Initial experience with laparoscopic posterior retroperitoneal adrenalectomy in single tertiary center

Purpose@#Laparoscopic posterior retroperitoneal adrenalectomy (LPRA) is a surgical method that accesses the adrenal gland through the back. The aim of this study was to report initial experience of LPRA and evaluate possibilities for surgical application. @*Methods@#From March 2018 to December 2019, a total of 30 consecutive patients diagnosed with adrenal tumor underwent surgical treatment at Pusan National University Hospital were enrolled. Clinicopathologic features and various peri- and postoperative parameters were analyzed by retrospective medical record review. The mean age of the patients was 48.20 ± 13.66 years. @*Results@#The mean body mass index (BMI) was 25.50 ± 4.30 kg/m2 . Primary hyperaldosteronism was the most frequently preoperative diagnosed disease (n = 13, 43.4%), followed by adrenal incidentaloma (n = 8, 26.6%), Cushing syndrome (n = 5, 16.6%) and pheochromocytoma (n = 4, 13.3%). The mean size of postoperative adrenal tumor was 2.72 ± 1.76 cm. The mean operating time was 162 ± 58.14 minutes. Among the 30 patients, 28 patients underwent total adrenalectomy (93.3%) and two patients underwent cortical sparing adrenalectomy (6.7%). When LPRA was performed for patients with BMI > 23.16 kg/m2 , the operating time was longer than the average (P = 0.016). @*Conclusion@#LPRA was suitable and safe for patients with benign adrenal tumors. BMI, retroperitoneal fat density and postoperative adrenal weight may be related to the operating time, so they should be considered when deciding on a surgical method for adrenalectomy.

Influence of Infrapopliteal Runoff Vessels on Primary Patency after Superficial Femoral Artery Angioplasty with Stenting in Patients with Claudication

Purpose@#The number of infrapopliteal runoff vessels seems to be one of the factors influencing arterial patency in patients who had undergone superficial femoral artery (SFA) angioplasty with stenting. However, the effectiveness of infrapopliteal runoff vessels in predicting patency during SFA angioplasty remains unclear. This study aimed to determine whether the number and quality of infrapopliteal runoff vessels affect the primary patency after SFA angioplasty with stenting in patients with claudication. @*Materials and Methods@#This study reviewed a retrospective database of patients with claudication who underwent SFA angioplasty with stenting between March 2011 and December 2016. The preoperative computed tomography findings of all patients were reviewed to assess infrapopliteal runoff vessels. The Trans-Atlantic Inter-Society (TASC) II classification and modified Society for Vascular Surgery (SVS) runoff score were used for subsequent analysis. Kaplan–Meier survival curves were constructed, and Fisher’s exact and chi-square tests were used for data analysis. @*Results@#A total of 153 limbs of 122 patients (88.2% male, mean age: 69.1 years) underwent SFA angioplasty with stenting. The overall primary patency rates of TASC II A/B and C/D cases were 77.1% and 31.2%, respectively, at 36 months (P<0.001). The primary patency rates at 36 months using the modified SVS runoff scoring system were 64.6% and 49.8% for the good-to-compromised (≤9 points) and poor (≥10 points) runoff groups, respectively (P=0.011). @*Conclusion@#The modified SVS runoff scoring system is effective in predicting primary patency after SFA angioplasty with stenting in patients treated for claudication.

Thyrotropin suppression therapy for papillary thyroid carcinoma with a huge recurred neck lymph node

Differentiated thyroid cancer (DTC) originating from thyroid tissue is affected by thyrotropin (TSH). TSH suppression therapy is usually recommended after thyroidectomy in cases of DTC. A 57-year-old woman who harbored a very huge recurred lymph node underwent TSH suppression therapy because of the risk of surgical complications. After TSH suppression, the huge neck lymph node exhibited a response and decreased in size. She had been followed up for 144 months. TSH suppression therapy could be considered as an alternative treatment option in a recurred DTC patient with a high perioperative risk.

