The Impact of Mechanical Bowel Preparation in Elective Colorectal Surgery: A Propensity Score Matching Analysis

PURPOSE: To evaluate the influence of preoperative mechanical bowel preparation (MBP) based on the occurrence of anastomosis leakage, surgical site infection (SSI), and severity of surgical complication when performing elective colorectal surgery. MATERIALS AND METHODS: MBP and non-MBP patients were matched using propensity score. The outcomes were evaluated according to tumor location such as right- (n=84) and left-sided colon (n=50) and rectum (n=100). In the non-MBP group, patients with right-sided colon cancer did not receive any preparation, and patients with both left-sided colon and rectal cancers were given one rectal enema before surgery. RESULTS: In the right-sided colon surgery, there was no anastomosis leakage. SSI occurred in 2 (4.8%) and 4 patients (9.5%) in the non-MBP and MBP groups, respectively. In the left-sided colon cancer surgery, there was one anastomosis leakage (4.0%) in each group. SSI occurred in none in the rectal enema group and in 2 patients (8.0%) in the MBP group. In the rectal cancer surgery, there were 5 anastomosis leakages (10.0%) in the rectal enema group and 2 (4.0%) in the MBP group. SSI occurred in 3 patients (6.0%) in each groups. Severe surgical complications (Grade III, IV, or V) based on Dindo-Clavien classification, occurred in 7 patients (14.0%) in the rectal enema group and 1 patient (2.0%) in the MBP group (p=0.03). CONCLUSION: Right- and left-sided colon cancer surgery can be performed safely without MBP. In rectal cancer surgery, rectal enema only before surgery seems to be dangerous because of the higher rate of severe postoperative complications.

Therapeutic Considerations of Percutaneous Sacroplasty for the Sacral Insufficiency Fracture

Sacral insufficiency fracture is a debilitating injury not easily found in general radiologic examinations and is rarely diagnosed, since its symptoms are obscure. It is known to frequently occur in patients with osteoporosis, but the treatment has not yet been established and various kinds of treatment methods are being attempted. Sacroplasty is sometimes performed by applying percutaneous vertebroplasty which is known to be a less invasive treatment. Since the course of diagnosis of sacral insufficiency fracture is difficult and clear guidelines for treatments have not yet been established, many spine surgeons fail to diagnose patients or speculate on treatment methods. We report our experience in diagnosing a sacral insufficiency fracture in a 54-year-old healthy female patient using MRI and treating her with sacroplasty. From a therapeutic point of view, we then cover the usefulness, effects and characteristics relating to the complications of sacroplasty, along with literature review.

Pedicular and Extrapedicular Morphometric Analysis in the Korean Population : Computed Tomographic Assessment Relevance to Pedicle and Extrapedicle Screw Fixation in the Thoracic Spine

OBJECTIVE: To evaluate the anatomical parameters that must be considered when performing thoracic transpedicular or extrapedicular screw fixation. METHODS: We selected 958 vertebrae (1,916 pedicles) from 98 patients for analysis. Eight parameters were measured from CT scans : the transverse outer pedicular diameter, transverse inner pedicular diameter, length, angle, chord length of the pedicles and the transverse width, angle, and chord length of the pedicle-rib units. RESULTS: The age of the patients ranged from 21 to 82 years (mean : 48.2 years) and there were 57 men and 41 women. The narrowest transverse outer pedicular diameter was at T5 (4.4 mm). The narrowest pedicle length was at T1 (15.9 mm). For pedicle angle, T1 was 31.6 degrees, which was the most convergent angle, and it showed the tendency of the lower the level, the lesser the convergent angle. The chord length showed a horizontal pattern with similar values at all levels. For the PRU width, T5 showed a similar pattern to the pedicle width at 13.4 mm. For the PRU angle, T1 was the largest angle at 46.2 degrees and the tendency was the lower the level, the narrower the angle. For chord length, T1 was the shortest at 46.9 mm and T8 was the longest at 60.1 mm. CONCLUSION: When transpedicular screw fixations carried out at the mid-thoracic level, special care must be taken because there is a high chance of danger of medial wall violation. In these circumstances, extrapedicular screw fixation may be considered as an alternative treatment.

