Short-term outcomes of a multicentre randomized clinical trial comparing laparoscopic pylorus-preserving gastrectomy with laparoscopic distal gastrectomy for gastric cancer (the KLASS-04 trial)

BACKGROUND

There remain concerns about the safety and functional benefit of laparoscopic pylorus-preserving gastrectomy (LPPG) compared with laparoscopic distal gastrectomy (LDG). This study evaluated short-term outcomes of a randomized clinical trial (RCT) comparing LPPG with LDG for gastric cancer.

METHODS

The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-04 trial was an investigator-initiated, open-label, parallel-assigned, superiority, multicentre RCT in Korea. Patients with cT1N0M0 cancer located in the middle third of the stomach at least 5 cm from the pylorus were randomized to undergo LPPG or LDG. Participants, care givers and those assessing the outcomes were not blinded to group assignment. Outcomes were 30-day postoperative morbidity rate and death at 90 days.

RESULTS

Some 256 patients from nine institutions were randomized (LPPG 129 patients, LDG 127 patients) between July 2015 and July 2017 and outcomes for 253 patients were analysed. Postoperative complications within 30 days were seen in 19.3 and 15.5 per cent in the LPPG and LDG groups respectively (P = 0·419). Postoperative pyloric stenosis was observed in nine (7.2 per cent) and two (1·5 per cent) patients in the LPPG and LDG groups (P = 0·026) respectively. In multivariable analysis higher BMI was a risk factor for postoperative complications (odds ratio 1·17, 95 per cent c.i. 1·04 to 1·32; P = 0·011). Death at 90 days was zero in both groups.

CONCLUSION

Postoperative complications and mortality was comparable in patients undergoing LPPG and LDG. Registration number: NCT02595086 (http://www.clinicaltrials.gov).

Personal exposure to fine particulate air pollutants impacts blood pressure and heart rate variability

Air pollution has increasingly been recognized as a major healthcare concern. Air pollution, particularly fine particulate matter (≤ 2.5 μm in aerodynamic diameter [PM_2.5]) has demonstrated an increase in adverse cardiovascular events. This study aimed to assess the cardiovascular response to personal exposure to different levels of PM_2.5. This prospective cohort study enrolled healthy volunteers aged ≥ 18 years with no cardiovascular disease. Study subjects carried personal exposure monitor of PM_2.5, digital thermo-hygrometer for temperature and humidity, 24-h blood pressure monitor, and continuous electrocardiogram monitor. Measurements were repeated twice with an interval of 6-12 months. Statistical models consisted of generalized estimation equations to various repeated measures of each subject. A total of 22 subjects were enrolled in this study between July 2018 and January 2019. Measurement was performed twice in all participants, and a total of 36 data were collected except for insufficient data collection. The mean age of the study population was 41.6 years, and 95% of the subjects were females. No study subjects had hypertension or other cardiovascular diseases. The average systolic blood pressure increased with higher PM_2.5 levels with marginal significance (0.22 mmHg [95% confidential intervals - 0.04 to 0.48 mmHg] per 10 μg/m³ of PM_2.5). All parameters for heart rate variability significantly decreased with a higher level of PM_2.5. In this study, we measured individual personal exposure to PM_2.5 by using a portable device. We found that 24-h exposure to high levels of PM_2.5 was associated with a significant decrease in heart rate variability, suggesting impaired autonomous nervous function.

A feasibility study of laparoscopic total gastrectomy for clinical stage I gastric cancer: a prospective multi-center phase II clinical trial, KLASS 03

BACKGROUND

With improved short-term surgical outcomes, laparoscopic distal gastrectomy has rapidly gained popularity. However, the safety and feasibility of laparoscopic total gastrectomy (LTG) has not yet been proven due to the difficulty of the technique. This single-arm prospective multi-center study was conducted to evaluate the use of LTG for clinical stage I gastric cancer.

METHODS

Between October 2012 and January 2014, 170 patients with pathologically proven, clinical stage I gastric adenocarcinoma located at the proximal stomach were enrolled. Twenty-two experienced surgeons from 19 institutions participated in this clinical trial. The primary end point was the incidence of postoperative morbidity and mortality at postoperative 30 days. The severity of postoperative complications was categorized according to Clavien-Dindo classification, and the incidence of postoperative morbidity and mortality was compared with that in a historical control.

