbits if proper technique is used, (2) the effect of steroid on the protection of brain edema related to Trendelenburg position during CA is not established within the scope of this experiment.