Dosang Lee

Single-Incision Endoscopic Thyroidectomy by the Axillary Approach

INTRODUCTION As endoscopic skills and instruments continue to improve, many surgeons have begun to pay more attention to minimally invasive surgical techniques. Ever since Gagner first described endoscopic neck surgery, various techniques for endoscopic thyroidectomy have been attempted to improve the cosmetic results therein. The invasiveness of conventional endoscopic thyroidectomy is its main disadvantage, because the procedure requires a wide dissection just to reach the target site. More recently, single-incision laparoscopic surgery has received favorable attention due to the reduction of both scars and postoperative pain in various surgical fields. In this article, we report the initial clinical experiences with single-incision endoscopic thyroidectomies (SIETs) that have been performed via the axillary approach. MATERIALS AND METHODS We performed multiple SIETs via the axillary approach to overcome the known disadvantages of conventional endoscopic thyroidectomy. Four consecutive patients underwent SIETs that were undertaken using the standard laparoscopic instruments at our institution. In this study, we analyzed tumor size, operative time, length of hospital stay, complications, and cosmetic results. RESULTS All patients were women and had undergone successful SIET operations. The mean age was 35.6 ± 11.4 years (range, 19-43 years), and the mean time of the operation was 160 ± 19.2 minutes (range 145-185 minutes). There were no reported complications, and all the patients were very satisfied with the cosmetic results. CONCLUSIONS SIET via the axillary approach is safe and feasible for the treatment of patients with thyroid tumors.

Pinch-off syndrome

Subclavian venous catheterization was previously frequently performed, but because of life-threatening complications such as hemothorax, pneumothorax, mediastinal hematoma, and myocardial injury, its use has become less common. However, this practice has some advantages in patient mobility, secured dressing, and rapidity and adequacy of vascular access. In some situations where patient comfort is an especially important consideration, such as with totally implantable venous port insertion for chemotherapy, the subclavian route can be a good choice if an experienced and well-trained faculty is available. The authors have had recent experience with pinch-off syndrome-in other words, spontaneous catheter fracture-in 3 patients who had undergone venous port implantation through the right subclavian route. Through these cases, we intend to review the dangers of subclavian venous catheterization, the causes of pinch-off syndrome, and its clinical presentation, progress, treatments, and prevention.

Risk Factors for Postoperative Intra-Abdominal Abscess after Laparoscopic Appendectomy: Analysis for Consecutive 1,817 Experiences

Background: Possible risk factors for postoperative intra-abdominal abscess (IAA) formation after laparoscopic appendectomy (LA) remain controversial. A perforated appendicitis, diabetes mellitus, peritoneal irrigation, obesity and age are considered to be possible risk factors for postoperative IAA, but the existing evidence is insufficient. This study aimed to identify the risk factors for IAA formation in patients receiving LA. Methods: Between January 2010 and December 2013, 1,817 patients who underwent 3-port LA were enrolled in this study. Patients were classified into 2 groups according to the development of postoperative IAA, and the differences between the groups were analyzed. Results: The incidence of IAA after LA was 1.5%, and the only identified risk factor for IAA was peritoneal irrigation. On logistic regression analysis of those patients who received peritoneal irrigation, suppurative appendicitis and non-placement of the peritoneal drain were found to be significant risk factors for the development of IAA. Conclusions: Peritoneal irrigation in a case of abdomen contamination was shown to be a risk factor for the development of postoperative IAA after LA. When peritoneal irrigation is performed, surgeons should consider using peritoneal drainage and postoperative antibiotics (including anti-anaerobic antibiotics) to prevent postoperative IAA formation.

