Adrenocorticotropic hormone and β-endorphin concentration as a prognostic factor in patients with subarachnoid hemorrhage due to aneurysmal rupture

Objective@#Adrenocorticotropic hormone (ACTH) and β-endorphin are pituitary neuro-peptides released by acute stress. We determined why the prognosis of patients with subarachnoid hemorrhages (SAH) due to aneurysmal rupture is not always dependent on the Hunt–Hess grading system (HHS) and delta-National Institutes of Health Stroke Scale (NIHSS), while studying endogenous neuropeptides, including ACTH and β-endorphin. @*Methods@#We analyzed blood samples collected from patients with SAH (SAH group; n=37) and those with unruptured intracranial aneurysms (control group; n=37). Blood sampling was performed before any procedure or chemical agents administration. The results of ACTH and β-endorphin measurements were compared using the delta-NIHSS and HHS. The data were analyzed using descriptive statistics, independent samples t-tests, and Pearson’s correlations. @*Results@#Of the 18 patients with low-grade HHS, 13 had low delta-NIHSS and five showed high delta-NIHSS. Of the 19 patients with high-grade HHS, the delta-NIHSS was ≥14 in the other five patients. ACTH concentration was high (497.3 pg/mL) in five patients with high-grade HHS and high delta-NIHSS. β-endorphin concentration was high (159.7 pg/mL) in 13 patients with low-grade HHS and low delta-NIHSS. @*Conclusions@#High ACTH levels in patients with massive bleeding and poor neurological status suggests increasing ACTH secretion in response to bleeding stress, which may aggravate neurological status. Contrary to ACTH, high β-endorphin levels in patients with low-grade HHS implied the involvement of additional factors in predicting fair outcomes related to low delta-NIHSS. These results may provide insight into the varying prognostic potential of HHS in SAH patients.

Early Phase of Achalasia Manifested as an Esophageal Subepithelial Tumor / 대한소화기학회지

The Chicago classification (CC) defines an esophagogastric junction outflow obstruction (EGJOO) as the presence of several instances of intact or weak peristalsis, elevated median integrated relaxation pressure above 15 mmHg, and a discrepancy from the criteria of achalasia. The revised CC addresses the potential etiology of EGJOO, including the early forms of achalasia, mechanical obstruction, esophageal wall stiffness, or manifestation of hiatal hernia. A 58-year-old woman visited the Presbyterian Medical Center with swallowing difficulty. The patient underwent a high resolution manometry (HRM) examination and was diagnosed with EGJOO. Chest CT was performed to exclude a mechanical obstruction as a cause, and CT revealed a subepithelial tumor (SET) at the upper part of the esophagogastric junction. Therefore, laparoscopic surgery was performed and eccentric muscular hypertrophy of the distal esophagus was observed. Longitudinal myotomy and Dor fundoplication were also performed. The histology findings of the surgical specimens were consistent with achalasia. This paper reports a case of early achalasia that was finally diagnosed by the histology findings, but was initially diagnosed as EGJOO using HRM and misdiagnosed as SET in the image study.

Early Phase of Achalasia Manifested as an Esophageal Subepithelial Tumor / 대한소화기학회지

The Chicago classification (CC) defines an esophagogastric junction outflow obstruction (EGJOO) as the presence of several instances of intact or weak peristalsis, elevated median integrated relaxation pressure above 15 mmHg, and a discrepancy from the criteria of achalasia. The revised CC addresses the potential etiology of EGJOO, including the early forms of achalasia, mechanical obstruction, esophageal wall stiffness, or manifestation of hiatal hernia. A 58-year-old woman visited the Presbyterian Medical Center with swallowing difficulty. The patient underwent a high resolution manometry (HRM) examination and was diagnosed with EGJOO. Chest CT was performed to exclude a mechanical obstruction as a cause, and CT revealed a subepithelial tumor (SET) at the upper part of the esophagogastric junction. Therefore, laparoscopic surgery was performed and eccentric muscular hypertrophy of the distal esophagus was observed. Longitudinal myotomy and Dor fundoplication were also performed. The histology findings of the surgical specimens were consistent with achalasia. This paper reports a case of early achalasia that was finally diagnosed by the histology findings, but was initially diagnosed as EGJOO using HRM and misdiagnosed as SET in the image study.

