Arteriovenous Malformation on the Medial Plantar Area of the Foot: A Case Report / 대한족부족관절학회지

Arteriovenous malformation (A-V malformation) is defined as an abnormal connection between arteries and veins that lead to A-V shunting with an intervening network of vessels. A-V malformation is a rare condition, and spontaneous regression is also rare. A-V malformation becomes symptomatic when the surrounding tissue and osseous structures are negatively affected. A-V malformation has a high recurrence rate and is relatively hard to treat. In this case, a huge mass with pulsatile and bruit on the medial plantar area were observed. With the diagnosis of A-V malformation in accordance with the results from ultrasonography, magnetic resonance imaging and computed tomography angiography, and mass excision with feeding vessel ligation through plantar midfoot approach was completed successfully.

Acute Peritonitis Caused by a Fibrosarcoma of the Transverse Colon in an Adult

A fibrosarcoma is a malignant mesenchymal tumor derived from fibrous connective tissue. It usually develops in the deep soft tissues of the extremities, as well as the trunk, head, and neck. In extremely rare cases, a fibrosarcoma may occur in the gastrointestinal tract. Most cases of fibrosarcoma in the gastrointestinal tract have been observed in the pediatric age group while only a few cases have been reported in adults. A 61-year-old male presented with pain in the entire abdominal region. Chest radiography showed free air in the subphrenic space. After an emergency operation, we found a solid mass around the transverse colon and performed a segmental resection with a lymphatic dissection of the transverse colon, including the mass. A pathologic examination showed a fibrosarcoma with a perforation. There was no perioperative complication. The patient was discharged on postoperative day 11 and had follow-ups for 1 year without any recurrence.

Digital Pulse Oximetry for the Screeing of Lower Extremity Arterial Disease

STUDY DESIGN: Retrospective study. OBJECTIVES: The aim of the study was to investigate the usefulness of a handheld digital pulse oximetry in the detection of lower extremity arterial disease. SUMMARY OF LITERATURE REVIEW: Pulse oximetry is a well-established method for noninvasive evaluation of arterial oxygenation. MATERIALS AND METHODS: A Retrospective study was performed in 45 patients with lower extremity arterial disease. We compared the accuracy of a handheld digital pulse oximetry and the ankle brachial index (ABI). Digital pulse oximetry was conducted for 42 patients with 84 limbs to measure the SaO2 of their index fingers and big toes in supine position. The ABI was defined as abnormal if it was less than 0.9. Pulse oximetry of big toes was defined as abnormal if the SPO2 was less than 96% or it was more than 2% lower than that of the index finger. RESULTS: Digital pulse oximetry had a sensitivity of 47%(95% CI, 34-60%) and specificity of 86%(95% CI, 64-96%). ABI had a sensitivity of 49%(95% CI, 34-64%) and specificity of 95%(95% CI, 72-99%). Positive predictive values were 91%(95% CI, 74-98%) for digital pulse oximetry and 96%(95% CI, 77-99%) for ABI. Negative predictive values were 37%(95% CI, 24-51%) for digitial pulse oximetry and 43%(95% CI, 25-72%) for ABI. In 22 cases with acute ischemicwere the sensitivity 73%, the specifity 100%, the positive predictive value 100% and the negative predictive value 79%. CONCLUSIONS: Handheld digital pulse oximetry of the big toes seems as accurate as ABI to detect lower extremity arterial diseases. The combination of both will help to distinguish low extremity arterial disease and spinal radiculopathy.

Intraluminal Snared-Atheroma Causing Common Femoral Artery Stenosis after Using Perclose Suture-Mediated Closure System / 대한혈관외과학회지

Mechanical closing devices were developed to shorten bed rest following percutaneous vascular intervention, and recently, the devices are replacing the conventional manual compression. Among the closing devices, the Perclose suture-mediated closure system (Perclose/Proglide) is known to be a safe and effective method that permits faster hemostasis and earlier ambulation compared with manual compression. However, with increased usage of femoral closure devices, reports of complications have emerged. Most reported complications are local bleedings, hematomas, and wound infections. Herein, we report a rare case: common femoral artery (CFA) stenosis after using Perclose suture-mediated closure system. After failure of secondary ballooning of the CFA stenotic segment, CFA was opened operatively and we found that snared atheroma by Perclose suture material was occupying the CFA lumen. Endarterectomy was performed for the lesion and the CFA stenosis was improved.

