Effects of the Genetic Polymorphisms of CYP1A1 and GSTP1 on the Risk of Laryngeal Cancer in Koreans / 대한이비인후과학회지

BACKGROUND AND ackground and Objectives: Smoking has been reported as an important risk factor of laryngeal cancer. Cytochrome P450 1A1 (CYP1A1) and glutathione S-transferase P1 (GSTP1) are genes that encode enzymes which are involved in the metabolism of carcinogens in cigarette smoke. In this study, we statistically tested the significances of smoking and genotypes of CYP1A1 and GSTP1 as risk factors of laryngeal cancer. MATERIALS AND METHOD: In this case-control study, 84 pathologically proven laryngeal cancer patients and 168 age- and sex-matched controls were included as the study subjects. Information on smoking habit was collected using a self-administered questionnaire, and CYP1A1 and GSTP1 genotypes were analyzed using PCR-RFLP method. Chi-square test, Student's t-test and conditional logistic analysis were used to test statistical significance. RESULTS: Smoking was turned out to be a significant risk factor of laryngeal cancer both in univariate and multivariate analyses. The CYP1A1 Ile/Ile genotype was significant in the univariate test, but the statistical significance disappeared in the multivariate conditional logistic model including smoking. The odds ratio (95% confidence interval) of GSTP1 A/A genotype for laryngeal cancer was 0.71 (0.38, 1.33), which was not statistically significant. CONCLUSION: Smoking is the most potent risk factor among the three factors, and the genotypes of CYP1A1 and GSTP1 would not be major risk factors for laryngeal cancer in Koreans.

A Case of Nonrecurrent Inferior Laryngeal Nerve / 대한이비인후과학회지

Damages on the recurrent laryngeal nerve (RLN) during thyroid surgery is the most common iatrogenic cause of vocal cord paralysis. Identification of the recurrent laryngeal nerve and meticulous surgical techniques can significantly decrease the incidence of this complication. The nonrecurrent inferior laryngeal nerve is an exceedingly rare anomaly of the recurrent laryngeal nerve. The nonrecurrent inferior laryngeal nerve is associated with abnormal development of the aortic arch, where the innominate (brachiorephalic) artery is not found and the right common carotid artery rises directly from the aortic arch. The aberrant right subclavian artery can always be felt against the vertebral column behind the esophagus. Surgeons need to be aware of the positions of these arteries to avoid damaging them. We experienced a case of nonrecurrent inferior laryngeal nerve in the right side with the aberrant right subclavian artery. The patient received a total thyroidectomy with neck dissection for thyroid carcinoma with nodal metastasis. Incidentally, we also found nonrecurrent inferior laryngeal nerve, and also found an aberrant right subclavian artery by the computed tomography scan. The patient presented transient vocal cord paralysis but gained complete recovery of vocal cord mobility after one and a half month later.

Alteration of Coagulation and Fibrinolysis in Multiple Trauma

BACKGROUND: After multiple trauma, blood coagulation activity is enhanced and fibrinolytic activity is suppressed. Due to high tissue thromboplastin concentration in cerebral tissue, more serious coagulation and fibrinolytic abnormalities may occur when concomitant head trauma is present. The aim of this study was to determine the changes in coagulation and fibrinolysis after trauma and the effects of head trauma on coagulation and fibrinolysis. METHODS: This study includes 35 trauma patients: 16 patients with head trauma (group A) and 19 patients without head trauma (group B). We measured the plasma levels of functional protein C, antithrombin III (AT III), thrombin antithrombin III complex (TAT), plasmin alpha 2 plasmin inhibitor complex (PIC), tissue plasminogen activator antigen (t-PA), and plasminogen activator inhibitor-1 antigen (PAI-1) on admission and on days 1, 2, 4, and 6 after the trauma. RESULTS: The TAT and the TAT/PIC were significantly higher in group A than in group B on all days. PIC was significantly lower in group A than in group B on all days except the day of admission. Over the course of time, the TAT and the TAT/PIC decreased in both groups and PIC increased. On admission, the PAI-1 of both groups was increased, but it decreased over the course of time. The t-PA was increased on admission, was suppressed on the 1st day, and then increased again. The PAI-1 and the t-PA showed no significant difference between the two groups. CONCLUSIONS: After multiple trauma, coagulation was enhanced and fibrinolysis was suppressed. Enhanced coagulation and suppressed fibrinolysis were significantly greater in group A than in group B.