Thoracic Extrapedicular (Transverse Process) Screws Fixation : Technical Note

Authors performed extrapedicular screws fixation in thoracic spines. Because patient had very narrow thoracic pedicles, classical transpedicular screws fixation could not be accomplished. In case of narrow thoracic pedicles, extrapedicular screws fixation would be a good alternative technique. We describe here a method for thoracic extrapedicular screws fixation.

Clinical Analysis of Spontaneous Intracerebral Hemorrhage in Young People / 대한뇌혈관외과학회지

OBJECTIVE: Spontaneous intracerebral hemorrhage (sICH) is a leading cause of morbidity and mortality, especially in Asian countries. Nevertheless, few reports of sICH in young people have been published. This study investigates the clinical features of sICH in young people. METHODS: Between February 1999 and December 2007, we retrospectively reviewed the medical records of patients aged 45 years diagnosed with sICH at our institute. We analyzed the causes, locations, risk factors, and final outcomes of sICH in these patients. RESULTS: Twenty-one patients (14.5%) were younger than 25 years, while 27 patients (18.6%) were 25~34 years old. Ninety-seven patients (66.9%) were between the ages of 35~45. The most common cause of sICH was hypertension (57.9%). The most common location of sICH was in the lobar region (35.2%). Vascular anomaly was the main cause in both the <25 age group (76.2%) and the 25~34 age group (70.4%). The diagnostic rate of angiography was 75% for the under 25 age group and 80% in the 25~34 age group. CONCLUSIONS: Hypertension is the most common cause of sICH in people between 35 and 45, and vascular anomaly is the main cause in people under 35 years of age. Thus, angiography should be mandatory for people under 35 with sICH, and for people with lobar hemorrhage. For young people, early diagnosis of hypertension and strict blood pressure control is recommended.

Surgical Treatment of the Atlantoaxial Osteoarthritis

Atlantoaxial facet joint osteoarthritis is rare, often undiagnosed because it may be misdiagnosed as occipital neuralgia, or degenerative cervical spondylosis. Unilateral occipitocervical pain aggravated by head rotation is a specific symptom. Conservative treatment is usually effective. But when the patient complains of intractable neck pain localized to occipitocervical junction and unresponsive to medical therapy, surgical treatment should be considered. Though a few reports of surgically treated atlantoaxial osteoarthritis has been published, surgical outcome is favorable. A case of a surgically treated atlantoaxial osteoarthritis is presented with a review of the literatures.

A Case of Brachial Plexus Schwannoma

Brachial plexus schwannoma is rare. A case of a 28-year old woman who complained of a palpable mass in the right axilla is presented. She had previous incisional biopsy on the axillary mass. Brachial plexus magnetic resonance imaging revealed a well circumscribed contrast enhancing mass on the right distal cord of the brachial plexus. EMG revealed normal. Tumor resection was performed with the transaxillary approach. Though dense granulation tissue obscured normal brachial plexus nerve anatomy, using the surgical microscope and nerve stimulator, grossly total tumor resection was performed. She is free of any neurologic symptom at three months postoperatively.

Ruptured Intracranial Aneurysm in a 45-day-old Infant

The incidence of intracranial aneurysms in childhood is rare, especially in infancy. We report a case of a 45-day-old girl who presented with seizure due to a ruptured large saccular aneurysm of the middle cerebral artery(MCA) with subsequent subarachnoid, intracerebral and intraventricular hemorrhage. The baby has enjoyed an excellent clinical outcome after surgical management. The clinical features of the case and review of the literature are presented.

Intra-arterial Nimodipine for the Treatment of Symptomatic Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage : Preliminary Report Clinical Research / 대한뇌혈관외과학회지