Influence of Infrapopliteal Runoff Vessels on Primary Patency after Superficial Femoral Artery Angioplasty with Stenting in Patients with Claudication

Purpose@#The number of infrapopliteal runoff vessels seems to be one of the factors influencing arterial patency in patients who had undergone superficial femoral artery (SFA) angioplasty with stenting. However, the effectiveness of infrapopliteal runoff vessels in predicting patency during SFA angioplasty remains unclear. This study aimed to determine whether the number and quality of infrapopliteal runoff vessels affect the primary patency after SFA angioplasty with stenting in patients with claudication. @*Materials and Methods@#This study reviewed a retrospective database of patients with claudication who underwent SFA angioplasty with stenting between March 2011 and December 2016. The preoperative computed tomography findings of all patients were reviewed to assess infrapopliteal runoff vessels. The Trans-Atlantic Inter-Society (TASC) II classification and modified Society for Vascular Surgery (SVS) runoff score were used for subsequent analysis. Kaplan–Meier survival curves were constructed, and Fisher’s exact and chi-square tests were used for data analysis. @*Results@#A total of 153 limbs of 122 patients (88.2% male, mean age: 69.1 years) underwent SFA angioplasty with stenting. The overall primary patency rates of TASC II A/B and C/D cases were 77.1% and 31.2%, respectively, at 36 months (P<0.001). The primary patency rates at 36 months using the modified SVS runoff scoring system were 64.6% and 49.8% for the good-to-compromised (≤9 points) and poor (≥10 points) runoff groups, respectively (P=0.011). @*Conclusion@#The modified SVS runoff scoring system is effective in predicting primary patency after SFA angioplasty with stenting in patients treated for claudication.

Thyrotropin suppression therapy for papillary thyroid carcinoma with a huge recurred neck lymph node

Differentiated thyroid cancer (DTC) originating from thyroid tissue is affected by thyrotropin (TSH). TSH suppression therapy is usually recommended after thyroidectomy in cases of DTC. A 57-year-old woman who harbored a very huge recurred lymph node underwent TSH suppression therapy because of the risk of surgical complications. After TSH suppression, the huge neck lymph node exhibited a response and decreased in size. She had been followed up for 144 months. TSH suppression therapy could be considered as an alternative treatment option in a recurred DTC patient with a high perioperative risk.

Usefulness of dynamic risk stratification in pediatric patients with differentiated thyroid carcinoma

PURPOSE: Recently, the American Thyroid Association (ATA) dynamic risk stratification (DRS) has been verified to be more valuable than the static anatomical staging system for predicting prognosis in patients with differentiated thyroid carcinoma (DTC). The purpose of this retrospective study was to compare the clinical usefulness of DRS, which is based on the response to initial treatment, with that of ATA initial risk stratification in pediatric patients. METHODS: A total of 144 pediatric patients underwent thyroid operation from August 1982 to December 2013 at Yonsei University Hospital (Seoul, Korea). Among them, 128 patients with complete clinical data were enrolled in this study. Clinicopathologic features and surgical outcomes were retrospectively analyzed by medical chart review. The mean follow-up duration was 11.5 years. RESULTS: The mean tumor size was 2.1 cm; 80.4% of patients were diagnosed with conventional papillary thyroid carcinoma, and 7.0% of patients were diagnosed with follicular thyroid carcinoma. Low-risk patients had the highest probability of an excellent response to initial treatment (66.6%). High-risk patients had the highest probability of a structural incomplete response (100%) and the lowest probability of an excellent response (11.1%). The ATA risk stratification and the DRS system were independent risk factors for disease-free survival (DFS) (P = 0.041 and P < 0.001, respectively). CONCLUSION: The DRS system, which is based on the response to initial treatment, can offer more useful prognostic information compared with ATA risk stratification in pediatric patients with DTC.

Erratum to: The Usefulness of Critical Pathway in Laparoscopic Cholecystectomy

Authors requested to change the name of the hospital to proper name.