T-shaped Modified Delta Anastomosis as a Simple Intracorporeal Gastroduodenostomy

PURPOSE: A delta-shaped anastomosis (DA) is a widely accepted technique used for a totally laparoscopic distal gastrectomy (TLDG). Several studies have suggested various modifications to overcome the drawbacks of an original DA. We present our novel technique―a T-shaped modified delta anastomosis (TDA), and we report the early outcomes with its use in a case series. METHODS: We retrospectively reviewed the medical records of 40 patients who underwent a TLDG with TDA for early gastric cancer at OOO between February 2016 and May 2017. Perioperative outcomes, postoperative complications, and operating time were analyzed, and all data were expressed as means±standard deviation. RESULTS: We observed no major complications that required immediate postoperative intervention. Other minor and non-surgical complications were delayed gastric emptying (n=1), pneumonia (n=2), atelectasis (n=3), dumping symptom (n=1), and symptomatic bile reflux (n=1). No wound infection was reported in any patient. The total operative time was 206.5±25.4 min and the estimated blood loss was 27.8±33.5 ml. The mean time required to perform the anastomosis was 20.9±6.7 min, and the mean number of cartridges used during the operation was 4.78±0.66. CONCLUSION: We conclude that a TDA following a laparoscopic distal gastrectomy was successfully developed and showed acceptable clinical outcome.

Evaluation of Different Methods of Gastroenterostomy after Distal Gastrectomy for Gastric Carcinoma

PURPOSE: Billroth II gastroenterostomy is a typical reconstruction method after distal gastrectomy for gastric carcinoma, but it has problems, especially frequent reflux esophagitis. Various methods have been tried to address this problem. Among them are Braun enteroenterostomy and Roux-en-Y gastroenterostomy, which are performed separately according to the size of the gastric remnant. The aim of our study was to determine whether these applications are compatible. MATERIALS AND METHODS: Between September 2003 and April 2007, we performed Roux-en-Y gastroenterostomy operations (14 patients) when the size of the gastric remnant was <10%, Braun enteroenterostomy (17 patients) when the size was between 10 and 20%, and Billroth II gastroenterostomy (14 patients) when the size was between 20 and 40% after subtotal gastrectomy for gastric cancer by a single surgeon at our hospital. We analyzed the results of each treatment. We evaluated the symptoms and endoscopic findings using questionnaires and hospital records. To evaluate nutritional states, we reviewed albumin and hemoglobin levels and body weight changes. RESULTS: All operations were performed safely mortality was 0% and postoperative complications were 8.9%. On endoscopy, reflux gastritis was observed to occur in 7.63%, 18.65% and 40.0%, respectively, of patients who had undergone Roux-en-Y, Braun and Billroth II operations (P=0.13). Reflux esophagitis was observed in 1 patient in the Roux-en-Y group and 1 patient in the Braun group. Endoscopic gastrostasis was observed in 2 patients in the Roux-en-Y group, one of which was thought to cause reflux esophagitis. Patients in the Roux-en-Y group and Braun groups ingested a lower volume of food than did those in the Billroth II group (respectively, 7.1%, 0.0% and 28.7%) and complained less of postprandial discomforts (respectively, 14.3%, 23.5% and 57.1%) and reflux symptoms (respectively 0.0%, 11.8% and 42.9%). CONCLUSION: The application of Braun enteroenterostomy and Roux-en-Y gastroenterostomy to the small gastric remnant may be effective for reducing reflux symptoms and abdominal discomfort after distal gastric resection. We recommend Roux-en-Y gastroenterostomy when the size of the gastric remnant is <10%, and Braun anastomosis in the others. It will need to be determined which reconstructive procedure is better for many different conditions.