OBJECTIVE: We evaluated the efficacy of intra-arterial nimodipine, a calcium-channel blocker acting mainly on cerebral vessels, in patients with symptomatic cerebral vasospasm following subarachnoid hemorrhage. METHODS: Clinical records of 8 consecutively treated patients were reviewed. Patients were considered to determine the indication for cerebral angiography and subsequent endovascular treatment if they presented symptomatic cerebral vasospasm. Nimodipine was infused intra-arterially via microcatheter in the internal carotid artery or basilar artery at a rate of 0.1 mg/min. Immediate angiographic vasodilatation and clinical improvement were assessed. RESULTS: Thirteen procedures were performed in 8 patients. Clinical improvement was observed in 7 (88%) patients. 5 of 8 patients were clinically improved within 24 hours after the first endovascular treatment, and two after the third. The notable arterial dilatation at postprocedural angiography was observed in 9 (70%) of 13 procedures. After follow-up of 3-6 months, 7 (88%) patients had a favorable outcome (Glasgow Outcome Scale score of 5-4). No procedure related complications were observed. CONCLUSION: Intra-arterial nimodipine infusion is effective and safe for the treatment of symptomatic vasospasm after subarachnoid hemorrhage. Further prospective randomized studies are needed to support these results.

Results of Surgical and Endovascular Treatment of Middle Cerebral Artery Bifurcation Aneurysms: Clinical Research / 대한뇌혈관외과학회지

OBJECTIVE: Endovascular treatment as well as surgical treatment has become a treatment method for the management of the intracerebral aneurysms. The authors present the results of surgical and endovascular treatment of middle cerebral artery (MCA) bifurcation aneurysms. METHODS: From 1999 to 2005, 54 MCA bifurcation aneurysms were treated with surgical or endovascular methods at our hospital. Forty two patients had ruptured aneurysms and 12 had unruptured aneurysms. Of 54 aneurysms, 33 were treated with surgical clipping, 20 with Guglielmi detachable coil (GDC) embolization and 1 with cross over treatment. The medical, radiological and operation records were reviewed retrospectively. RESULTS: Of the 54 patients, 37 (68.5%) were female and 17 (31.5%) were male. In the surgically treated group, 22 (66.7%) experienced excellent or good outcomes (GOS 5 or 4), 8 (24.2%) had fair or poor outcomes (GOS 2 to 3), and 3 (9.1%) died (GOS 1). In the endovascularly treated group, 15 (75%) had excellent or good outcomes, 1 (5.0%) had fair outcomes (GOS 3), and 4 (20%) died. Symptomatic vasospasm revealed 9 (25.7%) in the surgically treated group, and 6 (30%) in the endovascularly treated group. Seven (20.5%) complications occurred from the surgical group, 3 (15%) from the endovascular group. On logistic regression analysis, there were no significant differences in GOS and vasospasm between surgically treated group and endovascularly treated group (p=0.788, 0.643, respectively). CONCLUSION: Endovascular treatment of MCA bifurcation aneurysms results in clinical outcome equal to the outcome of surgical treatment of MCA bifurcation aneurysms and it can be a good alternative method for MCA bifurcation aneurysms treatment.

A case of nizatidine induced cholestatic hepatitis / 대한내과학회지

Histamine H2-receptor antagonists are commonly used in many clinical conditions, and their hepatotoxicity has been reported occasionally.However, cholestatic hepatitis induced by nizatidine is very rare. Here, we report a young female patient with severe cholestatic hepatitis associated with nizatidine use. She had taken nizatidine to manage asymptomatic reflux laryngitis by an otonasolaryngology doctorfor about 20 days. After about 15 days of nizatidine administration, jaundice developed and continued for more than2 months withmaximal serum total bilirubin reaching 17.5 mg/dL, in spite of the discontinuation of medication. Liver specimen obtained by needle biopsy revealed severe centrilobular cholestatic hepatitis. Her liver function improved slowly and serum total bilirubin decreased down to 1.7 mg/dL after months later from the development of jaundice. As far as our knowledge, this is the second case of nizatidine- induced cholestatic hepatitis reported in the literature.