RESULTS

Of the enrolled patients, 160 met criteria for inclusion in the full analysis set. Postoperative morbidity and mortality rates reached 20.6% (33/160) and 0.6% (1/160), respectively. Fifteen patients (9.4%) had grade III or higher complications, and three reoperations (1.9%) were performed. The incidence of morbidity after LTG in this trial did not significantly differ from that reported in a previous study for open total gastrectomy (18%).

CONCLUSIONS

LTG performed by experienced surgeons showed acceptable postoperative morbidity and mortality for patients with clinical stage I gastric cancer.

Prophylactic Antiplatelet Medication in Endovascular Treatment of Intracranial Aneurysms: Low-Dose Prasugrel versus Clopidogrel

BACKGROUND AND PURPOSE

Prophylactic antiplatelet medication is beneficial in decreasing thromboembolic complications during endovascular treatment of unruptured intracranial aneurysms. The efficacy may be limited by variability of individual response to antiplatelet medication, especially clopidogrel. We compared the efficacy of 2 antiplatelet medications, low-dose prasugrel and clopidogrel, in patients undergoing endovascular treatment of unruptured aneurysms.

MATERIALS AND METHODS

From November 2014 to July 2015, 194 patients with a total of 222 unruptured aneurysms underwent endovascular treatment at a single institution. Laboratory and clinical data from the prospectively maintained registry were used in this study. Antiplatelet medication was given the day before endovascular treatment (prasugrel 20 mg or 30 mg or clopidogrel 300 mg). Response to the antiplatelet medication was measured by the VerifyNow system. Periprocedural adverse event rates between the 2 groups were compared.

RESULTS

There were no significant differences in the baseline characteristics of patients and aneurysms between the 2 groups. The P2Y12 reaction unit values were lower (clopidogrel group versus prasugrel group, 242.7 ± 69.8 vs 125.7 ± 79.4; P < .0001) and percentage inhibition values were higher (22.1% ± 19.7% vs 60.2 ± 24.7%; P < .0001) in the prasugrel group. There were no thromboembolic events, but there was 1 procedural bleed in each group, without any clinical consequences.

CONCLUSIONS

The prasugrel group showed more effective and consistent platelet inhibition. We may omit the antiplatelet response assay with the low-dose prasugrel premedication before the endovascular treatment of patients with unruptured aneurysms. Further study is required to determine whether there is benefit of this strategy regarding clinical outcome.

Prognostic value of tumor-infiltrating lymphocytes in Epstein-Barr virus-associated gastric cancer

BACKGROUND

This study explored the prognostic impact of tumor-infiltrating lymphocytes (TILs) and investigated whether three histologic subtypes (lymphoepithelioma-like carcinoma, carcinoma with Crohn's disease-like lymphoid reaction, and conventional-type adenocarcinoma) could stratify a prognostic subset for patients with Epstein-Barr virus (EBV)-associated gastric cancer (EBVaGC).

MATERIALS AND METHODS

After reviewing 1318 consecutive cases of surgically resected or endoscopic submucosal dissected gastric cancers, 120 patients were identified as EBV-positive using EBV-encoded RNA in situ hybridization. The evaluation of the percentage of intratumoral (iTu-) and stromal (str-) TILs was carried out, and the cases were also subclassified into three histologic subtypes as noted above.

RESULTS

Among the 120 patients, 73 patients (60.8%) and 60 patients (50.0%) were determined as str-TIL-positive and iTu-TIL-positive, respectively. In a univariate analysis, str-TIL-positivity was significantly associated with longer recurrence-free survival (RFS; P = 0.002) and disease-free survival (DFS; P = 0.008), yet not overall survival (OS; P = 0.145). While iTu-TIL-positivity has a tendency of favorable outcome indicator for DFS and OS, but statistically significant differences were not shown, respectively (RFS, P = 0.058; DFS, P = 0.151; OS, P = 0.191). In a multivariate analysis using a Cox proportional hazard model adjusted for age, pTNM stage, lymphatic invasion, perineural invasion, and venous invasion; histologic subtype, WHO classification, and str-TIL-positivity were independently or tentatively associated with favorable RFS (hazard ratio [HR] = 12.193, 95% confidence interval [95% CI] 1.039-143.055, P = 0.047) or DFS (HR = 4.836, 95% CI 0.917-25.525, P = 0.063).

CONCLUSION

The histologic subclassification and TILs can be used to predict RFS and DFS for patients with EBVaGC.