Risk Factors of Postoperative Hypocalcemia after Total Thyroidectomy of Papillary Thyroid Carcinoma Patients / 대한내분비외과학회지

PURPOSE: Postoperative hypocalcemia is a common complication of thyroidectomy. This study evaluated the incidence and predisposing risk factors for postoperative permanent hypocalcemia after total thyroidectomy. METHODS: There were 1,247 consecutive patients undergoing total thyroidectomy and complete treatment and observation for differentiated thyroid cancer between January 2012 to December 2012 who were enrolled in this study. Patients were divided into two groups, those remaining normalcalcemic (Group I-824 pts) and those who had hypocalcemia requiring treatment (Groups II-423 pts). Group II was subdivided into a transient hypocalcemic group (Group IIA-409 pts) and a permanent hypocalcemic group (Group IIB-14 pts). RESULTS: Female gender, thyroiditis, preserved parathyroid number, lateral lymph node metastasis, RAI treatment, preoperative parathyroid hormone and preoperative vitamin D were significantly associated with the development of postoperative hypocalcemia by multivariate analysis. Comparing patients with transient versus permanent hypocalcemia, tumor size and multiplicity were significantly related to the development of permanent hypocalcemia by multivariate analysis. RAI treatment and parathyroid hormone level on the postoperative third day were significantly related to recovery from transient hypocalcemia to normo-calcemia. CONCLUSION: Risk factors of postoperative hypocalcemia were associated with preoperative patient factors and advanced thyroid cancer. Advanced thyroid cancer was a risk factor for permanent hypocalcemia. To prevent postoperative hypocalcemia, we should focus on patient condition and need to preserve parathyroid gland more carefully in thyroid surgery.

The Usefulness of Critical Pathway in Laparoscopic Cholecystectomy

PURPOSE: Under the rising demand of health services, the critical pathway (CP) which standardizes the practice guideline was introduced as a means to provide quality healthcare service. CP may increase the patient's satisfaction rate by providing systematic and consistent service. We aimed to evaluate the significance of CP by development and application of CP to patients undergoing laparoscopic cholecystectomy. METHODS: From June 2010 to July 2011, 148 patients underwent elective laparoscopic cholecystectomy. Patients were divided into two groups, including 57 patients in the CP group and 91 patients in the non-CP group. In a retrospective review, related hospital costs were analyzed and compared for both groups. Survey results on satisfaction for the CP group were also analyzed. RESULTS: The mean age was 22.7 years in the CP group and 37.9 years in the non-CP group. Number of hospitalized days was one day for the CP group and 2.51 days for the Non-CP group with p<0.001. In cost analysis all variables showed a significant reduction in the CP group compared to the Non-CP group. The satisfaction rate in the CP group scored 8 points out of 10. CONCLUSION: Results have shown benefit from the financial point of the view for the CP group. Current inclusion criteria for CP are limited and still in development for a solid protocol. Further efforts with a large-scale comparative study to broaden the indication for CP are desired.

Clinical Features of Cataract Extraction with Negative-Power Intraocular Lens Implantation in High Myopia

PURPOSE: To evaluate the clinical features of high myopic eyes with cataracts implanted with negative power intraocular lenses (IOLs) at the time of cataract surgery. METHODS: A retrospective chart review was conducted of 18 eyes of 14 patients who underwent cataract surgery with negative power IOLs and 10 eyes in 9 patients with low power IOLs. We investigated axial length, IOL power, preoperative and postoperative best-corrected visual acuity (BCVA) and preoperative and postoperative spherical equivalent (SE) refractive errors. RESULTS: Mean BCVA showed significant improvement in both groups. We measured postoperative SE refraction and the difference between the mean intended and the mean achieved SE refractive errors in the negative power group (17 eyes) was +1.59 ± 1.34 D and +0.31 ± 0.50 D in the low power group. CONCLUSIONS: BCVA was significantly improved in the majority of eyes, although they had myopic macular degeneration or posterior staphyloma. However, the mean achieved postoperative SE refraction was more hyperopic than the predicted postoperative SE error. Additionally, hyperopic refractive error was greater in the negative power group than the low power group. Therefore, we recommend that postoperative hyperopic refractive error should be considered when performing cataract surgery in high myopic patients.

