Kyo Seon Lee

Tension Pneumothorax after Endoscopic Retrograde Pancreatocholangiogram

We report a case of tension pneumothorax after an endoscopic sphincterotomy. A 78-yr-old woman presented with progressing dyspnea. She had undergone an endoscopic retrograde cholangiopancreatogram three days before due to acute cholecystitis. She underwent endoscopic sphincterotomy for stone extraction, but the procedure failed. On arrival to our hospital, she complained about severe dyspnea and she had subcutaneous emphysema. A computed tomogram scan revealed severe subcutaneous emphysema, right-side tension pneumothorax, and pneumoretroperitoneum. Contrast media injected through a transnasal biliary drainage catheter spilled from the second portion of the duodenum. A second abdominal computed tomogram showed multiple air densities in the retroperitoneum and peritoneal cavity, which were consistent with panperitonitis. We recommended an emergent laparotomic exploration, but the patients guardians refused. She died eventually due to septic shock. Endoscopic retrograde cholangiopancreatogram is a popular procedure for biliary and pancreatic diseases, but it can cause severe complications such as intestinal perforation. Besides perforations, air can spread through the abdominal cavity, retroperitoneum, mediastinum, and the neck soft tissue, eventually causing pneumothorax. Early recognition and appropriate management is crucial to an optimal output of gastrointestinal perforation and pneumothorax.

Traumatic rupture of the coronary sinus following blunt chest trauma: a case report

Cardiac rupture is rare but potentially life-threatening complication after chest trauma. We present the case of a 57-year-old male who developed cardiac arrest because of extensive pericardial tamponade after a falling injury. We decided to perform an exploratory sternotomy in the operating room (OR). The patient was transported to the OR on extracorporeal membrane oxygenation (ECMO) support. We found a rupture of the coronary sinus after evacuation of an extensive hematoma in the pericardium and primarily repaired the injured site. After 2 days, the patient died due to refractory cardiogenic shock. To our knowledge, this is the first reported case of rupture of the coronary sinus after blunt chest trauma.

Subsequently occurring bilateral iliopsoas hematoma: a case report

BackgroundSpontaneous bilateral iliopsoas hematomas is a rare complication after anticoagulant therapy. Furthermore, the onset of bilateral iliopsoas hematoma is unknown because the causes are unclear.Case PresentationA 65-year-old man on anticoagulant therapy after mechanical aortic valve replacement was admitted after presenting with severe pain in the left flank and abdomen. Abdominal CT revealed a large left-sided iliopsoas hematoma with extravasation. Fresh frozen plasma was transfused due to prolonged prothrombin time. Transarterial embolization was successfully performed. During the hospital stay, follow-up abdominal CT was performed and a small right-sided iliopsoas hematoma was detected. This was closely observed and an intervention was not performed, as the patient was asymptomatic. The final CT prior to discharge revealed a reduction in size of each hematoma.ConclusionsSpontaneous bilateral iliopsoas hematoma can be developed subsequently. Patients with unilateral iliopsoas hematoma should be closely monitored for development of bilateral iliopsoas hematoma.

Nosocomial Infection in Adult Patients Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation

Data on the frequency of nosocomial infections during extracorporeal membrane oxygenation (ECMO) in adult populations remain scarce. We investigated the risk factors for nosocomial infections in adult patients undergoing venoarterial ECMO (VA-ECMO) support. From January 2011 to December 2015, a total of 259 patients underwent ECMO. Of these, patients aged 17 years or less and patients undergoing ECMO for less than 48 hours were excluded. Of these, 61 patients diagnosed with cardiogenic shock were evaluated. Mean patient age was 60.6 ± 14.3 years and 21 (34.4%) patients were female. The mean preoperative Sequential Organ Failure Assessment (SOFA) score was 8.6 ± 2.2. The mean duration of ECMO support was 6.8 ± 7.4 days. The rates of successful ECMO weaning and survival to discharge were 44.3% and 31.1%, respectively. There were 18 nosocomial infections in 14 (23.0%) patients. These included respiratory tract infections in 9 cases and bloodstream infections in a further 9. In multivariate analysis, independent predictors of infection during ECMO were the preoperative creatinine level (hazard ratio [HR], 2.176; 95% confidence interval [CI], 1.065–4.447; P = 0.033) and the duration of ECMO support (HR, 1.400; 95% CI, 1.081–1.815; P = 0.011). A higher preoperative creatinine level and an extended duration of ECMO support are risk factors for infection. Therefore, to avoid the development of nosocomial infections, strategies to shorten the length of ECMO support should be applied whenever possible.