Utility of digital pulse oximetry in the screening of lower extremity arterial disease / 대한외과학회지

PURPOSE: The aim of this study was to evaluate screening methods in the lower extremities by measurement of the digital pulse oximetry (oxygen percent saturation [SpO2]) of toes for peripheral arterial disease (PAD). METHODS: A prospective study was performed among 49 patients (98 limbs) with lower extremity arterial occlusive disease. We attempted to measure the ankle-brachial index (ABI), digital pulse oximetry (SpO2), and computerized tomographic angiography (CTA). Patients were divided into three groups by the traditional Fontaine classification system by symptom and CTA criteria: 1) Critical limb ischemia (Fontaine III and IV), 2) Claudication; (Fontaine II), and 3) asymptomatic limbs (Fontaine I). RESULTS: The sensitivity, specificity, positive and negative predictive values between active treatment groups (group I and II; endovascular and open surgery) and conservative group (group III) are all statistically significant. ABI; 55.09%, 94%, 96.7%, 39.02% (R = 12.54, P < 0.000) SpO2; 87.06%, 87.8%, 84.3%, 90% (R = 40.11, P < 0.000). Pre-SpO2 and pre-ABI all show statistically significant correlation in group I vs. group II, symptomatic PAD (group I and II) vs. asymptomatic PAD (group III), and the total PAD comparison. The Pearson's correlation coefficient between SpO2 and ABI all show significant correlation in group II. Pre-SpO2 vs. Pre-ABI show strong positive correlation except asymptomatic group (group III). CONCLUSION: Digital pulse oximetry can be a useful, simple, noninvasive screening device as well as ABI in PAD.

Hemorrhagic cholecystitis: report of a case

Hemorrhagic cholecystitis is an uncommon cause of abdominal pain that can be fatal. We report a case of hemorrhagic cholecystitis in a 75-year-old male taking an anticoagulant. The patient was brought to the hospital with uncontrolled right upper quadrant abdominal pain. On computed tomography, mild gallbladder wall thickening and high density with gallstones in the gallbladder suggested acute calculous cholecystitis or hemorrhagic cholecystitis. An urgent laparoscopic cholecystectomy was performed that revealed a gallbladder filled with large blood clots and two black stones. Patients who develop hemorrhagic complications were often receiving anticoagulation therapy or had pathologic coagulopathy. An early diagnosis of this potentially fatal condition is important to facilitate urgent surgical treatment.

Clinical Features of Lower Extremity Artery Embolism: Comparison of the Clinical Features between Ilio-femoral and Popliteal Artery Embolism

PURPOSE: Prompt operative management of patients with peripheral artery embolism remains the treatment of choice for this malady. The clinical status of the limb, rather than the elapsed time from the onset of occlusion, was recently determined to be the best predictor of limb salvage. We investigated the clinical features, therapeutic modalities and treatment results of popliteal artery embolism compared with that of ilio-femoral artery embolism. METHODS: A retrospective review was carried out for 21 cases that were treated for lower extremity arterial embolism, from March 2000 to June 2006. The patients were classified into two groups; Group A (ilio-femoral artery embolism, n=11) and Group B (popliteal artery embolism, n=10). We analyzed the interval time from the onset of symptoms to starting treatment (the interval time), the degree of limb ischemia, the therapeutic modalities and the treatment results. RESULTS: The average interval time was 16.2+/-16.9 hours in the total 21 cases; the average interval time for Group A was 7.7+/-2.9 hours and that for Group B was 25.5+/-20.9 hours (P<0.05), and the incidence of severe limb ischemia (class IIb according to the SVS/ISCVS reporting standard) was 72.7% vs 20.0%, respectively (P<0.05). For the therapeutic modalities, surgical thromboembolectomy was performed in all cases of Group A and for 3 cases of Group B. Seven cases of Group B received radiologic intervention (3 cases percutaneous aspiration embolectomy only, and 4 cases of additional thrombolytic therapy). CONCLUSION: This study shows that the interval time for popliteal artery embolism is longer than that for ilio-femoral artery embolism. In other words, it is suggested that the symptomatic progression of popliteal artery embolism is slower than that of ilio-femoral artery embolism. Therefore, we can have more chances for variable therapeutic options such as surgical thromboembolectomy, percutaneous aspiration embolectomy and/or thrombolytic therapy in patients suffering with popliteal artery embolism.