Comparison of Reconstructive Techniques after Total Gastrectomy as Determined by Patient Quality of Life and Nutritional Status

PURPOSE: Many reconstruction procedures have been developed in order to resolve patient complaints after a total gastrectomy. However, until now, there has been no general agreement with regard to the ideal reconstruction to perform after a total gastrectomy. Moreover, there have been few reports of the long-term effects of different reconstruction procedures. In this study, we compared the long-term nutritional status and quality of life for patients that received either a Roux-en-Y esophagojejunostomy (R-Y), jejunal interposition (JI), jejunal pouch interposition (JPI), or double tract reconstruction (DT), to determine the optimum reconstruction procedure after a total gastrectomy. MATERIALS AND METHODS: The study consisted of 41 patients younger than 80 years who had undergone a total gastrectomy with curative resection and who had no evidence of recurrence at our hospital between August 2000 and January 2004. The patients were classified into the following four groups, according to the type of reconstruction; simple Roux-en-Y (R-Y group, n=15), jejunal interposition (JI; group, n=8), j Jejunal pouch interposition (JPI group, n=8), double tract interposition (DT group, n=10). The nutritional status was assessed by measuring body weight, serum albumin level, serum hemoglobin level, and the level of serum total protein, and the PNI (Prognostic nutritional index). Quality of life was assessed by GSRS. In addition, endoscopy was performed to confirm the presence of reflux esophagitis. RESULTS: The laboratory findings showed no significant differences between the four groups except for a lower total protein and album level in the DT group after 3 years postoperatively (P=0.006, P=0.033). The percentage of body weight at 1 year, and 3 years postoperatively in the JI group (P=0.013, P=0.011) were significantly less than other groups (P=0.011, P=0.000). The frequency of postoperative symptoms and reflux esophagitis and eating capacity showed no significant differences between the four groups. The GSRS score in the JIP group was significantly better than for the other groups at 1 year, and 3 years postoperatively (P=0.028, P=0.003). CONCLUSION: We believe that the jejunal pouch interposition is the most useful of the four procedures for improving postoperative quality of life.

Surgical Treatment of Gastric Cancer Invading the Pancreatic Head or Duodenum

PURPOSE: Combined resection of an invaded organ in advanced gastric cancer (AGC) with infiltration of adjacent organs is essential to achieve R0 resection. However, when the tumor invades the head of the pancreas or duodenum, R0 resection interferes with the lower resectability and results in a higher morbidity. Wereviewed these cases retrospectively and considered the proper extent of the surgical resection. MATERIALS AND METHODS: We retrospectively analyzed cases where patients underwent surgery for gastric adenocarcinoma at the Department of Surgery, Presbyterian Medical Center, between January 1998 and December 2003. Among the 45 patients who were suspected to have pancreatic head or duodenum invasion by a primary tumor or metastatic lymph nodes based on the operative findings, we included 22 patients without incurable factors. The patients were classified into three groups: 4 patients that underwent a combined resection (PD group), 12 patients that underwent a palliative subtotal gastrectomy (STG group) and 6 patients that underwent bypass surgery only (GJ group). We analyzed the clinicopathological features, operative data and results. RESULTS: The patients of the PD group achieved R0 resection by PD with D3 Dissection in all Patients. A pancreatic fistula was observed in one patient (morbidity 25%). There was no surgery-associated mortality (mortality 0%). All patients of the PD group were in stage IV. However, the 2-year survival rate (SR) was 75% and the 5-year SR was 50%. Six patients of the STG group underwent surgery with marginal resection and the other six patients of the STG group had a positive distal resection margin. The 2-year SR was 41.7% and the 5-year SR was 16.7%. Most of the patients of group GJ were of old age (mean age: 72.7+/-8.6 years) or had chronic diseases. The 2-year SR was 0%. CONCLUSION: Combined resection of the pancreas and duodenum in AGC with pancreatic head invasion is relatively safe with moderate morbidity and a lower mortality. One can expect long-term survival if combined resectionis performed in cases without incurable factors.

Appendiceal Intussusception Caused by the Mucocele of the Appendix

Mucocele of the appendix is basically a cystic dilatation of the appendix distal to an obstruction of the appendiceal lumen. It develops in unusual situations in which the distal lumen does not contain enough bacteria to initiate appendicitis when obstruction develops. The continuing mucous secretion causes gradual distention of the appendix and thinning of the wall until mucous secretion stops. The changes after the sudden blocking of the lumen of the appendix depend on the amount and character of the content distal to the obstruction. If the lumen is empty, the appendix distends with mucus to form a mucocele. Here we report a case which we experienced a 68-years-old female patient whose vermiform appendix had mucoceles with appendiceal intussusception.