Clinical Features of Posterior Inferior Cerebella Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: The purpose of this study is to characterize the distribution of posterior inferior cerebellar artery (PICA) aneurysm, the computed tomography (CT) patterns of hemorrhage, and the clinical presentation thereof. METHODS: We reviewed the records 1050 patients with intracranial aneurysms treated at our institution between January 1999 and November 2003. Upon clinical review of radiological data and postoperative reports, we found 20 patients with PICA aneurysms. RESULTS: The incidence of PICA aneurysms was 1.9% of all intracranial aneurysms. The location of PICA aneurysms varied. Of the 20 PICA aneurysm cases, ruptured aneurysms accounted for 18 cases. Review of only these ruptured cases resulted in the following observations : Subarachnoid hemorrhage (SAH) was presented in 94.4% of cases. Isolated infratentorial and supratentorial SAH was present in 7 cases (38.9%) and 2 cases (11.1%), respectively. SAH involving the infratentorial and supratentorial region was present in 8 cases (44.5%). Intraventricular hemorrhage (IVH) with or without associated SAH was seen in 77.8% of cases, whereas isolated IVH was seen in only one case. Perimedullary large hematoma was present in 50% of cases, while the hematoma was consistently thicker on the aneurysm side. Hydrochephalus was present in 16 cases (88.9%). Although patients' postoperative outcomes were excellent or good in 70% of the above cases, initial angiograms failed to reveal ruptured PICA aneurysms in 3 cases. CONCLUSION: PICA aneurysm is rare in most aneurysm cases. However, awareness of a possibility of PICA aneurysm and its features are still nonetheless important. IVH and hydrocephalus are commonly presented with a ruptured PICA aneurysm and complete vertebral angiography is a required to recognize this condition.

28 cases of primary sclerosing cholangitis / 대한내과학회지

Backgroud : Primary sclerosing cholangitis (PSC) is a chronic progressive cholestatic hepatobiliary disease of unknown etiology, a characterized by inflammation, scarring and obliteration of bile ducts, eventually leading to biliary cirrhosis and liver failure. In Korea, reports on PSC have only been done anecdotally and there are hardly any large scale studies. METHODS: We retrospectively analyzed the clinical, laboratory, radiologic and histologic feature of 28 patients, who were diagnosed in Asan Medical Center during the last decade. A diagnosis of PSC was made by typical direct cholangiographic findings. RESULTS: The median age of the enrolled patients at diagnosis was 39.3 years, and there was a preponderance of men (M:F = 2.1:1). The major clinical features were abdominal pain and abnormal liver function tests of cholestatic pattern. The rate of positivity for autoantibody was 30.8% (8/26). On cholangiogram, 82.1% had evidence of both extra- and intrahepatic bile duct involvement, 10.7% of intrahepatic involvement only, and 7.1% of hilar involvement only. The pancreatic duct involvement was seen in 10.5% (2/19). The incidence of associated inflammatory bowel disease was 50% (6/12), UC in 5 cases and Crohn's disease in 1 case, respectively. Endoscopic or radiologic intervention for the dilatation of narrowed bile ducts were performed in 14.3% and 71.4%, respectively. Two cases (7.1%) underwent liver transplantation. CONCLUSION: Although PSC is a rare disease in Korea, we prospect that more cases will be reported as concern and knowledge of this entity increase.

A case of the extrapulmonary paragonimiasis presenting as pancreatic tumor / 대한내과학회지

Pancreatic tumor has a wide range of differential diagnosis, from the benign inflammatory diseases, to the malignant disease such as pancreatic cancer. Here, we report a case of extrapulmonary paragonimiasis involving pancreas which was difficult to differentiate from primary neoplasm of pancreas. A 44 year old man was presented with a pancreatic tumor having inhomogenous enhancement and cystic nature in part, and conglomerated mass with rim enhancement and central hypodensity along both anterior and posterior side of pancreas on CT. No diagnostic clue was obtained from those conventional procedures and then the surgical exploration was perfomed to confirm the histology. The pathologic finding revealed the Paragonimus eggs in the granulomatous inflammation with necrosis.

A Case of Recurrent Campylobacter fetus Endocarditis in a Healthy Person / 감염과화학요법

Campylobacter fetus is a rare cause of endocarditis. To date, only about 30 cases of C. fetus endocarditis have been reported mainly in the elderly with chronic underlying illnesses. Most cases showed tendency to involve aortic valve. This report describes a case of native tricuspid valve infective endocarditis in a 69-year-old man without any underlying disease. Despite adequate antibiotic therapy for 4-weeks, endocarditis recurred and leading to surgical valve replacement.

A Case of Recurrent Campylobacter fetus Endocarditis in a Healthy Person / 감염과화학요법

Campylobacter fetus is a rare cause of endocarditis. To date, only about 30 cases of C. fetus endocarditis have been reported mainly in the elderly with chronic underlying illnesses. Most cases showed tendency to involve aortic valve. This report describes a case of native tricuspid valve infective endocarditis in a 69-year-old man without any underlying disease. Despite adequate antibiotic therapy for 4-weeks, endocarditis recurred and leading to surgical valve replacement.