Preoperative Quality of Life in Patients with Gastric Cancer

Purpose

We evaluated the socio-personal and clinical factors that can affect preoperative quality of life to determine how to improve preoperative quality of life in patients with gastric cancer.

Materials and Methods

The preoperative quality of life data of 200 patients (68 females and 132 males; mean age 58.9±12.6 years) with gastric cancer were analyzed according to socio-personal and clinical factors. The Korean versions of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core (QLQ) 30 and the EORTC QLQ-STO22, a gastric cancer-specific module, were used to assess quality of life. Patients were asked to complete the questionnaire preoperatively by themselves.

Results

Patients with a higher academic background and stage I disease tended to have higher global health status scores. Highly educated younger men had better physical functioning scores. Highly educated and well-nourished patients with stage I cancer had higher role functioning scores. Married patients had better emotional scores. The symptom scales were affected by sex, age, education level, nutrition, and cancer stage.

Conclusions

Preoperative quality of life in patients with gastric cancer can be improved by nutritional support and treatment of symptoms caused by disease progression. Psychological support may be helpful for patients with a poor quality of life.

Two cases of gastrocolocutaneous fistula with a long asymptomatic period after percutaneous endoscopic gastrostomy

Gastrocolocutaneous fistula is a rare complication of the percutaneous endoscopic gastrostomy (PEG) procedure. Typical symptoms usually occur in the first few months. We recently encountered 2 patients with 8- and 33-month asymptomatic periods. A 74-year-old man presented with watery diarrhea for 1 month. He had undergone PEG 9 months earlier. During workup, an upper endoscopy and abdominal CT scan revealed the migration of the feeding tube into the transverse colon. He was discharged with a nasogastric tube after treatment. A 77-year-old man presented with sudden loosening of his PEG tube with a duration over 3 days. He had undergone PEG procedure three times until that time. During workup, a gastrocolocutaneous fistula was diagnosed. However, when previous studies were reviewed, an abdominal CT scan, which was done 6 months ago before the third PEG, showed the fistula already existed at that time, suggesting that it was created about 33 months earlier when he underwent the second PEG procedure. The patient died of pneumonia aggravation despite conservative treatment. Both a high index of suspicion and the careful inspection of the upper endoscopy are very important for early diagnosis regardless of symptoms.

Invasive pulmonary aspergillosis after influenza a infection in an immunocompetent patient

Invasive aspergillosis has emerged as a major cause of life-threatening infections in immunocompromised patients. Recently, patients with chronic obstructive pulmonary disease, who have been receiving corticosteroids for a long period, and immunocompetent patients in the intensive care unit have been identified as nontraditional hosts at risk for invasive aspergillosis. Here, we report a case of invasive pulmonary aspergillosis after influenza in an immunocompetent patient. The patient's symptoms were nonspecific, and the patient was unresponsive to treatments for pulmonary bacterial infection. Bronchoscopy revealed mucosa hyperemia, and wide, raised and cream-colored plaques throughout the trachea and both the main bronchi. Histologic examination revealed aspergillosis. The patient recovered quickly when treated systemically with voriconazole, although the reported mortality rates for aspergillosis are extremely high. This study showed that invasive aspergillosis should be considered in immunocompetent patients who are unresponsive to antibiotic treatments; further, early extensive use of all available diagnostic tools, especially bronchoscopy, is mandatory.

Changes of quality of life after gastric cancer surgery

Purpose

The aim of this study was to evaluate chronological change of quality of life after surgery in patients with gastric cancer during one year postoperatively.

Materials and Methods

Quality of life data were obtained from 272 gastric cancer patients who underwent curative gastrectomy between September 2008 and February 2011 at the Kyungpook National University Hospital. The Korean versions of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core (QLQ) 30 with gastric cancer-specific module, the EORTC QLQ-STO22 were used to assess quality of life. All patients had no evidence of recurrence or metastasis during the first postoperative year. Patients were asked to complete the questionnaire, by themselves preoperatively, 3-, 6-, 9-, and 12-months postoperatively.

Results

Physical functioning score and role functioning score significantly decreased at first 3 months after surgery and the significant differences were noticed until 12 months after surgery. Emotional functioning score started with the lowest score before surgery and significant improvement was shown 6 months after surgery. Most symptom scores and STO-22 scores were highest at 3 months after surgery and gradually decreased, thereafter. Eating restriction, anxiety, taste, body image scores was highest at 3 months after surgery without significant decrease afterwards.

