Feasibility of Ultrasound-Guided, Peripherally Inserted Central Catheter Placement at the Bedside in a Communicable-Disease Isolation Unit.

BACKGROUND: Previous studies have investigated the safety of peripherally inserted central catheters (PICCs) in the intensive care unit (ICU). However, it remains uncertain whether PICC placement can be successfully carried out in settings with limited resources and a challenging environment for procedures, such as communicable-disease isolation units (CDIUs). METHODS: This study investigated the safety of PICCs in patients admitted to CDIUs. These researchers used a handheld portable ultrasound device (PUD) to guide venous access and confirmed catheter-tip location with electrocardiography (ECG) or portable chest radiography. RESULTS: Among 74 patients, the basilic vein and the right arm were the most common access site and location, respectively. The incidence of malposition was significantly higher with chest radiography compared to ECG (52.4% vs. 2.0%, p < 0.001). CONCLUSIONS: Using a handheld PUD to place PICCs at the bedside and confirming the tip location with ECG is a feasible option for CDIU patients.

Initial Experience of Robot-Assisted Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair by a Single Surgeon in South Korea.

Background and Objectives: Inguinal hernia is a common surgical disease. Traditional open herniorrhaphy has been replaced by laparoscopic herniorrhaphy. Nowadays, many attempts at robotic herniorrhaphy have been reported in western countries, but there have been no reports in South Korea. The purpose of this study is to report our initial experience with robotic inguinal hernia surgery, compared to laparoscopic inguinal hernia surgery. Materials and Methods: We analyzed the clinical data from 100 patients who received inguinal hernia surgery in our hospital from November 2020 to June 2022. Fifty patients underwent laparoscopic surgery, and 50 patients underwent robotic surgery using the da Vinci Xi system. All hernia surgeries were performed by a single surgeon using the transabdominal preperitoneal (TAPP) method. Results: The mean operation time and hospital stay were not statistically different. On the first postoperative day, the visual analog scale (VAS) pain score was significantly lower in the robotic surgery group (2.9 ± 0.5 versus 2.5 ± 0.7, p = 0.015). Cumulative sum analysis revealed an approximately 12-case learning curve for robotic-assisted TAPP hernia surgery. Conclusions: Robotic-assisted TAPP inguinal hernia surgery is technically acceptable to surgeons who have performed laparoscopic inguinal hernia surgery, and the learning curve is relatively short. It is thought to be a good step toward learning other robot-assisted operations.

Learning curve for single-port robot-assisted colectomy.

Purpose: Since the introduction of robotic surgery, robots for colorectal cancer have replaced laparoscopic surgery, and a single-port robot (SPR) platform has been launched and is being used to treat patients. We analyzed the learning curve and initial complications of using an SPR platform in colorectal cancer surgery. Methods: We reviewed 39 patients who underwent SPR colectomy from April 2019 to October 2019. All surgeries were performed by the same surgeon using an SPR device. A learning curve was generated using the cumulative sum methodology to assess changes in total operation time (OT), docking time (DT), and surgeon console time (SCT). We grouped the patients into 3 groups according to the time period: the first 11 were phase 1, the next 11 were phase 2, and the last 17 were phase 3. Results: The mean age of the patients was 61.28±13.03 years, and they had a mean body mass index of 23.79±2.86 kg/m2. Among the patients, 23 (59.0%) were male, and 16 (41.0%) were female. The average OT was 186.59±51.30 minutes, the average SCT was 95.49±35.33 minutes, and the average DT (time from skin incision to robot docking) was 14.87±10.38 minutes. The SCT differed significantly among the different phases (P<0.001). Complications occurred in 8 patients: 2 ileus, 2 postoperation hemoglobin changes, 3 urinary retentions, and 1 complicated fluid collection. Conclusion: In our experience, the learning curve for SPR colectomy was achieved after the 18th case.

Clinical Characteristics of Symptomatic Cholecystitis in Post-Gastrectomy Patients: 11 Years of Experience in a Single Center.