Intrahepatic Cholangiocarcinoma Associated with Intrahepatic Duct Stones

OBJECTIVE It has been well established that the long-term prognosis of intrahepatic duct stones (IHDS) is complicated by the late development of biliary cirrhosis with associated intrahepatic cholangiocarcinoma (IHCC). Despite recent improvements in imaging studies, accurate preoperative diagnosis of IHCC is difficult. Therefore, we attempted to elucidate the clinical features of patients with IHDS with IHCC. METHODS We reviewed 80 patients with IHDS and divided them into two groups. The DS group included 72 patients who had only IHDS. The second group was defined as the CC group and included eight patients who had IHDS and IHCC. For diagnosis of IHDS and confirmation of coexisting IHCC, patients underwent various radiological evaluations and additional laboratory tests, such as serum carbohydrate antigen 19-9 (CA 19-9). RESULTS There was no significant difference in the symptoms and stone characteristics between the two groups. For the CC group, liver resection was performed in four patients. Three patients underwent curative resection, but only one of these patients was alive at 36 months without recurrence. CONCLUSION IHCC with IHDS was difficult to diagnose in the early phase. Therefore, while performing diagnostic studies and surgery for IHDS, one should always consider the possibility of coexisting cholangiocarcinoma.

Use of video-assisted thoracoscopic surgery to retrieve a broken guidewire

Subclavian venous catheterization was once widely used for volume resuscitation, emergency venous access, chemotherapy, parenteral nutrition, and hemodialysis. However, its use has drastically reduced recently because of life-threatening complications such as hemothorax, pneumothorax. In this case, a patient admitted for a scheduled operation underwent right subclavian venous catheterization for preoperative, intraoperative, and postoperative volume resuscitation and parenteral nutrition. The procedure was performed by an experienced senior resident. Despite detecting slight resistance during the guidewire insertion, the resident continued the procedure to the point of being unable to advance or remove it, then attempted to forcefully remove the guidewire, but it broke and became entrapped within the thorax. We tried to remove the guidewire through infraclavicular skin incision but failed. So video-assisted thoracoscopic surgery was used to remove the broken guidewire. This incident demonstrates the risks of subclavian venous catheterization and the importance of using a proper and gentle technique.

Popliteal Vein Aneurysm as a Source of Pulmonary Embolism: Report of a Case and Review of the World Literature

Although popliteal vein aneurysms are uncommon, they are potentially fatal because they can cause a pulmonary embolism. One-third of patients have further embolic events despite therapeutic anticoagulation. We report the case of a 67-year-old man who presented with dyspnea, rapid respirations, and dull, left pleuritic chest pain of 3-day duration. Computed tomography scanning of chest confirmed the diagnosis of multiple bilateral pulmonary emboli. Color duplex scanning followed by ascending venography confirmed a 3 × 4 cm(2) right saccular aneurysm of above-knee popliteal vein--containing thrombus. Aneurysm was treated with open tangential aneurysmectomy and lateral venorrhaphy.

The clinical significance of standardized uptake value in breast cancer measured using 18F-fluorodeoxyglucose positron emission tomography/computed tomography.

OBJECTIVE The objective of this study was to investigate the clinical and biological significance of F-fluorodeoxyglucose (F-FDG) uptake levels in breast cancer patients. PATIENTS AND METHODS F-FDG PET/computed tomography was performed in 206 women with breast cancer, and the standardized uptake value (SUV) in breast cancer was analyzed to test associations with prognostic parameters. RESULTS PET/computed tomography sensitivity for primary tumor detection was 90.4% (206/228) and sensitivity and specificity for metastatic axillary lymph node were 72.6% (45/62) and 84.7% (122/144), respectively. A high SUV was significantly associated with large tumor size (>2 cm, P<0.001), positive axillary lymph node metastasis (P<0.001), distant metastasis (P=0.016), higher tumor node metastasis stage (P<0.001), higher histologic grade (P<0.001), higher nuclear grade (P<0.001), estrogen receptor negativity (P<0.001), progesterone receptor negativity (P<0.001), triple negativity (P=0.006), B-cell lymphoma/leukemia-2 negativity (P=0.031), cytokeratin 5/6 positivity (P=0.001), epidermal growth factor receptor positivity (P=0.005), and Ki67 positivity (P=0.003). Multivariate analysis showed that tumor size (>2 cm, P=0.001), positive axillary lymph node metastasis (P=0.028), and estrogen receptor negativity (P<0.001) were significantly associated with the SUV. CONCLUSION High levels of F-FDG uptake in primary breast cancer were correlated with poor prognostic factors and aggressive biologic markers such as triple negativity, markers of basal-type cancer, and Ki67. The SUV might be predictive of biologic markers and assist therapeutic decision making.