Effects of Intermittent Sequential Pneumatic Compression on Coagulation and Fibrinolysis in Multiple Trauma

BACKGROUND: After multiple trauma, blood coagulation activity is enhanced and fibrinolytic activity is suppressed by overproduction of plasminogen activator inhibitor-1 (PAI-1). Intermittent sequential pneumatic compression (ISPC) is an effective method to prevent deep vein thrombosis. Its action is explained by the mechanical effect on blood flow, as well as by the enhancement of fibrinolysis by the reduction of PAI-1. The aim of this study was to determine the effects of ISPC on coagulation and fibrinolysis after multiple trauma. METHODS: Thirty-nine trauma patients were either treated with ISPC (ISPC group, 20 patients) or without ISPC (control group, 19 patients). We measured the plasma levels of the thrombin antithrombin III complex (TAT), the plasmin alpha 2 plasmin inhibitor complex (PIC), the tissue plasminogen activator (t-PA), and the plasminogen activator inhibitor-1 (PAI-1) on admission and at 1, 2, 3, 6, 12, and 24 hours after admission. RESULTS: The TAT was higher than normal in both groups, with no significant difference between the two groups throughout the study period. The PIC level of ISPC group was significantly higher than that of the control group. In the ISPC group, the PIC level increased gradually, reaching a peak at 3 hours and decreasing thereafter. In the control group, the PIC level increased to a peak level at 2 hours. The TAT/PIC ratio dropped in the first two hours and increased at 3 hours, dropping again thereafter. In the ISPC group, the ratio dropped gradually without an intermittent fluctuation. At 3 and 6 hours, the control group showed a significantly greater ratio compared to the ISPC group. PAI-1 was higher than normal in bothgroups, with a significantly lower level in the ISPC group from 2 hours to 24 hours. For the t-PA level, no difference was noted between the two groups, with the peak level occurring at 1 hour. The PAI-1/t-PA ratio was significantly greater in the control group from 2 hours to 12 hours than in the ISPC group, but the difference was not significant at 24 hours. CONCLUSIONS: In multiple trauma patients, ISPC does not seem to affect coagulation, but enhances fibrinolysis through suppressed PAI-1 production. This effect of ISPC may be maintained for 12 hours.

Strategy of Early Diagnosis in Blunt Diaphragm Rupture

Diaphragm rupture often challenges the surgeon by it's subtle presentation in the face of more obvious injuries, equivocal chest roentgenography, and no obvious indication of celiotomy or thoracotomy. Delayed diagnosis is one variable implicated in increased morbidity and mortality. This retrospective study was performed to determine the diagnostic value of diaphragm rupture on initial evaluation and to present an algorithm for initial evaluation. We reviewed the hospital records and the radiographs of 37 patients with a blunt diaphragmatic rupture who were treated at Yongdong Severance Hospital during a period of 5 years. The blunt diaphragmatic ruptures in 14 (38.9%) of the thirty-seven patients were missed on initial admission. At admission, initial physical findings were diagnostic in 3 cases (8.1%), suspicious in 24 cases (64.9%) and normal in 10 cases (27%). On chest roentgenogram, findings were diagnostic in 6 cases (16.2%), suspicious in 28 cases (75.7%) and normal in 3 cases (8.1%). Chest CT scans were performed on 20 patients. Findings were diagnostic in 6 (30%) of these, suspicious in 11 (55%) and normal in 3 (15%). On the chest roentgenograms of the 15 cases with suspicious physical findings, which were diagnosed early, the findings were diagnostic in 4 cases (26.7%) and suspicious in 11 cases (73.3%). Chest CT scans were performed in 10 out of 15 cases with suspicious physical findings which were diagnosed early, and the findings were diagnostic in 3 cases (30%), suspicious in 6 cases (60%), normal in 1 case (10%). In 23 patients (61.1%), diagnosis was established within 48 hours. In 4 (17.4%) of these patients, the diaphragm rupture was detected at the time of the celiotomy performed for other injuries. In conclusion, a blunt diaphragm rupture can easily be missed in the absence of obvious indications for a celiotomy or a thoracotomy, because radiologic abnormalities are often interpreted as other injuries. In such cases, a high index of suspicion coupled with selective use of a CT scan, fluoroscopy, thoracoscopy, or laparoscopy may be necessary for early detection of the diaphragm rupture.