Feasible Factors to Reduce Hospital Days after Laparoscopic Cholecystectomy

PURPOSE: Under the proper program, day-case laparoscopic cholecystectomy is feasible in the aspect of postoperative recovery consisting of patient's satisfaction and postoperative complication. In this study, we plan a new protocol for laparoscopic cholecystectomy by analyzing factors that can reduce hospital days. METHODS: A total of 175 patients who underwent three-day laparoscopic cholecystectomy were initially selected. Out of 175 patients, secondary selection was executed using inclusion criteria. The selected patients were scheduled for new two-day laparoscopic cholecystectomy, and 89 patients were included in the data analysis. This study elucidated the comparative analysis between the discharged in the postoperative day 0 group and the postoperative day 1 group. RESULTS: The clinical characteristics were not significantly different between discharged in the postoperative day 0 group and the postoperative day 1 group. The combined diseases were not significantly different between the two groups. Post-operative complications in both groups were analyzed on the seventh day after the operation. No significant difference was observed between the two groups. Members of the patient group who were discharged on postoperative day 0 were given a survey regarding post-operative pain, desirability of discharge, and the level of satisfaction with patient education. The average score was 8.3 out of 10 points. In comparison of the total hospital cost between the two groups, the group discharged on postoperative day 0 had lower cost in all factors. CONCLUSION: We conclude that day-case laparoscopic cholecystectomy is as safe and effective as routine clinical pathway applied laparoscopic cholecystectomy in stable cardiovascular disease, uncomplicated pulmonary disease, and controlled DM patients.

A Case of Acute Nonarteritic Anterior Ischemic Optic Neuropathy in Patient on Hemodialysis

PURPOSE: To report a case of non-arteritic anterior ischemic optic neuropathy (NAION) in a patient on hemodialysis. CASE SUMMARY: A 59-year-old female undergoing intravenous hemodialysis developed sudden blurred vision for 2 days. Chronic hypotension and anemia may have been persisted for approximately 6 months before the onset of symptoms. Her corrected visual acuity in both eyes was 0.7 and visual field test showed superior arcuate defect in the left eye. Fundus photography showed inferonasal optic disc swelling and fluorescein angiography revealed hyperfluorescence of the disc in the late phase which was probably attributable to NAION. After 3 weeks, corrected visual acuity was 0.7 in the left eye and fundoscopic finding of the left eye was improved. CONCLUSIONS: Hemodialysis can cause a hypotensive event and anemia which may be associated with NAION. Avoiding acute hypotension and anemia should be advised to prevent development of NAION in dialysis patients.

Orbital Cellulitis Following Strabismus Surgery

PURPOSE: To report a case of sudden orbital cellulitis presenting 2 weeks after strabismus surgery in a patient who had previously undergone retinal surgery for rhegmatogenous retinal detachment. CASE SUMMARY: A 45-year-old male visited the ophthalmology clinic with a 3-day history of left eye pain and lid swelling which suddenly developed 2 weeks after left lateral rectus muscle recession surgery for secondary sensory exotropia. The patient had undergone trans pars plana vitrectomy twice, scleral encircling, oil injection and removal for rhegmatogenous retinal detachment 1.3 years prior. His best corrected visual acuity was 0.2 in his left eye and physical examination revealed eyelid edema, chemosis, and subconjunctival hemorrhage of the left eye. The next day, eye movements were moderately restricted. Computed tomography scanning with contrast enhancement demonstrated diffuse periorbital soft tissue swelling and enhanced fat stranding suggesting left orbital cellulitis. The patient was hospitalized with intravenous broad spectrum antibiotics. He was discharged after a 5-day course of intravenous antibiotic treatment, but readmitted for symptom aggravation and purulent discharge from the left conjunctival fornix. Culture of conjunctival fornices revealed penicillin-resistant staphylococcus aureus. Intravenous anitibiotics were maintained for 11 days additionally and left eye swelling, tenderness and ocular movement restrictions were improved. The patient was discharged from the hospital with a best corrected visual acuity of 0.2.

