A Case of the Traumatic Common Carotid Artery Injury Treated by Autograft / 대한이비인후과학회지

Cervical area is not protected by bony structures, so traumatic neck injuries can occur frequently. Emergent surgical exploration is necessary for immediate life threatening signs or symptoms, such as expanding hematoma, hematoma with hemodynamic instability, hemomediastinum, hemothorax or hypovolemic shock. Carotid artery reconstruction may be required in some cases of common carotid or internal carotid artery injury because these injuries could develop fatal or serious complications. We report here a case of common carotid artery injury treated by saphenous vein autograft in an emergent situation.

The True Deep Femoral Artery Aneurysm: A Case Report

A 55-year-old man with a palpable pulsatile mass and pain in his left thigh was presented to us. He had no history of trauma in his left leg, interventions, operation, or medical diseases, including cardiac valve disease, endocarditis, and systemic infection. The size of the aneurysm was 10 cm×7 cm with a mural thrombus in ultrasonography and multidetector computer tomography. There was no evidence of other aneurysms or occlusive lesions in the other arteries. The aneurysm was resected without a vascular reconstruction of the deep femoral artery. The patient’s symptom improved rapidly. The patient had an uneventful postoperative recovery without complications. We report a case of true deep femoral artery aneurysm, which was successfully treated with resection of an aneurysm without a vascular reconstruction.

Intensive Long Distance Running as a Possible Cause of Multiple Splanchnic Arterial Aneurysms: A Case Report

This is a case report that suggests the possible association between multiple splanchnic arterial aneurysms and long-distance running. The clinical features of one patient admitted at Chungbuk National University Hospital for treatment of multiple splanchnic arterial aneurysms were reviewed. A 54-year-old man had a recurrent, intermittent and epigastric pain for 2 months. There was no abnormality in gastroscopy and colonoscopy. An abdominal computed tomography angiography documented calcified superior mesenteric artery (SMA) and splenic artery aneurysms. The patient had a history of recreational long-distance running for over 10 years. His average running time per week was more than 10 hours. There was no evidence of systemic arteritis, connective tissue disorder or infectious process that may have caused the aneurysms. He did not take any drugs. The SMA aneurysm was opened, and the aneurysmal segment of SMA was replaced with a vein graft. The splenic aneurysm was observed. The patient recovered without any sequelae.

Anatomical Features and Early Outcomes of Endovascular Repair of Abdominal Aortic Aneurysm from a Korean Multicenter Registry

PURPOSE: To introduce a nation-based endovascular aneurysm repair (EVAR) registry in South Korea and to analyze the anatomical features and early clinical outcomes of abdominal aortic aneurysms (AAA) in patients who underwent EVAR. MATERIALS AND METHODS: The Korean EVAR registry (KER) was a template-based online registry developed and established in 2009. The KER recruited 389 patients who underwent EVAR from 13 medical centers in South Korea from January 2010 to June 2010. We retrospectively reviewed the anatomic features and 30-day clinical outcomes. RESULTS: Initial deployment without open conversion was achieved in all cases and procedure-related 30-day mortality rate was 1.9%. Anatomic features showed the following variables: proximal aortic neck angle 48.8+/-25.7degrees (mean+/-standard deviation), vertical neck length 35.0+/-17.2 mm, aneurysmal sac diameter 57.2+/-14.2 mm, common iliac artery (CIA) involvement in 218 (56.3%) patients, and median right CIA length 34.9 mm. Two hundred and nineteen (56.3%) patients showed neck calcification, 98 patients (25.2%) had neck thrombus, and the inferior mesenteric arteries of 91 patients (23.4%) were occluded. CONCLUSION: Anatomical features of AAA in patients from the KER were characterized as having angulated proximal neck, tortuous iliac artery, and a higher rate of CIA involvement. Long-term follow-up and ongoing studies are required.

Subepithelial Benign Duodenal Tumors Treated by Surgical Resection: A Case Series at A Single Institution / 대한췌담도학회지