Clinical trial of daclizumab in living renal transplantation / 대한내과학회지

BACKGROUN: Despite improvements in immunosuppressive therapy for use in renal transplantation, acute graft rejection remains a risk factor of chronic rejection and a major cause of graft loss and patient death. Recently, daclizumab, an anti IL-2 receptor monoclonal antibody has been shown to reduce the incidence of acute rejection. METHODS: To investigate the immunosuppressive effect of daclizumab and the incidence of acute rejection, we administered daclizumab intravenously (1 mg/kg of body weight within 24 hours before transplantation and once every other week afterward, for a total of 5 doses) in combination with cyclosporine microemulsion (CsA), steroid and mycophenolate mofetil (MMF) to 68 transplant recipients RESULTS: Among them 62 were undergoing their first transplantation and 6 were undergoing their second transplantation. 32 patients received living-related transplants and 36 patients received living-unrelated transplants: their HLA match were as follows:1 case with 1 Ag match, 13 cases with 2 Ag matches, 18 cases with 3 Ag matches, 3 cases with 4 Ag matches, 1 case with 5 Ag matches. The clinical characteristics of patients treated with daclizumab were as follows: 42 were male, 26 were female; the mean age of recipients was 42.94 +/- 11.2 years and that of donor was 34.1 +/- 9.9 years. The underlying renal diseases were glomerulonephritis (n=47), reflux nephropathy (n=6), diabetic nephropathy (n=12), polycystic kidney disease (n=2) and acute renal failure (n=1). During the observed period (17.41 +/- 4.34 months; min. 6 months, max. 26 months), 2 cases had acute rejection in the third month after transplantation and 1 case in the 6th month after transplantation, 1 case in the 24th month after transplantation (4/68, 5.8%). In the historical control, 20.8% of acute rejection (10/48) were noted in CsA, MMF and steroid regimen group and 36% of acute rejection (22/60) in CsA, azathioprine and steroid group. Serum creatinine level was 1.21 +/- 0.23, 1.31 +/- 0.25, 1.35 +/- 0.28 and 1.34 +/- 0.31 (mg/dL) during the 1st, 3rd, 6th month and 1 year after transplantation respectively. 10 patients developed herpes-zoster infection and 6 patients had CMV infection. 1 patient expired due to CMV pneumonitis on the 3 months after transplantation. The 2-year graft survival rate was 98.5% with daclizumab and 45 months graft survival rates were 92.9% and 89.3% for MMF group and azathioprine group respectively. CONCLUSION: Daclizumab, used in combination with CsA, MMF and steroid, reduced acute rejection episodes without serious short term side effects. Further observation is needed to evaluate the graft survival rate and uncover any long-term side effects.

Stage Migration of Gastric Cancer According to the Extent of Lymph Node Dissection

PURPOSE: In this study, the authors attempted to evaluate the stage migration phenomenon according to D1 lymphadectomy and D2 lymphadectomy in the same patients. METHODS: A retrospective study was performed in 300 consecutive patients with gastric cancer who had undergone curative resection with nodal yields of D2 or more from 1994 to 1997. The lymph node status was evaluated in two different extents. Group B included patients with whole harvested regional lymph nodes (D2<) while group A include patients with perigastric lymph nodes (D1). Each group was staged by the number of involved lymph nodes according to the UICC-TNM stage (5th), and by the ratio of involved to resected lymph nodes. Stage migration and the difference of 5YSR were observed between the two groups. RESULTS: In staging by the number of involved lymph nodes, 25 cases (8.3%) of group B were staged up. According to the status by the ratio of involved lymph nodes, 14 cases (4.6%) of group B were staged up and 28 (9.3%) were staged down. CONCLUSION: In the staging of gastric cancer, adequate lymph node dissection was essential for accurate lymph node staging. In the cases of limited lymph node dissection, some extent of stage migration was considered assessing in the prognosis.