Changes in Optic Nerve Parameter Measurements on Spectral-Domain Optical Coherence Tomography, after Cataract Surgery

PURPOSE: To assess changes in peripapillary retinal nerve fiber layer (RNFL) thickness and optic nerve head parameters after cataract surgery by using spectral-domain optical coherence tomography (OCT). METHODS: Twenty-nine eyes of 26 patients, who underwent cataract surgery, were imaged with spectral-domain OCT before and after surgery to measure peripapillary RNFL thickness and optic nerve head parameters, signal strength (SS), quadrant, 12 clock-hour RNFL thickness, rim area, disc area, cup/disc area ratio, vertical cup/disc ratio, and cup volume. RESULTS: The postoperative RNFL thickness and SS were higher than before surgery (p < 0.05). Regarding optic nerve head parameters, rim area was 0.07 +/- 0.10 mm2 higher than before surgery and disc area, cup/disc area ratio, vertical cup/disc ratio, cup volume were 0.07 +/- 0.15 mm2, 0.04 +/- 0.04, 0.03 +/- 0.05, 0.04 +/- 0.06 mm3, respectively, lower than before surgery (p < 0.05). CONCLUSIONS: Cataracts may decrease peripapillary RNFL thickness measurement and SS on OCT scans and change other optic nerve head parameters. Peripapillary RNFL thickness and optic nerve head parameter measurements should be interpreted with caution in eyes with significant cataracts.

The Effectiveness of Lacrimal Trephination for the Treatment of Canalicular Obstruction

PURPOSE: To determine the effectiveness of lacrimal trephination to treat canalicular obstruction. METHODS: Silicone intubation following lacrimal trephination was performed in 38 eyes of 29 patients with epiphora due to canalicular obstruction between December 2005 and October 2009. Medical records were retrospectively reviewed and telephone interviews were performed. The severity of epiphora was graded by Munk's scale, and anatomical improvement was evaluated by postoperative probing and syringing. RESULTS: The procedure was successful in 73.7% of the cases (grade 0 or 1), and 68.4% of the eyes had complete resolution of epiphora (grade 0). The anatomical success rate was 81.6%. CONCLUSIONS: Lacrimal trephination is a simple and effective treatment for canalicular obstructions. Therefore, lacrimal trephination could be performed prior to attempting an invasive conjunctivodacryocystorhinostomy.

A Case of Primary Sebaceous Carcinoma of the Lacrimal Gland

PURPOSE: To report a case of very limited primary sebaceous carcinoma of the lacrimal gland that soon recurred and rapidly progressed after excision and radiotherapy. METHODS: A 67-year-old man presented to our clinic with a history of proptosis in his right eye for 1 month. On physical examination, 4mm exophthalmos and a palpable mass at the superotemporal area of the lacrimal gland without tenderness were noted in his right eye. The eyelid was entirely normal on examination. A CT scan was taken which showed a heterogenous mass in the lacrimal gland area. We performed surgical excision and biopsy of the mass through lateral orbitotomy. RESULTS: Primary sebaceous carcinoma of the lacrimal gland was diagnosed pathologically. A 63-Gy electron beam was irradiated for 6 weeks. Five months after the operation, a large mass was again palpable at the superotemporal orbital area. MRI revealed recurrence of the sebaceous carcinoma and its metastasis to the brain. Systemic metastasis in multiple organs was noted on PET scan. CONCLUSIONS: As primary sebaceous carcinoma of the lacrimal gland has a very poor prognosis, aggressive treatment such as exenteration should be considered, and a CT scan should be taken early on to find any recurrence or metastasis.