Conclusions

Most scales worsened after surgery and gradually recovered afterwards with some differences in rate of recovery. However the scales did not fully recover by 1 year period. Further follow-up after 1 year would be helpful in determining which scales are permanently damaged and which are just taking longer time to recover.

A pulse wave simulator for palpation in the oriental medicine

Pulse diagnosis, which is one of methods of diagnosis, is an important factor in oriental medicine. However, a problem in diagnosis with the pulse is that there is no objective standard. Therefore, the practitioners pass on the skill and students learn about pulse diagnosis as a method that depends on speech. In this study, the electronic pulse wave reproduction apparatus, which is an objective and accurate means for measuring the pulse, was developed. The previous model reproduced the pulse wave in one part of the point, but it was made by using three pairs of voice coil motors (VCM) in order to similarly express the three parts of the pulse: Cun, Guan and Chi. To evaluate this system, the output of the pulse wave was confirmed in order to reproduce the pulse wave with these settings. Consequently, the targets for slow pulse and rapid pulse have a 7 ms standard deviation, which is within the error tolerance. A voltage value of H(1), utilized to verify vacuous pulse and the replete pulse, has a standard deviation range of 4.7-5.4 mV. This system, which is similar to a person's pulse diagnosis, can be used to educate others in pulse diagnosis both quantitatively and scientifically.

Two-year follow-up of contrast stasis within the sac in unruptured aneurysm coil embolization: progressive thrombosis or enlargement?

BACKGROUND AND PURPOSE

The fate of contrast stasis within an aneurysmal sac after coiling has not been established. We followed and evaluated the potential risks of recanalization of unruptured aneurysms embolized with BPCs for 2 years.

MATERIALS AND METHODS

A total of 301 unruptured aneurysms in 252 patients were treated with BPCs. Contrast stasis was observed on initial postembolization angiograms in 104 (34.6%) of these aneurysms. For follow-up, skull images by an angiographic unit (at 3, 9, 15, and 21 months), CE-MRA including TOF source images (at 6, 12, and 18 months), and DSA (at 24 months) were used.

RESULTS

In 89 (85.6%) of the 104 aneurysms with contrast stasis, the stasis disappeared on 6-month MRAs and occlusions remained unchanged without recanalization for 2 years. In the remaining 15 (14.4%), recanalization occurred during follow-up. The presence of contrast stasis was not found to be associated with the obliteration rate (P = .641) or packing attenuation (aneurysms without contrast stasis 30.7% ± 11.18 versus aneurysms with contrast stasis 33.0% ± 12.11, P = .113). Contrast stasis was not found to be a risk factor for recanalization (15/104 [14.4%] versus 29/197 [14.7%], P = 1.000).

CONCLUSIONS

Contrast stasis is a benign angiographic finding that can disappear within 6 months on follow-up MRA. In addition, contrast stasis was not found to be associated with a low obliteration rate or packing attenuation or to be a risk factor for recanalization. The present study shows that aneurysms with contrast stasis on initial postembolization angiograms are no more likely to recanalize than aneurysms without contrast stasis.

Spinal intraosseous arteriovenous fistula in the fractured vertebral body

A 68-year-old woman presenting with progressive paraparesis was diagnosed with an AVF involving a previously fractured L1 vertebral body on which feeders from multiple segmental arteries converged. The most distinctive feature in our patient was that the fistula was located in the vertebral body. Transarterial embolization of the segmental arteries with coils and glue resulted in total obliteration of the fistula, which in turn resulted in symptom improvement.

Prevalence study of proximal vertebral artery stenosis using high-resolution contrast-enhanced magnetic resonance angiography

PURPOSE

To evaluate the prevalence of proximal vertebral artery stenosis, compared wiith those of the distal vertebral/basilar artery and extracranial internal carotid artery, in a large population of stroke and non-stroke patients.

MATERIAL AND METHODS

Nine-hundred-and-thirty-five patients who underwent high-resolution contrast-enhanced magnetic resonance angiography in a regional general hospital were categorized into six groups based on neurological symptoms and disease: an asymptomatic group (n = 182), a minor symptom group with headache or dizziness (n = 519), a cardiac group with coronary artery steno-occlusive disease (n = 15), a hemorrhagic group with old cerebral hemorrhage (n=26), an anterior circulation infarct group (n = 121), and posterior circulation infarct group (n = 72). Prevalence of stenosis of the proximal vertebral artery, distal vertebral/basilar artery, and internal carotid artery was analyzed.