BACKGROUND/AIMS: The incidence of duodenal tumors has increased by health surveillance. However, preoperative diagnosis of subepithelial duodenal tumors remains difficult because of the wide variety of pathologies and the location of the tumors. We analyzed endoscopic, radiological, and pathological features of subepithelial benign duodenal tumors (BDTs), which were treated by surgical resection. METHODS: Five patients with subepithelial BDTs treated by surgical resection were analyzed retrospectively. We compared the preoperative and postoperative diagnosis and evaluated the clinical presentations, endoscopic and radiological findings, surgical treatments, pathological results, and outcomes of these patients. RESULTS: All the patients underwent successful surgical resection. There were two cases of gastrointestinal stromal tumors (GISTs) treated with segmental duodenectomy, one case of carcinoid tumor treated with antrectomy, one case of gangliocytic paraganglioma treated with ampullectomy, and a lipoma removed by mass excision. The two GISTs were in the duodenal third and fourth segment close to the pancreas, and it was difficult to exclude pancreatic tumors by imaging studies. All the patients remained healthy for more than three years. CONCLUSIONS: Subepithelial BDTs are rare and difficult to diagnosis. Awareness and preoperative diagnosis of subepithelial BDTs can lead to minimally invasive treatment, including endoscopic or local surgical resection.

Polyarteritis nodosa presented as a dilatation of the intrahepatic bile duct

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis of small- and medium-sized arteries in multiorgan systems. PAN may affect the gastrointestinal tract in 14%-65% of patients, but rarely involves the biliary tract and liver. We describe a patient without underlying disease who was diagnosed with PAN during resection of the gallbladder and liver.

The experience of transumbilical endoscopic appendectomies

Minimally invasive surgery is being widely accepted in various fields of surgery. Although several appendectomy techniques have been reported but, there is no standardization. We report here the experiences of transumbilical endoscopic appendectomy in humans. Between July 2008 and September 2010, ten patients with appendicitis successfully underwent transumbilical endoscopic appendectomies. There were 7 cases of suppurative, 2 cases of gangrenous and 1 case of perforated in operative findings. The ages of the patients were 13-56 years (mean age, 32.7 +/- 15.4 years). Under general anesthesia, a 15-mm port was inserted through the umbilicus and then a two-channel endoscope was inserted in the peritoneal cavity. After appendix identification, counter-traction of the appendix with a direct abdominal wall puncture using a straight round needle prolene was performed to achieve good visualization of the operative field. Tissue dissection was performed using an endoscopic needle knife. Tissue grasping and resected appendix retrieval were done with endoscopic forceps. The average operation time was 79.5 +/- 23.6 minutes (range, 45 to 110 minutes). No procedures were converted to laparoscopic or open appendectomy. Hospital stay was 4-6 days. All patients completely recovered without complications. As it is highly maneuverable, we believe transumbilical endoscopic appendectomy can be a feasible method. And, as surgeons want to proceed from laparoscopic surgery to natural orifice transluminal endoscopic surgery, this procedure could be a triable method.

Hospital Patients Based Incidence of Acute Aortic Dissection / 대한혈관외과학회지

PURPOSE: Acute aortic dissection (AAD) is considered one of the most common aortic catastrophes. However, there are a few epidemiological studies and true incidence was unknown in the general population. With the advent of newer diagnostic techniques, AAD is more frequently detected in radiological studies. We determined the incidence of AAD in a hospital patient group. METHODS: A hospital patient group was defined as all patients from the emergency room and outpatients' department (total number, 347,204) enrolled in Chungbuk National University Hospital between 2005 and 2010. Twenty-five AADs were detected by reviewing radiological reports (22,241 chest computed tomography [CT], 39,235 abdominal CT). A traumatic aortic dissection and isolated abdominal aortic dissection was excluded. We calculated person-years in all hospital patients and the incidence of AAD. We estimated a minimal general population based incidence by dividing a total population of geographical regions where patients of AAD were living. RESULTS: The annual age- and sex-adjusted hospital patients based incidence was 6.94 per 100,000 persons (95% confidence interval, 6.92 to 6.97). Nine dissections (36%) involved the ascending aorta, whereas sixteen (64%) involved the descending aorta. AAD was found in patients with six regions. A total population was 1,032,509 and patients included in the study were 296,505, in these six regions. An estimated minimal population based incidence was 1.99. CONCLUSION: In other studies, the incidence of AAD is approximately two to four per 100,000 persons per year. AAD in north area of Chungcheong, Korea occur with similar frequency when it is compared with other population based studies.