Management of Penetrating Neck Injuries

BACKGROUND: The management of penetrating neck injuries presents a difficult problem. Although many authors have stated that surgical exploration should be mandatory for all neck injuries that penetrate platysma, recent reports from many centers now claim selective exploration. The aim of this study was to review a policy of selective neck exploration based on clinical presentation, anatomic location, and the result of diagnostic studies. METHOD: We reviewed retrospectively medical records of 66 patients who were admitted and managed at Yongdong Severance hospital, Yonsei university college of medicine due to penetrating neck injuries from Jan. 1990 to Dec. 1996. RESULTS: Forty-one patients(62%) were underwent immediate neck exploration, while the remaining 25 patients(38%) were admitted and observed. Three had esophagoscopy, four had esophagogram, and three had direct laryngoscopy, all of which revealed normal result except one patient had blood tinged larynx on laryngoscopy. Results of 12 neck explorations(29%) were negative. There was no delayed diagnosis during conservative treatment. There was no mortality. CONCLUSION: We concluded that selective exploration of penetrating neck injuries is both safe and resonable.

Penetrating Zone II Neck Injuries

The management of penetrating injuries of zone II of the neck presents a difficult problem. The difficulties are due to the close anatomical relationships between the many vital structures in the neck and to the insidious nature in which some of the injuries may present themselves, for example, esophageal lacerations. If a significant injury is overlooked, the consequences may be dire with severe complication and mortality. Two management strategies have been developed for coping with these difficult injuries : (1) mandatory exploration of all injuries penetrating the platysma, and (2) a selective approach with neck exploration being performed based on clinical and investigative findings. The aim of this study was to review the clinical characteristics of and the various treatment protocols for II penetrating injuries of the neck. We reviewed retrospectively the medical records of 38 patients who were admitted to and treated at Yongdong Severance Hospital, College of Medicine, Yonsei University, due to penetraing injuries of the neck from Jan. 1990 to Dec. 1996. Twenty-three of the 38 patients (60.5%) underwent immediate operative exploration. In 13 of these patients, the exploration produced positive findings (56.5%), and in 10, the exploration produced negative findings (43.5%). Following neck exploration, 13 patients presenting acutely were found to have 21 injuries. The predominant injuries were vascular followed by neurologic and then respiratory. Eight of the 11 patients (73%) with positive clinical findings were found to have injuries at exploration, and 5 of the 12 patients (42%) with no clinical signs were found to have injuries (p=0.0432). Three of 4 patients (75%) with positive CT scan findings were found to have injuries at exploration and 4 of the 8 patients (50%) with no CT scan findings were found to have injuries (p=0.0455). The complication rate and the performance rate of CT scan were not statistically different between patients with a negative neck exploration and patients with conservative management. The duration of hospitalization was an average of 6.2 days for those patients with a negative neck exploration and 4.1 days for those patients with conservative management (p=0.0022). There was no mortality. In conclusion, it is possible, by careful physical examination and CT scan, it will be possible to reduce the rate of negative neck exploration without risk to those patients who need immediate surgery.

Penetrating Injury by an Iron Reinforcing Bar Associated with a Fall or Slip Injury