RESULTS

The prevalence of stenosis of the proximal vertebral artery, distal vertebral/ basilar artery, and internal carotid artery was 12.9%, 5.5%, and 7.2%, respectively, in the study population, and rose as the age increased (P < 0.0001 for all arteries). The prevalence of stenosis of the proximal vertebral artery, distal vertebral/basilar artery, and internal carotid artery was 3.3%, 0.5%, and 1.1%, respectively, in the asymptomatic group; 8.3%, 2.1%, and 3.7%, respectively, in the minor symptom group; 13.3%, 6.7% and 6.7%, respectively, in the cardiac group; 19.2%, 7.7%, and 7.7%, respectively, in the hemorrhagic group; 27.3%, 8.3%, and 25.6%, respectively, in the anterior circulation infarct group; and 44.4%, 36.1%, and 16.7%, respectively, in the posterior circulation infarct group. This increasing tendency of stenosis accordingly was statistically significant (P < 0.0001 for all arteries).

CONCLUSION

The prevalence of proximal vertebral artery stenosis was highest, compared with those of the distal vertebral/basilar artery and internal carotid artery, although the clinical significance of proximal vertebral artery stenosis should be investigated in further studies.

Coil Breakage during Aneurysm Embolization. Case Report

SUMMARY

Stretched Guglielmi detachable coils (GDCs; Boston Scientific, USA) can be easily broken if forceful manipulation is applied. However, coil fracture without stretching has not been known. We report an extremely unusual occurrence of fracture without coil stretching during aneurysm embolization.

PC-Based 3D Reconstruction of MR Angiography in Evaluation of Intracranial Aneurysms. The Value of Pre-Treatment Planning for Embolization and Post-Treatment Follow-up

SUMMARY

In this study, we present our experiences of personal computer-based 3D reconstructions of MRA for pre-treatment planning and post-treatment follow-up for cerebral aneurysms. Twentynine ruptured or unruptured intracranial aneurysm patients with 36 intracranial aneurysms, who underwent embolization and pretreatment and/or follow up 3D MRA were included in this study. All 29 patients were examined by DSA and MRA before (18 patients, 24 aneurysms) and/or after embolization (16 patients, 17 aneurysms). The MRA source images were transported to a personal computer in DICOM format for viewing, post-processing, and 3D reconstruction. DSA and PC based SSD 3D MRA equally well demonstrated most aneurysms before embolization (17 patients, 22 aneurysms). The depiction of aneurysm morphology, neck evaluation and branch vessel interpretation were much easier on 3D MRA, which has the ability to manipulate images in real time. When the vascular anatomy was complicated by another vascular system, the anterior or posterior circulations were separately reconstructed easily by using PC based reconstruction software. The 3D MRA also well demonstrated post-embolization recurrence or remnant aneurysmal cavities. In one giant aneurysm, the 3D MRA was unable to show the entire aneurysmal sac due to a blood flow saturation effect, but this was resolved by additional contrast material injection. PC-based 3D MRA proved to be a useful tool for the pretreatment planning of embolization procedures and for follow up after treatment in the case of cerebral aneurysms.

An angiographic lesion mimicking pseudo-aneurysm in cerebral arteriovenous malformation

In cerebral arteriovenous malformations (AVMs), a pseudo-aneurysm represents rupture site, and its presence is known as a factor for rebleeding. We report a case of cerebral AVM presenting with intracerebral haemorrhage in which cerebral angiography showed a lesion mimicking pseudo-aneurysm. Although the patient needed urgent surgical decompression, it was delayed because early haematoma evacuation would induce rebleeding from the rupture site. The authors attempted to occlude the pseudoaneurysm interventionally before surgery. After surgical excision, the lesion that was believed to be a pseudo-aneurysm was revealed as a partially thrombosed venous sac having a thick fibrous wall. In this report, the authors discuss the pitfalls in the interpretation of pseudo-aneurysms in angiographic AVM architecture.