Acute Gastric Necrosis Due to Gastric Outlet Obstruction Accompanied with Gastric Cancer and Trichophytobezoar

Gastric necrosis due to gastric outlet obstruction is a very rare condition, but it might be fatal if missed or if diagnosis is delayed. Our patient was a 73-year-old male complaining of abdominal pain, distension and dyspnea for 1 day. In plain radiography and computed tomography, a markedly distended stomach and decreased enhancement at the gastric wall were noted. He underwent explo-laparotomy, and near-total gastric mucosal necrosis accompanied by sludge from the soaked laver was noted. A total gastrectomy with esophagojejunostomy was performed, and he recovered without sequelae. Final pathologic examination revealed advanced gastric cancer at the antrum with near-total gastric mucosal necrosis.

Magnetic foreign body ingestion in pediatric patients: report of three cases

BackgroundAlthough foreign bodies (FBs) typically pass spontaneously and uneventfully through the digestive tract, a subset of such bodies may become trapped, eventually leading to significant injury. In particular, the ingestion of magnetic materials can cause serious morbidity due to proximate attraction through the intestinal wall.Case presentationWe recently treated three pediatric patients who had ingested several magnetic foreign materials. None of these patients exhibited any clinical symptoms or signs suggestive of surgical abdomen. Moreover, it was difficult to determine a definite diagnosis and a treatment plan due to limitations in history taking and radiologic examination. After admission to the hospital, these patients underwent surgery for the following reasons: (1) failure to spontaneously pass ingested foreign materials; (2) sudden-onset abdominal pain and vomiting during hospitalization; and (3) gastric perforation incidentally discovered during gastroduodenoscopy. Subsequently, all patients were discharged without complications; however, their conditions might have been fatal without surgery at an appropriate time.ConclusionsAs the clear identification about the number and characteristics of ingested magnets via radiographic examination or patient history appears to be difficult in pediatric patients, close inpatient observation would be required in any case of undetermined metallic FB ingestion. Patients who are confirmed to have ingested multiple magnets should be regarded as conditional surgical patients, although their clinical conditions are stable.

Ischemic necrosis of the tongue in surgical patients with septic shock: a case report

BackgroundAs the tongue is a well-vascularized organ, ischemic necrosis of the tongue is a rare disease entity. Critically ill patients with profound shock may experience end-organ hypoperfusion, which might result in tongue necrosis. However, to our best knowledge, there are no reports regarding ischemic necrosis of the tongue in surgical patients with septic shock.Case presentationTwo patients recently developed ischemic necrosis of the tongue in our surgical intensive care unit. Both patients had undergone emergent surgery for ischemic enteritis and developed postoperative septic shock. The first patient responded to critical treatment with a short period of circulatory shock, and the delivered dose of the vasopressor seemed to be acceptable. In contrast, the second patient developed postoperative refractory shock, and high-dose vasopressor treatment was required to maintain adequate tissue perfusion. Both patients developed ischemic necrosis of the tongue and died shortly after its emergence, despite vigorous resuscitation.ConclusionsWe suggest that ischemic necrosis of the tongue is an under-reported manifestation of any type of circulatory shock, which may have a complex pathogenic mechanism. Clinicians should be aware of the possibility of ischemic necrosis of the tongue in patients with circulatory shock, even if the patient exhibits clinical improvement, as this awareness may facilitate estimation of their prognosis and preparation for clinical deterioration.