INTRODUCTION: There was increase in a fall injury at the field of construction work, nowadays. There was also increase in penetrating injury by an iron reinforcing bar associated with a fall or slip injury. But this is not widely discussed in the surgical literature. The purpose of this study was to define the characteristics of injury, diagnosis, treatment and prognosis of the penetrating injury by an iron reinforcing bar associated with a fall or slip injury. METHODS AND MATERIALS: We reviewed retrospectively medical records of 17 patients who admitted and managed at Yongdong Severance hospital, Yonsei university college of medicine due to penetrating injury by an iron reinforcing bar associated with a fall or slip injury from Nov. 1987 to Dec. 1996. RESULTS: The penetrating injuries by an iron reinforcing bar associated with a fall or slip injury were 5 cases of a slip injury and 12 cases of a fall injury. The insertion site of an iron reinforcing bar was perineum in all of a slip injury. In a fall injury, insertion site was flank and back in 5 cases, perineum 4 cases, chest 2 cases and abdomen 1 case. In a fall injury, 9 patients had two or more organ injuries. CT scan was taken in 3 cases, sigmoidoscopy 3 cases and fistulogram 1 case in a slip injury. CT scan was done in 5 cases, sigmoidoscopy 1 case, cystogram 2 cases and intravenous pyelogram 1 case in a fall injury. 2 cases was cured conservatively, and operation was done in 3 cases in a slip injury in contrast to 2 cases of conservative management and operation 10 cases in a fall injury. There was no negative celiotomy. Complication was only one wound infection in a slip injury. There were wound infection 6 cases, pulmonary complication 4 cases, sepsis 1 case, necrotizing fascitis 1 case, anal sphincter injury 1 case, intraabdominal abscess 1 case and neurogenic bladder 1 case in a fall injury. There was no mortality. CONCLUSION: The penetrating injuries by an iron reinforcing bar associated with a fall or slip injury had characteristics of both penetrating and blunt injury. The chest and abdominal penetrating injuries lead to multiple organ injury. In perineal penetrating injury, we should evaluate the injury of urinary bladder, rectum and genital organ.

Does low dose dopamine attenuate the decrease of renal function in the treatment of patients under controlled mechanical ventilation with positive end expiratory pressure?

Controlled mechanical ventilation (CMV) with positive and expiratory pressure (PEEP) is often used to improve the pulmonary gas exchange in patients with acute respiratory distress syndrome. However, this ventilatory technique may induce hemodynamic and hormonal changes which may lead to vital organ dysfunction, such as oliguria. Low dose dopamine, acting as a dopaminergic receptor agonist, may improve vital organ perfusions, i.e. renal, mesenteric and coronary perfusions. The purpose of this current study was to evaluate the effects of low dose dopamine on renal function and hemodynamic change during controlled mechanical ventilation with PEEP. The study was performed on 10 patients treated with PEEP in the surgical intensive care unit. Starting with 0 cmH2O of PEEP and adding 4 cmH2O of PEEP at 4-hour intervals until it reached 12 cmH2O of PEEP, dopamine, 2 ug/kg/min, was selectively, administered, intravenously during the last two hours of each four hour intervals. Following each procedure, hemodynamic parameters, urine output, creatinine clearance and fractional excretion of sodium were measured. The cardiac index and mean arterial pressure had both decreased, but the mean pulmonary arterial pressure was increased at 12 cmH2O of PEEP compared with 0 cmH2O of PEEP in both groups with and without low dose dopamine. The main result of this study was that low dose dopamine attenuated the decrease of the cardiac index, urine output and creatinine clearance induced by mechanical ventilation with PEEP at 12 cmH2O.

The Surgical Treatment of Acute Necrotizing Pancreatitis : Does Presense of Infection Affect on Determinant of Intervention?

We retrospectively analyzed 17 necrotizing pancreatitis patients who were treated surgicaly at the Department of Surgery, Yonsei University, from April 1983 to October 1996 in order to identify that the presence of intra-abdominal infection. The mean age was 46.5 years old. There were 11 male patients and 6 female patients. The most common etiology was alcohol and trauma. The mortality rate was 6%, for which etiology was alcohol. We grouped the patients into three groups, which is the infected, non-infected, and no culture performed. There were 6 non-infected patients, 6 infected patients, and 5 no culture performed patients. The most frequent infecting organism was E. coli. Others were E. faecalis, P. aeruginosa, K. pneumonia, and E. cloacae. There were 6 non-infected patients. The complication rate was 50% in infected cases, the 67% in non-infected cases, and 80% in no culture performed cases. In non-infected patients, Ranson's criteria, APACHE II score, total transfusion of packed red blood cell, and hospital stay were greater than infected patients. The ICU stay was longer in infected patients. However, there were no significant differences among the three groups. The basic operation procedure was necrosectomy and drainage. Others were cholecystectomy, segmental resection of colon, etc. We concluded that the presense of intra-abdominal infection should not be the sole determinant for intervention, so, the early and aggressive surgical intervention in case of symptomatic pancreatic necrosis is more beneficial irrespective of infection.