Background and Objectives: Gallbladder (GB) stones, a major cause of symptomatic cholecystitis, are more likely to develop in post gastrectomy people. Our purpose is to evaluate characteristics of symptomatic cholecystitis after gastrectomy. Materials and Method: In January 2011−December 2021, total 1587 patients underwent operations for symptomatic cholecystitis at our hospital. We reviewed the patients' general characteristics, operation results, pathologic results, and postoperative complications. We classified the patients into non-gastrectomy and gastrectomy groups, further divided into subtotal gastrectomy and total gastrectomy groups. Result: The patients' ages, male proportion, and the open surgery rate were significantly higher (127/1543 (8.2%) vs. 17/44 (38.6%); p < 0.001), and the operation time was longer (102.51 ± 52.43 vs. 167.39 ± 82.95; p < 0.001) in the gastrectomy group. Extended surgery rates were significantly higher in the gastrectomy group (56/1543 (3.6%) vs. 12/44 (27.3%); p < 0.001). The period from gastrectomy to symptomatic cholecystitis was significantly shorter in the total gastrectomy group (12.72 ± 10.50 vs. 7.25 ± 4.80; p = 0.040). Conclusion: GB stones were more likely to develop in post-gastrectomy patients and extended surgery rates were higher. The period to cholecystitis was shorter in total gastrectomy. Efforts to prevent GB stones are considered in post-gastrectomy patients.

Learning curve for single-port robot-assisted rectal cancer surgery.

Purpose: We analyzed the learning curve of single-port robotic (SPR)-assisted rectal cancer surgery. Methods: Fifty-seven consecutive SPR-assisted rectal cancer surgery cases performed by the same surgeon were considered in surgical interventions for rectal cancer. Total operation time (OT), docking time (DT), and surgeon console time (SCT) measured during surgery were used to parametrize the learning curve. The parameters representing the learning curve were evaluated using the cumulative sum (CUSUM). Results: The mean value of total OT was 241.8 ± 91.7 minutes, the mean value of DT was 20.6 ± 19.1 minutes, and the mean value of SCT was 135.9 ± 66.7 minutes. The learning curve was divided into phase 1 (initial 16 cases), phase 2 (second 16 cases), and phase 3 (subsequent 25 cases). The peak on the CUSUM graph occurred in the 21st case. The longest OT among phases was in phase 2. Complications were most frequent in phase 2. However, complications of Clavien-Dindo (CD) grade IIIb were most frequent in phase 3 with 2 patients. The most common complications were fluid collection and urinary retention (7 patients each). Complications of CD grade IIIb required one stomal revision due to stoma obstruction and one irrigation and loop ileostomy due to anastomosis leakage. Conclusion: Improvement in surgical performance of SPR assisted rectal cancer operation was achieved after 21 cases. The three phases identified in the cumulative sum analysis showed a significant decrease in operative time after the middle stage of the learning curve without an increase in the complication rate.

Single-port robot-assisted abdominoperineal resection: a case review of the first four experiences.

Recently, abdominoperineal resection (APR) using a robot has been demonstrated in other studies. However, there has been no report on APR for rectal cancer using the single-port robot (SPR) platform. In response to this research gap, we described the clinical experience of APR using a SPR. From April 2019 to March 2020, APR using a SPR platform was performed in a total of 4 patients. Three patients had a transumbilical approach, and 1 patient had a transstoma site approach. The average operation time was 307 minutes, and the patient docking time to the SPR platform was 133.5 minutes. There were no complications during the operation, and no laparoscopy or open conversion. No reoperation occurred within 30 days. Mild postoperative complications occurred in 2 patients. We found that APR has safety and feasibility in surgery using an SPR platform. There was no intraoperative event and severe postoperative complications.

Prognostic Factors and Treatment of Recurrence after Local Excision of Rectal Cancer.