Hemoperitoneum due to Ruptured Paraumbilical Vein in a Cirrhotic Patient with Portal Hypertension: Treatment by means of Coil Embolization

The paraumbilical vein is one of the anastomotic channels between the portal and systemic circulatory systems, and rupture of the intra-abdominal varix is an unusual complication of portal hypertension that can lead to life-threatening hemoperitoneum. We experienced a case of hemoperitoneum due to a ruptured paraumbilical vein revealed by ultrasonography (US), computed tomography (CT) and percutaneous transhepatic portography. The last mentioned demonstrated a dilated paraumbilical ve i n draining two branches of the left portal vein into the right external iliac vein, and we performed coil embolization at the site at which the presumed site of paraumbilical vein was presumed to cause hemoperitoneum. We describe this unusual case of hemoperitoneum due to a ruptured paraumbilical vein in a known liver cirrhosis patient in whom portal hypertension was treated by means of coil embolization.

The Preoperative Factors for Conversion of Laparoscopic to Open Cholecystectomy for Treatment of Acute Cholecystitis

BACKGROUND: Since its introduction in 1987, the laparoscopic cholecystectomy has become the treatment of choice for most patients with symptomatic cholelithiasis. However, about 20% of the patients requiring a cholecystectomy present with acute cholecystitis, and the safety of a laparoscopic cholecystectomy in these patients has been questioned. With increasing experience, many studies have reported that a laparoscopic cholecystectomy in patients with acute cholecystitis is safe and cost effective. This study was to review retrospectively the results of laparoscopic cholecystectomies in patients with acute inflamed gallbladders. METHODS: From July 1993 through Fabruary 1997, laparoscopic cholecystectomies were attempted in 250 patients with or without symptomatic gallbladder disease. Acute cholecystitis, confirmed by clinical, laboratory, operative, and histological findings, was present in 61 patients. The preoperative factors that may be useful in predicting conversion to an open operation were analyzed. RESULTS: The frequency of conversion to an open operation was 19.7% for acute inflammation and 3.2% for chronic inflammation. Patients who had a laparoscopic cholecystectomy done within 72 hours of the onset of symptoms had a lower rate of conversion to open procedures. Patients who had a laparoscopic cholecystectomy done and who had a white blood cell count over 15 10(9)/L, persistant high fever (>38.0degrees C) over 3 days, and managed diabetes mellitus for over 3 years had a high rate of conversion to open procedures. There were no bile-duct injuries and no mortalites. CONCLUSIONS: Laparoscopic intervention appears to be a safe and beneficial option in the management of patients with acute cholecystitis. Surgeons should have extensive experience with both routine laparoscopic cholecystectomy and conventional open biliary tract surgery. A greater number of patients with inflammation require conversion to an open operation compared with the number of patients with no obvious inflammation who require conversion. Conversion to an open operation was frequent for patients with empyema, with symptoms that had lasted for longer than 72 hours prior to the operation, with white blood cell counts over 15 10(9)/L, with persistant high fever (>38.0degrees C) over 3 days and with managed diabetes mellitus for over 3 years, suggesting that once this diagnosis of acute cholecystitis is made, excessive time should not be spent in a laparoscopic trial dissection before conversion to an open operation.