The Study of Prognostic Factor of the Parotid Tumor / 대한이비인후과학회지

BACKGROUND: Tumors developing in the parotid gland tend to be of a large variety of histopathologic types. The relative rarity of parotid gland tumors makes epidemiologic study more difficult. To develop a rational therapeutic plan for tumors of the parotid gland, the surgeon must be fully cognizant of the factors that may affect survival. MATERIALS AND METHOD: The authors retrospectively studied 110 patients with histologically confirmed salivary gland tumor in the parotid glands at Korea Cancer Center between 1986 and 1995. We analyzed the histopatologic type and 5-year survival rate according to the some prognostic factors. RESULTS: Among the 110 patients, 39 had malignant parotid tumors. There were no recurtence in those who had parotid tumors. The overall 5-year survival rate was 62.4%. We observed statistically significant differences for patients of different clinical stages and histological grade. CONCLUSION: In summary, the clinical stage and histological grade are the significant prognostic factors, and these factors need to be considered in the treatment of parotid gland tumors.

A Case of the Rhabdomyosarcoma Involving Maxillary Sinus and Orbit / 대한이비인후과학회지

Recently, the 5-year survival rate of rhabdomyosarcoma has been greatly increased by combining therapy with radical surgery, radiation and chemotherapy. But it still has poor prognosis and there are few case reports of rhabdomyosarcoma of head and neck with long term survival rate. Here, we treated a rhabdomyosarcoma patient with radical surgery, radiation and chemotherpy. The patient visited our hospital in 1990 with a complaint of left facial protruding mass, diplopia and exopthalmos. She was diagnosed as rhabdomyosarcoma involving maxillary sinus and orbit. In september 1990, she received left total maxillectomy and eyeball exentration. After the surgery, we applied a 5000 cGy neutron therapy, 2000 cGy external radiation and 9 cycle pulse, along with VAC chemotherapy. She remains free of disease as of her last follow-up in February 1998.

Effects on Hemodynamics and Renal Function of PEEP

BACKGROUND AND OBJECTIVE: Controlled mechanical ventilation(CMV) with positive end expiratory pressure(PEEP) is frequently employed in the treatment of critically ill patients in the surgical intensive care unit. CMV with PEEP can impair many hemodynamic parameters such as a decrease in cardiac index. These hemodynamic changes may lead to vital organ dysfunctions such as oliguria. The purpose of this current study is to examine the effect on the hemodynamic and renal function of positive end expiratory pressure. MATERIALS AND METHODS: The study is performed in 10 patients treated with PEEP. Starting with no PEEP and then adding 4cmH2O of PEEP in 2 hrs interval till 12cmH2O of PEEP is reached. At each procedure, the hemodynamic parameters, urine output, creatinine clearance, fractional excretion of sodium are measured. RESULTS: The mean arterial pressure was decreased from 102.2+/-5mmHg(mean+/-SEM) at 0cmH2O of PEEP to 91.6+/-5.4mmHg at 12cmH2O of PEEP(P<0.05). The cardiac index decreased from 4.21+/-0.21L/min/m2 at 0cmH2O of PEEP to 3.59+/-0.14L/min/m2 at 8cmH2O of PEEP(P<0.01) and 3.25+/-0.12L/min/m2 at 12cmH2O of PEEP(P<0.01). Urine output decreased from 1.61+/-0.21ml/hr/kg at 0cmH2O of PEEP to 1.21+/-0.19ml/hr/kg at 8cmH2O of PEEP(P<0.05), 0.85+/-0.13ml/hr/kg at 12cmH2O of PEEP(P<0.01). Creatinine clearance decreased from 114.9+/-3.36ml/min at 0cmH2O of PEEP to 97+/-5.28ml/min at 8cmH2O of PEEP(P<0.01) and 80.2+/-3.11ml/min at 12cmH2O of PEEP(P<0.01). The pulmonary capillary wedge pressure, fractional excretion of sodium were unchanged. CONCLUSION: CMV with 8cmH2O of PEEP significantly affected the hemodynamic and renal function. At 12 cmH2O of PEEP, the changes in urine output and renal function may be affected more by hemodynamic changes than hormonal changes.

Surgical treatment of comminuted distal humerus intercondylar fracture in adult using transolecranon approach and AO method / 대한정형외과학회잡지

No abstract available.