PURPOSE: Indications for local excision in patients with rectal cancer remain controversial. We reviewed factors affecting survival rate and treatment effectiveness in cancer recurrence after local excision among patients with rectal cancer. MATERIALS AND METHODS: A total of 831 patients was enrolled. Of these, 391 patients were diagnosed with primary rectal cancer and underwent local excision. A retrospective observational study was performed on patients who underwent full-thickness local excision for rectal cancer. RESULTS: The median duration of follow-up was 61 months. The overall recurrence rate was 11.5%. The rate of local recurrence was 5.1%. Five-year overall survival rate among recurrent patients was 66.8%; the rate among patients who underwent salvage operation due to recurrence was 84.7%, compared with 44.2% among patients treated with non-operative management (p<0.001). Multivariate analysis of disease-free survival identified distance from the anal verge (p=0.038) and histologic grade (p=0.047) as factors predicting poor prognosis. Multivariate analysis of overall survival showed that age (p<0.001), serum carcinoembryonic antigen (CEA) levels (p=0.001), and histologic grade (p=0.013) also affected poor prognosis. In subgroup analysis of patients with recurrence, 25 patients underwent reoperation, while 20 patients did not. For 5-year overall survival rate, there was a significant difference between 84.7% of the reoperation group and 44.2% of the non-operation group (p<0.001). CONCLUSION: The risk factors affecting overall survival rate after local excision were age 65 years or older, preoperative CEA level 5 or higher, and high histologic grade. In cases of recurrence after local excision of rectal cancer, salvage operation might improve overall survival.

Clinical Significance of Systemic Inflammation Markers in Newly Diagnosed, Previously Untreated Hepatocellular Carcinoma.

This study aimed to investigate the clinical significance of systemic inflammation markers (SIMs)-including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR)-in patients with newly diagnosed, previously untreated hepatocellular carcinoma (HCC). The present study was performed using prospectively collected registry data of newly diagnosed, previously untreated HCC from a single institution. The training set included 6619 patients from 2005 to 2013 and the validation set included 2084 patients from 2014 to 2016. The SIMs as continuous variables significantly affected the overall survival (OS), and the optimal cut-off value of NLR, PLR, and LMR was 3.0, 100.0, and 3.0, respectively. There were significant correlations between SIMs and the albumin-bilirubin grade/Child-Turcotte-Pugh class (indicative of liver function status) and the staging system/portal vein invasion (indicative of the tumor burden). The OS curves were well stratified according to the prognostic model of SIMs and validated using the bootstrap method (1000 times, C-index 0.6367, 95% confidence interval (CI) 0.6274-0.6459) and validation cohort (C-index 0.6810, 95% CI 0.6570-0.7049). SIMs showed significant prognostic ability for OS, independent of liver function and tumor extent, although these factors were significantly correlated with SIMs in patients with newly diagnosed, previously untreated HCC.

Long-term Oncologic Outcome of Postoperative Complications After Colorectal Cancer Surgery.

PURPOSE: The impact of postoperative complications on long-term oncologic outcome after radical colorectal cancer surgery is controversial. The aim of this study was to examine the risk factors and oncologic outcomes of surgery-related postoperative complication groups. METHODS: From January 2010 to December 2010, 310 patients experienced surgery-related postoperative complications after radical colorectal cancer surgery. These stage I-III patients were classified into 2 subgroups, minor (grades I, II) and major (grades III, IV) complication groups, according to extended Clavien-Dindo classification system criteria. Clinicopathologic differences between the 2 groups were analyzed to identify risk factors for major complications. The disease-free survival rates of surgery-related postoperative complication groups were also compared. RESULTS: Minor and major complication groups were stratified with 194 patients (62.6%) and 116 patients (37.4%), respectively. The risk factors influencing the major complication group were pathologic N category and operative method. The prognostic factors associated with disease-free survival were preoperative perforation, perineural invasion, tumor budding, and receiving neoadjuvant therapy. With a median follow-up period of 72.2 months, the 5-year disease-free survival rates were 84.4% in the minor group and 78.5% in the major group, but there was no statistical significance between the minor and major groups (P = 0.392). CONCLUSION: Advanced cancer and open surgery were identified as risk factors for increased surgery-related major complications after radical colorectal cancer surgery. However, severity of postoperative complications did not affect disease-free survival from colorectal cancer.

The Role of the Signal-to-Cutoff Ratio in Automated Anti-HCV Chemiluminescent Immunoassays by Referring to the Nucleic Acid Amplification Test and the Recombinant Immunoblot Assay.