The Risk Factors of Pancreatic Fistula after Pancratoduodenectomy

PURPOSE: Pancretojejunostomy leakage is the most dreaded complication after a pancratoduodenectomy. However, little is known about what causes the leakage and how to prevent it. The aim of this study was to dentify the risk factors for pancreatic leakage. This paper describes our experience of its management. METHODS: Between Aug. 1996 and Aug. 2003, 75 consecutive patients with periampullary cancer or benign disease received a pancreatoduodenectomy. The patients' clinical characterisitcs, pathological features and surgical findings were retrospectively evaluated. The patients were classified into those with major complication and rhose with no complications and the risk factors were analyzed. Pancreatic leakage, intraabdomnial fluid collection and abscess, intraabdomnial bleeding were categorized as major complications related to a pancreatic fistula. RESULTS: The postoperative mortality and morbidity rate was 2.6% and 36%, respectively. Univariate analysis showed that the pancreatic texture, pathologic diagnoses and comorbidity were significant risk factors for major complications (P= 0.003, 0.045, 0.02). Multivariate analyses revealed that the, pancreatic texture was the only significant risk factor (P=0.003). The preoperative serum albumin level and pancreatic texture were significant risk factors for pancreatic leakage (p=0.03, 0.025) and multivariate analysis showed that the pancreatic texture was also the most significant risk factor. CONCLUSION: Considering that the pancreatic texture is the most significant risk factor for a pancreatic fistula, the technical skill and experience of the surgeon appears to be important for its prevention.

A Case of Hemoperitoneum Caused by Spontaneous Rupture of Metastatic Omental Hepatocellular Carcinoma

It is known that most of the extrahepatic metastasis of hepatocellular carcinoma occurs through the blood stream and the most frequent target organ is the lung. Intraperitoneal metastasis via the lymphatics is rare (2~16%) and this has been largely demonstrated by laparosopy or on the autopsy findings. Especially, omental metastasis of hepatocellular carcinoma has only been rarely reported on. A 62-year-old male patient who underwent TACE for hepatocellular carcinoma was admitted for an emergency operation for hemoperitoneum. On the operative findings, there were two 1.5 by 3 cm-sized masses in the omentum and one of them was ruptured and bleeding. The masses were diagnosed as metastatic hepatocellular carcinoma on the pathologic examination. The patient recovered and is being followed.

Clinical Consideration of Choledocholithiasis Treatment: Analysis of Primary Closure versus T-tube Drainage after Choledochotomy

PURPOSE: The placement of a drainage tube in the common bile duct, following a choledochotomy, has become accepted as routine procedure since it was first reported, by Abbe, in 1892. However, many complications are associated with T-tube drainage, such as bile peritonitis after its removal, accidental dislodgement, bile leakage from the T-tube track and a high incidence of postoperative bacteremia, have been reported. This study was designed to evaluate the primary closure as a suitable surgical technique in placce of T-tube drainage following a choledochotomy METHODS: Between January and December 2002, primary closures were performed in 41 cases and T tube drainage in 112, following a choledochotomy. These cases were divided into 2 groups (group A: primary closure, and group B: T-tube drainage). The medical records of the patients were reviewed, and the following data analysed -age, sex, preoperative laboratory value, intraoperative finding, postoperative laboratory value, complication, and days of postoperative hospital stay. RESULTS: There were no significant differences observed in the data of the investigated parameters, with the exception of the mean post-operative hospital stay. The mean post- operative hospital stays were 11.82 and 18.08 days in groups A and B (P=0.0034), respectively. The complication rates of each group showed no statistical difference. However bile peritonitis or bile leakage after T-tube removal developed 5 cases from group B. There were 2 and 5 deaths due to MODS & ARDS, respectively. CONCLUSION: A primary closure, following a choledochotomy, may be a suitable alternative technique to T-tube drainage under reasonable conditions.