The Prevalence of Abdominal Aortoiliac Artery Aneurysm in the Hospital Patient Group and Treatment Status / 대한혈관외과학회지

PURPOSE: Abdominal aortoiliac artery aneurysm (AIAA) is a common disease in the elderly. The prevalence of AIAA was well known in western countries. However, in Korea, there are a few studies regarding the prevalence. This study was carried out to determine the prevalence of AIAA by reviewing the radiological reports of abdominal computed tomography (CT). METHODS: We searched the words like "aneu" or "rysm" in radiological reports of 22,520 abdominal CT (11,974 patients) between January 1, 2005 and March 31, 2010 in patients over 50 years old. We found 121 patients who had AIAA of more than 3 cm or more than 1.8 cm isolated iliac artery aneurysm. We analyzed the characteristics of these patients with aneurysm. RESULTS: The prevalence of aneurysms was 1.01% (121 patients). The aneurysms in men were more prevalent than women (1.39% vs. 0.51%). In the octogenarian, the aneurysms were found to be most frequent (2.75%). Among the 121 aneurysms, aortic, aortoiliac, and isolated iliac artery aneurysms were 66 (54.6%), 28 (23.1%), and 27 (22.3%). In terms of aneurysmal size, greater than 6 cm, 5 to 6 cm, and less than 5 cm were 19 (20%), 13 (14%), and 62 (66%), respectively. The rupture rate was 18% (6 patients) in more than 5 cm abdominal aortic aneurysm. CONCLUSION: The prevalence of AIAA is lower than Western countries. This is not a national-wide survey, but results are similar to the other Korean reports. Reviewing radiologic reports of abdominal CT is another way to study the prevalence of aneurysms.

A Dissecting Aneurysm of the Common and Proper Hepatic Artery with Dissection of the Celiac Axis and the SMA / 대한혈관외과학회지

A spontaneous dissecting aneurysm of visceral arteries without trauma or an iatrogenic cause is rare. We would like to report a case of a dissecting aneurysm of the common and proper hepatic artery with dissection of the celiac axis and the superior mesenteric artery (SMA). A 55-year-old man presented abdominal pain. In the abdominal computed tomography (CT), an intraabdominal hematoma and a dissecting aneurysm of the common and proper hepatic artery with dissection of the celiac axis as well as the SMA had been found. The size of the dissecting aneurysm was growing in a follow-up CT. We performed a bypass between the right hepatic artery and a celiac artery with a saphenous vein after exclusion of the aneurysm. A bypass graft was occluded in the early postoperative period but the patient recovered without major sequelae.

Metastatic Clear Cell Renal Cell Carcinoma to the Thyroid Gland / 대한내분비외과학회지

Clear cell renal cell carcinoma (RCC) is the most common histological subtype of malignant renal tumors. Although RCC frequently metastasizes to many organs, it rarely metastasizes to the thyroid gland without evidence of other organ involvement. We report a case of a metastatic renal cell carcinoma to the thyroid gland, which was misdiagnosed preoperatively as a follicular neoplasm from the fine needle aspiration cytology.

Common bile duct dilatation after cholecystectomy: a one-year prospective study / 대한외과학회지

PURPOSE: Bile duct dilatation after cholecystectomy continues to be a matter of controversy. We aimed determine the magnitude of common bile duct (CBD) dilatation after cholecystectomy followed up to 1 year. METHODS: Sixty-four cases (age, 47.3 +/- 11.7 years; men, 28; women, 36) enrolled in this study. They received laparoscopic cholecystectomy in Chungbuk National University Hospital for symptomatic cholelithiasis or gallbladder polyps with normal bile duct, less than 7 mm. The CBD diameter was measured by one radiologist using ultrasonography at the maximum point after full length evaluation of extrahepatic bile duct. Forty-five and thirty-one cases were followed at 6 months and 1 year, respectively. RESULTS: The CBD was dilated slightly from 4.1 mm at baseline to 5.1 mm at 6 months and 6.1 mm at 12 months after cholecystectomy. The number of cases of CBD dilatation of more than 7 mm at 6 months and at 12 months after cholecystectomy were 11 (24.4%) and 9 (29.0%), respectively. Seven cases at 6 months and 5 cases at 12 months showed bile duct dilation of more than 3 mm compared to baseline. There were no cases having bile duct dilation of more than 10 mm. CONCLUSION: Postcholecystectomy dilatation of the bile duct occured slightly in most cases. But some cases showed more than 3 mm dilatation over baseline. Asymptomatic bile duct dilatation of up to 10 mm can be considered as normal range in patients after cholecystectomy.

Retroperitoneal Tumors Mimicking Adrenal Tumor / 대한내분비외과학회지

Periadrenal retroperitoneal tumors are frequently misdiagnosed as adrenal tumors because of its rarity and anatomical vicinity. Thus, there are only very few cases reported and little information available in the literature. Preoperative diagnoses of theses tumors are challenging. The definitive diagnosis is based on postoperative pathological findings. We report two cases of periadrenal retroperitoneal tumors that mimicked adrenal neoplasms. Final diagnoses were mature cystic teratoma and papillary renal carcinoma, respectively. Although periadrenal retroperitoneal tumors are rare, it should be considered in the differential diagnosis of adrenal incidentalomas.