BACKGROUND: Following discontinuation of the recombinant immunoblot assay (RIBA), the only available supplementary test for the detection of hepatitis C virus (HCV) is the nucleic acid amplification test (NAAT). However, the NAAT does not adequately detect past HCV. Consequently, it is hard to distinguish between past HCV infection and biological false positivity with an anti-HCV result alone. We assessed the diagnostic performance of two immunoassays: the ARCHITECT anti-HCV chemiluminescent microparticle immunoassay (CMIA; Abbott Diagnostics, Wiesbaden, Germany) and the Access HCV Ab PLUS chemiluminescent immunoassay (CIA; Bio-Rad, Marnes-la-Coquette, France). We also explored an optimized algorithm to determine the anti-HCV results. METHODS: We tested 126,919 patients and 44,556 individuals who underwent a medical checkup. RIBA and NAAT were conducted for samples that tested anti-HCV-positive using CMIA and CIA. We assessed the optimal signal-to-cutoff (S/CO) ratio in HCV-positive samples. RESULTS: In total, 1,035 blood samples tested anti-HCV-positive. Of these, RIBA was positive in 512, indeterminate in 160, and negative in 363 samples. One hundred sixty-five samples were NAAT-positive. Diagnostic sensitivity and positive predictive value (PPV) were 96.7% and 52.1%, respectively, for CMIA, and 94.7% and 72.3%, respectively, for CIA. The optimal S/CO ratio was 5.2 for CMIA and 2.6 for CIA at 95% PPV. In total, 286 samples tested positive in CMIA and 444 in CIA, while 443 samples tested positive in both assays. CONCLUSIONS: It is hard to determine anti-HCV positivity based on the S/CO ratio alone. However, this study elucidated the role of the S/CO ratio by using the NAAT and RIBA.

Application of the isoniazid assay in dried blood spots using the ultra-performance liquid chromatography-tandem mass spectrometry.

OBJECTIVES: Therapeutic drug monitoring (TDM) of anti-tuberculosis (TB) drugs is important for proper treatment of TB. Dried blood spots (DBSs) are widely used for TDM because of their several advantages. Rifampicin and pyrazinamide assays with DBSs have already been developed. However, isoniazid (INH) assay for capillary DBSs have not been reported because of INH instability. We developed an ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for measuring INH concentrations in venous and capillary DBSs. METHODS: Each DBS was analyzed on an UPLC system. INH and internal standard (IS) concentrations were determined by multiple-reaction monitoring in positive ion mode. Analytical performances, including precision, linearity, and comparison of different types of specimens were determined. Further, the stability of INH in venous DBSs was tested. RESULTS: INH and IS were clearly separated in the UPLC-MS/MS system without matrix effect. Within-run precision and between-day precision were 2.68-8.02% and 2.54-5.45%, respectively. INH concentrations in venous DBS showed proportional bias compared with those in plasma (Slope: 0.8704) with good correlation. INH concentration in capillary DBS was slightly but not significantly higher than that in venous DBS. CONCLUSIONS: The findings of our study show that the analytical performance of this novel method for capillary and venous DBSs was clinically acceptable for the TDM of INH.

Characteristics of radio frequency-sputtered ZnS on the flexible polyethylene terephthalate (PET) substrate.

Zinc sulfide (ZnS) thin film was deposited on the flexible polyethylene-terephtalate (PET) polymer substrate by radio frequency (RF) magnetron sputtering system. ZnS film has a critical thickness range affecting crystal structure where it shows preferred orientation with intensity peak of X-ray diffractometer at 28.4 degrees for ZnS thinner than 200 nm while hexagonal wurtzite and cubic zinc-blend (101) are co-existed for film thicker than 200 nm. Optical band gap energy (Eg) decreases with increasing RF-powers, resulting from increase in film thickness. Eg of ZnS films on PET is 3.68-3.86 eV, which is lower than that of ZnS on the rigid substrate by 0.27-0.28 eV. This is attributed to amount of incorporated oxygen to ZnS material as well as residual strain and disorder of grain boundary. Transmittance of ZnS on PET degrades due to surface defects and complex internal structure. Energy dispersive spectroscopy reveals out that ZnS film does not have a unity of Zn to S ratio, but it is close to stoichiometric composition with increasing thickness.

Ginsenoside Rg3 attenuates microglia activation following systemic lipopolysaccharide treatment in mice.