Cervical Spinal Epidural Abscess due to Salmonella Group D

We report a case of cervical spinal epidural abcess due to Salmonella group D. A 58-year-old man complained of progressive neck pain and right arm weakness with fever. Clinical and radiographic findings including cervical magnetic resonance(MR) image showed paraspinal soft tissue inflammation of neck and abcesses in prevertebral and epidural space at C3-5 level. The patient underwent a C4 corpectomy and adjacent diskectomy and continous irrigation suction drainage. A MR image taken at second postoperative day revealed diffuse cord swelling from C2 to T1 suggesting edema and/or myelitis and then laminectomy from C3 to C6 was performed immediately to decompress the spinal cord. The patient recovered excellently and the abscess culture revealed Salmonella group D.

The Effects of Plate Stabilization on Maintenance of Interspace Height in Patients with Lower Cervical Lesion Underwent Anterior Cervical Interbody Fusion

OBJECTIVEL: Anterior cervical discectomy and fusion has been successfully performed for many years using a variety of techniques. Recently, the concept of internal fixation has been applied to the lower cervical lesions. The need for postoperative immobilization, usually required to stabilize the patient while the fusion mass heals, is decreased or negated by internal fixation. In order to determine the effects of plate stabilization on maintenance of interspace height during postoperative period, we assessed the potential differences between anterior interbody fusion without plate and fusion with plate in patients with lower cervical lesions. PATIENTS AND METHODS: The authors analyzed the results of 76 patients with lower cervical lesions, who underwent anterior interbody fusion between May, 1991 and December, 1997. Of these, 36 underwent only anterior interbody bony fusion and 40 underwent bony fusion plus interbody fixation with plate system. RESULTS: In order to compare the difference of two groups, we investigated the pre- and postoperative interspace height, clinical outcomes, and radiographic fusion success rates. Anterior interbody fusion with plate was found to be superior to anterior interbody fusion without plate after anterior cervical decompression procedures with respect to maintenance of cervical interspace height(p<0.01), and radiographic and clinical fusion success rates. CONCLUSION: The authors concluded that the use of anterior plate fixation may provide added security to the nervous system before bony fusion occurs, may potentiate the maintenance of interspace height, may increase the probability of successful fusion, and may permit early ambulation.

Anterior Cervical Fusion and Plate Stabilization in Patients with Lower Cervical Lesions

Anterior cervical discectomy and fusion is an efficacious procedure used to treat a variety of cervical spinal disorders, including spondylosis, myelopathy, herniated discs, trauma, and degenerative disc diseases. Refinements in instrumentation for the cervical spine have led to an increase in experience with these devices during the past decade. The need for postoperative immobilization, required to stabilize the patient while the fusion mass heals, is decreased or negated by internal fixation. The authors analyzed the results in 30 patients(22 traumatic; 8 non-traumatic) with lower cervical lesions, who underwent anterior interbody fixation with cervical plates between April, 1994 and June, 1996. We used either a unicortical(Orion TM) or bicortical screw system(Top TM): these two types of plates had no specific differences, but the Orion TM was easier and safer to operate. Although postoperative stability was successfully attained in all patients, two screw-related complications, which were fully resolved without causing any specific problems, were detected during the postoperative follow-up period. In nontraumatic lesions, we measured pre-and postoperative interbody heights at ten levels; postoperative interbody height was well preserved for one year. In conclusion, internal fixation may provide added security to the nervous system before bony fusion occurs, may lessen the number of levels requiring fusion, may increase the probability of successful fusion, and is conducive to early patient mobilization.

Lumbar Intraspinal Synovial Cyst: Case Report

True synovial cysts of the spine are rare, though they are included in the differential diagnosis of an extradural lesion in a patient with pain which is radicular or localized at the involved level of the spine. A case of a lumbar synovial cyst causing lumbar radiculopathy and mimicking an extradural tumor is presented. The lesion was demonstrated by magnetic resonance imaging, and the relief of symptoms was achieved by decompressive laminectomy and total removal of the mass.