Relationship between Tortuosity and Atherosclerotic Changes of the Abdominal Aorta / 대한혈관외과학회지

PURPOSE: Tortuosity and atherosclerosis of the abdominal aorta are commonly observed in the elderly. Few studies about aortic tortuous changes have been performed. This study was carried out to investigate the relationship between aortic tortuous and atherosclerotic changes. METHODS: We included 2,920 patients by reviewing computerized tomography scans in Chungbuk National University Hospital during 2007. We classified the abdominal aorta into straight (I form) and tortuous forms (T form), defined as a deviation involving more than half the aortic diameter. The T form was further subdivided into 2 types (C type, 1 curve; T type, >2 curves). The calcification index (CI) was also measured. The tortuosity index (TI) was measured in 60 patients each with the I form and the C and S types. We analyzed relationships between tortuosity and clinical variables. RESULTS: The incidence of tortuosity was 56.2%, and in the 7th, 8th, 9th decades of life it was 61.7%, 77.3%, and 91.0%, respectively. In univariate analysis, age, female sex, hypertension, and CI were statistically significant. In multivariate analysis, CI was not statistically significant between the I and T forms but significant between the I form and the S type. TI in the T form was lower than in the I form. However, no difference was seen between the I form and C type. CONCLUSION: A tortuous change of the abdominal aorta was seen earlier and more frequently than an atherosclerotic change and were associated with aging, calcification, and hypertension. Aortic calcification was associated with more complex tortuous changes.

Sonic Hedgehog Protein Expression in Various Thyroid Tissues and Its Clinical Implication / 대한내분비외과학회지

PURPOSE: The Hedgehog (Hh) signaling pathway is important in embryonic development including cell differentiation and proliferation. Recently, activation of this pathway has been implicated in several forms of solid cancers. We investigated sonic hedgehog (Shh) protein expression and its relation to differentiation and clinicopathologic characteristics in thyroid cancer cell lines and tissues. METHODS: FTC-236, FTC-238, and XTC-1. We made tissue microarray slides using 80 thyroid surgical specimen: 40 benign and 40 malignant lesions. Immunohistochemical staining was performed using anti-Shh antibody. mRNA expression of NIS, thyroglobulin, and CD97 were evaluated by RT-PCR. Cyclopamine was used as a Shh signal inhibitor. RESULTS: Shh expression was more prominent in TPC-1, FTC-133, and XTC-1 cell lines than the others. Cyclopamine downregulated CD97 and upregulated thyroglobulin mRNA expression, but did not induce mRNA expression of NIS. Thyroid tissues showed varied expression of Shh in both benign and malignant diseases. Shh expression was detected in 38 of 50 (76%) normal, in 18 of 25 (72%) non-neoplastic benign, in nine of 15 (60%) benign tumors, and in 31 of 40 (77%) malignant tumors. Shh over-expression was significantly less frequent in papillary thyroid carcinomas than in normal or benign thyroid tissues. In addition, Shh protein expression did not relate to clinicopathologic characteristics in papillary thyroid carcinomas. CONCLUSION: Thyroid tissues and cell lines vary in expression of Shh. Cyclopamine can induce redifferentiation in thyroid cancer cell lines. Shh protein expression, however, is unrelated to clinicopathologic characteristics in papillary thyroid carcinomas.

Successful Removal of a Migrated Catheter of Chemoport in Right Atrium

The use of totally implantable central venous access devices (chemoport) has increased with the development of chemotherapeutic agents in oncologic patients, especially with no venous access site. However, there can be various complications such as port site infection, thromboembolism, injury of central vein, fracture of catheter, and migration of catheter. We report a rare case of migration of catheter to right atrium due to the separation of the catheter from the chemoport.

Can Review of Sonographic Findings Spare Diagnostic Thyroidectomy in Patients with Thyroid Nodules Suspicious of Follicular Neoplasm Cytologically?