Neuroinflammation, characterized by activation of microglia and expression of major inflammatory mediators, contributes to neuronal damage in addition to acute and chronic central nervous system (CNS) disease progression. The present study investigated the immune modulatory effects of ginsenoside Rg3, a principle active ingredient in Panax ginseng, on pro-inflammatory cytokines and microglia activation in brain tissue induced by systemic lipopolysaccharide (LPS) treatment in C57BL/6 mice. Systemic LPS treatment induces immediate microglia activation in the brain. Based on this information, ginsenoside Rg3 was treated orally with 10, 20, and 30 mg/kg 1 h prior to the LPS (3 mg/kg, intraperitoneally (i.p.)) injection. Ginsenoside Rg3 at 20 and 30 mg/kg oral doses significantly attenuated up-regulation of tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1ß) and IL-6 mRNA in brain tissue at 4 h after LPS injection. Morphological activation of microglia and Iba1 protein expression by systemic LPS injection were reduced with ginsenoside Rg3 (30 mg/kg) treatment. In addition, inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) expression in brain tissue were also attenuated with oral treatment of ginsenoside Rg3 at 30 mg/kg. These results indicate that ginsenoside Rg3 plays a modulatory role in neuroinflammation. This study shows that ginsenoside Rg3 attenuates microglia activation using an in vivo animal model.

Clinical significance of core gene mutations during the course of genotype C chronic hepatitis B virus infection.

BACKGROUND/AIMS: The aim of this study was to investigate the association of HBV core gene mutations with disease severity in HBV-infected patients. METHODOLOGY: We included 249 genotype C HBV infected patients: 39 asymptomatic carriers (AC), 68 with chronic hepatitis (CH), 75 with liver cirrhosis (LC), and 67 with HCC. HBV DNA was extracted from patient sera and the HBV core gene was analyzed by PCR and sequencing. RESULTS: The overall frequency of a codon substitution, which was caused by a missense mutation in the HBV core region, was 4.5±9.0/patient. The codon substitutions were predominantly clustered in the mid-core regions; 22.3% of codon substitutions were found in codons 13, 87, 97 and 130. The rate of substitution for codon 13 was higher in CH and LC than in AC. For codons 87 and 130, AC had a lower substitution rate compared to the other 3 groups. The substitution rate for codon 97 was higher in CH and HCC than in AC. CONCLUSIONS: Core gene mutations were frequently detected during the course of chronic HBV infection, and some mutational hot spots were correlated with severe forms of disease. Thus, these mutations might play a pathophysiological role in the disease progression in HBV infected patients.

The correlation of hepatitis B virus pre-S mutation with mitochondrial D-loop mutations and common deletions in hepatocellular carcinoma.

BACKGROUND/AIMS: We investigated the correlation of HBV pre-S mutation with the sites and frequencies of mtDNA mutations in HCC patients. METHODOLOGY: Twenty-seven HBV-related HCC patients and 8 control patients were included. HBV DNA was extracted from sera and the HBV S coding region was analyzed. Direct sequencing of the mtDNA D-loop was performed in paired HCC and adjacent non-neoplastic liver tissues. The common 4977 bp deletion of miDNA was examined by PCR. RESULTS: Study subjects were categorized into three groups: the pre-S mutant HBV-infected HCC patients (group 1), wild-type HBV-infected HCC patients (group 2) and HBV non-infected patients (group 3). The frequency of mtDNA D-loop mutations in non-neoplastic tissue was higher in group 1/2 than in group 3; however, there was no significant difference between group 1 and 2. The frequency of mtDNA D-loop mutations showed no significant difference between HCC and nonneoplastic tissues. The prevalence of the common 4977 bp deletion was lower in HCC compared to non-neoplastic tissues, however, there was no difference according to the pre-S mutation. CONCLUSION: The present study does not support a pathophysiological role for the HBV pre-S mutation, related to mtDNA D-loop mutation or alteration of the common 4977 bp deletion, in hepatocarcinogenesis.

The efficacy of combined transarterial chemoembolization and 3-dimensional conformal radiotherapy for hepatocellular carcinoma with main portal vein thrombosis.