CT Findings of the Pulmonary Tuberculosis in Patients with Diabetes Mellitus

PURPOSE: To evaluate the CT findings of pulmonary tuberculosis in patients with diabetes mellitus (MD),according to the diabetic control state. MATERIALS AND METHODS: We retrospectively studied 34 cases of pulmonarytuberculosis accompanied by DM. We divided the right lung three lobes and ten segments and the left into two lobesand eight segments and analyzed CT findings of bronchogenic spread, cavitary lesion, ill-defined nodule, lobularconsolidation, lobar and segmental consolidation, atelectasis, interlobular septal thickening, fibrotic band, andassociated findings such as lymph node enlargement, pleural effusion and empyema. We also tried to determine thetypical CT findings of pulmonary tuberculosis according to diabetic duration and controlled state of DM focusingby FBS 160 and HbA1C 8.0. RESULT: Among 34 CT scans, bronchogenic spread was seen on 29 (85.3%), cavitary lesionon 26 (76.5%), ill-defined nodules on 11 (32.4%), lobular consolidation on 14 (41.2%), lobar and segmentalconsolidation on 12 (35.3%), atelectasis on four (14.7%), and fibrotic band on eight (23.5%). Multiple cavitieswere present in 76.9% of total cavitary lesions, and consolidation with bronchogenic spread in 75%; associatedfindings were as follows: lymph node enlargement (n=1), pleural effusion (n=10), empyema (n=2), and pericardialeffusion (n=2). In 46.7% of cases, general tubercular lesions were in an unusual location, but among cases ofsecondary pulmonary tuberculosis, 73.9% of lesions were in the usual location. More lobular consolidation was seenin patients with less than FBS 160 on admission, and this result was statistically significant (p<0.05); CTfindings did not, however, differ according to diabetic duration and HbA1C. CONCLUSION: In patients with DM,general fubercular lesions were found infrequently, but in secondary tubereulosis, multiple cavitary lesions-inthe usual location-were very frequent. In patients with DM, CT findings of pulmonary tuberculosis did not varyaccording to the diabetic control state, except that in patients with less than FBS 160 on admission, there was agreater degree of lobular consolidation.

Dumbbell-shaped Epidural Cavernous Hemangioma: A Case Report

It has been reported that cavernous hemangiomas in the spine are generally located in vertebral bodies. Wereport a case of epidural cavernous hemangioma, a very rare condition, at the C7-T2 level. MR images showed adumbbell-shaped mass, with iso and high signal intensity on T1- and T2-weighted images, respectively. The mass wasintensely enhanced following Gd-DTPA injection.

A Case of Acute Typhlitis Complicating Drug-induced Agranulocytosis / 대한내과학회지

Increasingly aggressive chemotherapy regimens, advances in transplantation technology, and the acquired immunodeficiency syndrome have resulted in a growing number of immunocompromised patients. Infections are a major cause of morbidity and mortality in this population. One of the most ominous complications is the development of typhlitis in this immunocompromised patients. Treatment of this process is controversial, and no consensus has emerged. We report a case of typhlitis who complicated agranulocytosis after exposure to drugs to treat "flu" like illness and recovered completely after two operations of appendectomy and ileocolectomy. Reviewing articles and this case, the favorable outcome seemed to be related to following three factors recognition of the acute surgical abdomen by abdominal CT scan, a prompt return of normal circulating white cells by the use of Granulocyte Colony Stimulating Factor and discontinuation of causative drugs, and an appropriately timed surgical intervention.

The Prediction of Postoperative Pulmonary Complications in the Elderly Patients / 결핵

BACKGROUND: we have evaluated the association of age, smoking, type of anesthesia, type of operation, duration of surgery, previous history of chronic pulmonary diseases with postoperative pulmonary complications and identified which parameter of preoperative spirometry was a predictor of postoperative pulmonary complications. METHOD: In 270 patients older than 60 years, the postoperative pulmonary complications were evaluated according to age, smoking, type of anesthesia, type of operation, duration of surgery, previous history of chronic pulmonary diseases and the parameters of preoperative spirometry were analyzed. RESULTS: The postoperative pulmonary complications rates were significant higher among patients older than 70 years, and among those with previous chronic pulmonary diseases or their smoking history. The pulmonary complications were increased among patients with general anesthesia or duration of surgery more than 2 hours. The pulmonary complications rates did not differ according to sex, type of operation. The patients with hypercarbia(PaCO2> 45mmHg) have more increased postoperative complications. The preoperative FEVl less than 1 liter, FVC, MMEFR & MVV less than 50% of predicted respectively were predictive of complications. CONCLUSION: Age 70, history of smoking,duration of operation more than 2 hours, general anesthesia, previous chronic pulmonary disease and hypercarbia (> or=45mmHg) on preoperative arterial blood gas analysis were predictivd of pulmonary complications. Among the parameters of spirometry, FEV1, FVC, MMEFR and MVV were indicator of predicting postoperative pulmonary complications.

The clinical analysis of biliary pancreatitis

No abstract available.