Early Antithrombotic Therapy after Bioprosthetic Aortic Valve Replacement in Elderly Patients: A Single-Center Experience

PURPOSE Early antithrombotic therapy after bioprosthetic aortic valve replacement (AVR) is controversial. This study aimed to retrospectively compare between warfarin and aspirin treatment in the 3 months after bioprosthetic AVR for elderly patients more than 60 years old, and to determine the optimal antithrombotic therapy. METHODS This retrospective study included 479 patients in single center from January 1994 to June 2014. Patients were divided into two groups (Wa group, warfarin; As group, aspirin). We searched our computerized clinical database for thromboembolic or bleeding events. Propensity score analysis was conducted to adjust for selection bias. RESULTS All patients, except one patient, were followed-up in the out-patient department for 3 months after the operation. In all, 86 propensity-matched patient-pairs were derived. Early operative outcomes were similar in both the groups. There are one patient of thromboembolic event and three patients of bleeding events, but the prevalence was not significantly different (p >0.999). CONCLUSION The incidence of thromboembolic and bleeding events during early 3 months after bioprosthetic AVR were similar in Wa and As groups. If the patient does not have indications of warfarin, early antithrombotic therapy with aspirin only may be easier and more feasible for elderly patients.

A rare case of pericarditis and pleural empyema secondary to transdiaphragmatic extension of pyogenic liver abscess

BackgroundTransdiaphragmatic extension of pyogenic liver abscess is the rarest cause of pericarditis and pleural empyema. It is a rapidly progressive and highly lethal infection with mortality rates reaching 100% if left untreated. However, the transmission route, treatment methods and prognosis have not been well studied.Case presentationA 65-year-old male patient presented with a fever, dyspnea, and right upper quadrant abdominal pain. Computed tomography of the chest and abdomen showed huge liver abscess without full liquefaction in the left lobe, large amount of left pleural effusion, and mild pericardial effusion, and the patient was treated with parenteral antibiotics and pigtail insertion at the left pleura. However, four days later, cardiac tamponade was developed and surgical drainage of the abscess and pericardium was performed. Klebsiella pneumonia was isolated from pleural empyema. Twenty-five days after surgery, the patient was discharged without any complications.ConclusionsHerein, we report a rare case of pleural empyema and pericarditis in that resulted from the extension of huge pyogenic liver abscess. Early surgical treatment may have prevented progression of the pericarditis to the more dismal purulent pericarditis. We also review pertinent English literature on pericarditis as a complication of PLA.

Supraclavicular transposition of aberrant left vertebral artery for hybrid treatment of aortic arch aneurysm: a case report

BackgroundVertebral artery variations are common in thoracic aortic patients. If patients have the aberrant left vertebral artery, the more difficult to determine the treatment modality.Case presentationWe report the case of a 63-year-old man with an aberrant left vertebral artery originating from an aneurysmal aortic arch. The patient underwent a successful hybrid thoracic endovascular aortic repair after aortic arch debranching and transposition of the aberrant left vertebral artery to the left common carotid artery through a supraclavicular incision without sternotomy.ConclusionsThe aberrant left vertebral artery originating from the aortic arch can be safely transposed to the left common carotid artery through a supraclavicular approach.

Coarctation with a calcified aneurysm of the descending thoracic aorta.

A 51-year-old male presented with blood-tinged sputum and a 40mmHg difference in pressure between the upper and lower extremities. A computed tomographic angiogram (CTA) of the chest showed a calcified and tortuous focal aneurysmal descending thoracic aorta with features of a coarctation (Fig. 1). There was dilatation of the bronchial and internal mammary arteries. At the time of surgery, the aorta

Supermoon-like Thrombus at the Mitral Valve: Struggle between the Bad and the Worse

Figure 1 Cerebral angiography showing acute cerebral infarction due to occlusion of the proximal posterior cerebral artery. An 81 year-old woman was referred to the echocardiography laboratory for evaluation of the cardioembolic source of cerebral infarction. Earlier, the patient was diagnosed with acute cerebral infarction due to occlusion of the proximal posterior cerebral artery (Figure 1), which was successfully treated with mechanical thrombectomy. Echocardiography revealed moderate mitral stenosis (MS) with a mitral valve area of 1.23 cm and a large ball-valve thrombus, which was freely floating within the enlarged left atrium. As blood flowed from the left atrium to the ventricle, this supermoon-like thrombus tried to pass through the mitral valve but failed repeatedly because of MS (Figure 2, Movie I-III in the online-only data supplement). Considering the risk of fatal embolisation, the thrombus was surgically removed and mitral valvuloplasty was performed. A large 4.3 x 2.8 cm round free-floating mass was removed from the left atrium (Figure 3). Histopathological examination showed the mass to be an organised thrombus. Thrombus formation and subsequent embolisation are not uncommon in MS. Sometimes, sudden cardiac death may occur owing to total obstruction of the mitral valve [1,2]. This patient, however, survived and was discharged uneventfully. This case was extremely unusual in that MS prevented