PURPOSE: Follicular neoplasms (FNs) such as follicular adenoma and carcinoma (FTC), nodular hyperplasia (NH) and follicular variant of papillary carcinoma (FVPC) share cytological features. In the present study, we investigate whether review of sonographic findings in patients with thyroid nodules suspicious of FN spares diagnostic thyroidectomies (DTs) by excluding benign diseases such as NH or not. METHODS: From June 1999 to May 2007, DTs were performed on 98 patients who had nodules suspicious of FN. High resolution sonographic findings are available for 53 patients. According to the final histologic diagnosis: Group I (23 patients) consisted of 20 FNs (11 FTCs), 1 Hurthle cell adenoma, 2 FVPC; Group II (30 patients) consisted of all others (23 NHs, 4 Hashimoto's thyroiditis, 3 papillary carcinomas (PTCs). Sonographic features were compared between the two groups. RESULTS: Three differential sonographic findings (DSF) i.e. irregular margin, absence of peripheral halo or marked inhomogeniety were identified more often in Group II than Group I (P<0.05). If we spared DTs for patients who have at least one DSF, 18 patients (34.0%) would have been selected for clinical follow-up whose final diagnoses were 14 NHs and 4 PTCs (including 1 FVPC). Sparing DTs by DSFs shows sensitivity, 56.7%; specificity, 95.7%; positive predictive value, 94.4%; negative predictive value, 62.9%; and accuracy, 73.6%, respectively. CONCLUSION: In patients with thyroid nodules suspicious of FN, sonographic findings such as irregular margin, absence of peripheral halo or marked inhomogeneity might spare DTs with the help of other diagnostic modalities such as cytogenetic or immunohistochemical studies.

Acute Ischemic Hepatitis and Pancreatic Abscess after Elective Abdominal Aortic Aneurysm Repair: A Case Report

Acute ischemic hepatitis and pancreatic abscess after aortic surgery are not common gastrointestinal complications. We report here on a case of ischemic hepatitis and pancreatic abscess that occurred sequentially after elective AAA (abdominial aortic aneurysm) repair. The patient recovered with careful supportive management and external drainage without the graft becoming infected.

Single Incision Three Ports Laparoscopic Appendectomy / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic appendectomy (LA) is becoming popular for the treatment of acute appendicitis. The laparoscopic appendectomy has the advantages of a more rapid recovery, better cosmetic outcome and reduced postoperative pain compared to the open appendectomy. Several laparoscopic procedures have been described that used two or more trocars. We present the results of a new LA technique that performed through three ports in a single incision. METHODS: A single incision three-port LA was performed in 10 patients. Under general anesthesia, a 5 mm scope (0degrees), 2 mm working port and 5 mm working port were inserted through the umbilicus. The appendix was grasped and dissected from the surrounding tissues with a grasper or dissector. The base of the appendix was ligated with an endo-loop two times and cut by scissors. The appendix was then withdrawn through the umbilicus. RESULTS: The average operating time in our series was 69.5+/-23.3 minutes and the median time to discharge 4.5+/-1.9 days. Wound infection developed in two patients. There was no conversion to traditional LA or laparotomy. CONCLUSION: A single incision three port LA was safe and effective for LA. The availability of laparoscopic procedures has expanded the range of options available from which to choose a suitable procedure for individual cases.

Left Iliac Vein Compressions and Venous Hemodynamic Changes

PURPOSE: Left iliac vein compression is a risk factor for deep vein thrombosis (DVT) and often can be symptomatic. We wanted to know the incidence of left iliac vein compressions in the general population and the relationship between iliac vein compression and outflow fraction of the lower extremities. METHODS: 1,523 cases examined with abdomen - pelvis CT were included in this study. Left iliac vein compression was calculated as the diameter of left common iliac vein at the site of maximal compression divided by the diameter of the uncompressed caudal common iliac vein. These cases were divided into 4 groups by the degree of iliac vein compression. In addition, left lower extremity venous outflow fractions in 106 patients with abdomen - pelvis CT images were recorded and analyzed. RESULTS: The number and mean age of each group (group 1, 2, 3 and 4) were 351 (23%) & 62.3+/-13.4, 426 (28%) & 57.7+/-16.1, 529 (35%) & 50.1+/-20.4 and 217 (14%) & 40.7+/-22.9, respectively. While the age of patients was decreasing, the occurrence of left iliac vein compression increased (P<0.01). The mean left low extremity venous outflow fractions of each group (group 1, 2, 3 and 4) was 27.9+/-6.9%, 26.9+/-6.4%, 25.9+/-6.7% and 19.1+/-6.6%, respectively. The mean outflow fraction of group 4 was significantly lower than that of other groups (P<0.01). There was a tendency that the more left iliac vein compression increased, the more outflow fraction decreased (P=0.011). CONCLUSION: In 14% of 1,523 cases, there were severe left iliac vein compressions, more than 75% diameter, and the mean outflow fraction of that was lower than in others. Further study is needed to realize the relationship between left iliac vein compression and DVT.