Minimal invasive treatment of uterine myoma: Laparoscopic radiofrequency myolysis / 대한산부인과학회지

OBJECTIVE: To evaluate the feasibility, efficacy and safety of minimal invasive treatment of uterine myoma with laparoscopic radiofrequency (RF) myolysis. METHODS: 69 patients with symptomatic uterine myomas underwent laparoscopy assisted RF myolysis. The accurate targeting and thermal intensity during the procedure were guided by trans-vaginal ultrasound. The measurement of myoma volume and UFS-QOL (Uterine fibroid symptom-quality of life) were obtained once at preoperative period and four times at postoperative period of one week, 1, 3, 6 months. Wilcoxon signed rank test (SPSS 7.5) was used to compare the volume changes of myoma. A significant level of p<0.05 was considered. RESULTS: 107 fibroids were treated with RF myolysis. The mean duration of RF procedure was 15.2+/-18.5 minutes. Mean preoperative volume of treated fibroids was 75.7 cm3 (range: 8.2-367.7) and the mean volume decrease was 12.1+/-10.2%, 32.3+/-40.2%, 48.3+/-33.6%, 53.5+/-18.1% at one week, 1, 3, 6 months. Fifty eight patients had improved symptom severity with UFS-QOL score: symptom severity score 30.8+/-8.2 (mean+/-S.D.), quality of life score 20.3+/-9.2 after RF myolysis. There were 3 cases of RF heat related complication. CONCLUSION: Early experience of laparoscopy assisted RF myolysis in the treatment of uterine fibroids shows that the method is safe and effective under the guidance of trans-vaginal sonification.

A Case Report: Treatment of Orbital Lymphangioma with Intralesional OK-432 Injection

PURPOSE: To report the first domestic case of orbital lymphangioma treated with intralesional OK-432 injection. METHODS: Initial treatment with systemic corticosteroid had failed. After aspirating the blood, we injected OK-432 (0.05 mg) into the cystic space of the orbital lymphangioma. RESULTS: Although there were minor complications, such as fever and mild tenderness, the patient had an uneventful recovery. After 6 weeks, her visual axis was restored. CONCLUSIONS: We successfully treated this infant patient with an intralesional OK-432 injection. Based on this success, we suggest that treatment of orbital lymphangioma which is refractory to conservative treatment and difficult to resect, may include an intralesional OK-432 injection.

A Case of Advanced Gastric Cancer in Third trimester / 대한산부인과학회지

Gastric cancer associated with pregnancy is extremely rare and the information on this particular subject is limited. Gastrointestinal symptoms such as abdominal pain, nausea, vomiting and loss of appetite are common during pregnancy but also can be the only symptoms in stomach cancer until the late stage. Clinicians' reluctance to pursue diagnostic studies appears to be a major contributing factor of delayed diagnosis and poor outcome. A 33-year-old-women at 30 weeks gestation with advanced gastric cancer died sixteen days after emergency cesarean delivery. We report this case to alert clinicians to this rare possibility.

Classification of Ptosis in Korea

PURPOSE: To classify blepharoptosis in Korean patients, investigate the type of surgery used, and to compare the results with the data from Western countries. METHODS: A total of 913 patients (1147 eyes) who underwent surgery for blepharoptosis from 1991 to 2003 were classified as either being congenital or acquired blepharoptosis, and then further subclassified into myogenic, aponeurotic, mechanical, or neurogenic ptosis according to Freuh's mechanistic classification. The type of surgery for each type of blepharoptosis was investigated. RESULTS: Of the 913 patients, 695 (76.1%) were congenital type, and 218 (23.9%) were acquired type. Freuh's mechanistic classification by type was 84.7% myogenic type, 10.5% aponeurotic, 3.4% neurogenic, and 1.6% mechanical. By order of frequency, the type of surgery used was 60% frontalis suspension, 26.4% levator resection, 12.2% aponeurosis repair, and 1.4% conjunctivomullerectomy. CONCLUSIONS: Congenital type was more common than acquired type. The proportion of congenital type was higher than the results reported from Western countries, but lower than those of previous Korean studies. This is probably due to the increased number of adults undergoing surgery for blepharoptosis compared to the past, and is a reflection of influence of socio-economic levels.