BACKGROUND/AIMS: The goal of this study was to evaluate the efficacy of combined therapy with TAE and 3-dimensional conformal radiotherapy (3D-CRT) for HCC with main portal vein thrombosis (MPVT). METHODOLOGY: We retrospectively reviewed the medical records of 18 patients who had an unresectable HCC with MPVT and underwent combined TAE and 3D-CRT. Treatment responses for the main tumor and the MPVT were assessed. In addition, patient survival and the prognostic factors associated with survival were analyzed. RESULTS: The overall survival for the 18 patients was 13.0 +/- 8.5 months. For the main tumor response, 8 patients were responders and 10 were non-responders. For the MPVT, an objective response was observed in 10 out of the 18 cases. The univariate analysis revealed that the pretreatment AFP level, presence of regional lymph node metastasis, main tumor response and the MPVT response were prognostic factors for survival; however, these factors failed to reach significance on the multivariate analysis. Most of the treatment-related complications were resolved within 4 weeks. No patient had clinical evidence of progressive hepatic insufficiency related to the treatment. CONCLUSIONS: Combined therapy with TAE and 3D-CRT was safe and effective for the treatment of HCC patients with MPVT and might provide a survival benefit.

Analysis of risk factors associated with early multinodular recurrences after hepatic resection for hepatocellular carcinoma.

BACKGROUND: Sometimes patients experience an unexpected fulminant recurrence after partial hepatic resection for the treatment of hepatocellular carcinoma, and this carries a dismal prognosis. We conducted this retrospective study to investigate the risk factors of early multinodular (ie, 10 nodules within 6 months of surgery) recurrence in hepatocellular carcinoma. METHODS: The study population consisted of 409 patients who underwent curative hepatic resection between January 2000 and April 2003. Patients were divided into 3 groups: nodular (<10 nodules) recurrence, multinodular (> or =10 nodules) recurrence, and no recurrence within the 6-month postoperative period. Twenty-six clinicopathologic and surgical variables were subject to univariate and multivariate analysis. RESULTS: According to univariate analysis, the risk factors for early multinodular recurrence in HCC were microvascular tumor emboli, portal vein tumor thrombi, intrahepatic metastases, high Edmonson-Steiner classification, lack of tumor capsule formation, increased alpha-fetoprotein concentration, and tumor size. Of these factors, intrahepatic metastases and portal vein thrombi proved to be significant predictive factors of multinodular recurrence by multivariate analysis. COMMENTS: Postoperative early multinodular recurrence was found to be related to portal vein tumor thrombi and intrahepatic metastases. Accordingly, an effective adjuvant therapeutic modality should be made available for patients with these risk factors.

[A case of hepatocellular carcinoma complicating cardiac cirrhosis caused by constrictive pericarditis].

Hepatocellular carcinoma (HCC) is one of the most common malignancies. Many factors are considered to be etiology associated with HCC; the important factors are hepatitis B and C viruses and alcohol. Cirrhosis is present in the majority of patients with HCC. It is assumed that all diseases, which lead to liver cirrhosis, may be complicated by the development of HCC. We report a 36-year-old man with HCC which developed from cardiac cirrhosis caused by constrictive pericarditis in whom both hepatitis B virus and hepatitis C viral marker tests were all negative. CT scan of his heart showed pericardial calcification with diastolic dysfunction of right ventricle. Abdominal CT scan revealed mottled mosaic pattern of contrast enhancement of liver parenchyme and two hepatic lesions that were considered to be HCCs. Left lateral segmentectomy of liver was performed. There were two well-circumscribed masses which were confirmed to be HCC and the remaining hepatic parenchyma showed bridging fibrosis between central zonal regions. To our knowledge, this is the first case of HCC complicating cardiac cirrhosis in Korea.

Characteristics and prevalence of intrapulmonary shunt detected by contrast echocardiography with harmonic imaging in liver transplant candidates.

We investigated the prevalence and characteristics of intrapulmonary shunt using contrast echocardiography with harmonic imaging in 130 liver transplant candidates. We found a high prevalence of intrapulmonary shunts and a significant correlation between the degree of intrapulmonary shunt and the Child-Pugh classification score.