Multiple meningiomas of different pathological features: case report

Meningioma is a common intracranial tumour and it may occur not infrequently as one of the multiple tumours, especially in patients with neurofibromatosis. The incidence of multiple meningiomas (MMs) without the stigmata of neurofibromatosis is rare, ranging from 1 to 9% of all meningiomas in the literature. Multiple meningiomas with different pathologic features are even rarer, and most of them are benign histologies. The authors report an extremely rare case of MMs which were presented with malignant and benign histological features simultaneously. The underlying mechanism of MM formation is still unclear, however, subarachnoid spread was thought to be the most likely mechanism. The findings of most of MMs showed identical histopathological features and several molecular biologic studies provided evidence for the monoclonal origin of MMs to back up the above hypothesis. However, different histological features among the reported multiple meningioma cases including our particular one, suggests their origin from multicentric neoplastic foci activated by a supposed tumour-producing factor. However, we cannot completely exclude the possibility of independent progression from monoclonal origin.

A co-operative study: clinical characteristics of 334 Korean patients with moyamoya disease treated at neurosurgical institutes (1976-1994). The Korean Society for Cerebrovascular Disease

A co-operative study was conducted to determine the clinical characteristics of patients with moyamoya disease who were diagnosed and treated at neurosurgical institutes in Korea before 1995. Twenty-six hospitals contributed 505 cases and among them, the clinical characteristics of 334 patients with definite moyamoya disease were evaluated. The number of patients began to increase from the late 1980s, and after that approximately 20 patients were treated each year. There were two age peaks: from six to 15 and from 31 to 40 years of age. Haemorrhagic manifestations occurred in approximately 43% of the patients. The major clinical manifestations were haemorrhage in adults (62.4%) and ischaemia in children (61.2%). Overall 54.5% of the patients experienced decreased consciousness levels, mainly due to intracranial haemorrhage or cerebral infarction. In the patients with ischemic manifestations, the adult patients were more likely to have cerebral infarction than the pediatric patients (80% vs. 39%) and the pediatric patients were more likely to have TIA (61% vs. 25%). Thirty eight percent of the patients underwent bypass surgery and 53% of these procedures were performed bilaterally. Treatment policies, including indications for bypass surgery and commonly used drugs, were somewhat different according to the institution. Overall favorable outcome was 73%, and the most significant factor affecting poor outcome was haemorrhagic manifestation. This article describes the characteristics of 334 patients with moyamoya disease, who were diagnosed and treated at neurosurgical institutes in Korea before 1995.

The optimal management of pediatric steam burn from electric rice-cooker: STSG or FTSG?

The steam burn caused by an electric rice-cooker is a unique mode of burn injury in Asian countries, especially Korea and Japan. This type of burn injury is characterized by 1) occurring most frequently on the volar aspect of the hand in toddlers younger than 2 years of age (92.8%); 2) the depth of burns are normally deep second-degree to third-degree (98%) and usually need surgery at the time of injury; 3) flexion contractures of multiple finger joints and web space contracture are common sequelae. We hypothesized that primary full-thickness skin graft (FTSG) would give more reliable results and eliminate the late reconstructive procedures. Between January 1997 and September 1999, 36 patients underwent primary FTSG, and the results of this primary FTSG group were compared with 124 patients who were treated with split-thickness skin graft (STSG; 79/124; 63.7%) or by conservative management (45/124; 36.3%), and readmitted for the correction of hand deformities between September 1995 and September 1999. In the primary FTSG group, 11.1% (4/36) of mild web contractures and 5.5% (2/36) of finger joint contractures were documented, and these did not require the reconstructive procedure during a follow-up period of 8.8 +/- 4.8 months. In 124 patients of the primary STSG or conservative group, the mean time interval to reoperation was 8.9 +/- 4.0 months and all patients received FTSG for correction of late hand deformities. In a retrospective study of the primary STSG group, 42 of 53 patients (79.2%) received reconstructive procedure during a 5-year follow-up period. In this report, we introduce the nature of steam burn caused by electric rice-cooker and propose that primary FTSG may be a reliable method for the treatment of this more severe type of acute burn in pediatric patients.

Epidural naloxone reduces intestinal hypomotility but not analgesia of epidural morphine

PURPOSE

Epidural morphine is associated with decreased bowel motility and increased transit time. Low doses of intravenous naloxone reduce morphine-induced pruritus without reversing analgesia, but the effect of epidural naloxone on bowel motility has not been studied. Therefore we evaluated bowel motility and analgesia when naloxone was co-administered with morphine into the epidural space.

METHODS

Forty-three patients having combined thoracic epidural and general anesthesia for subtotal gastrectomy were randomly assigned to one of two study groups. All received a bolus dose of 3 mg epidural morphine at the beginning of surgery, followed by a continuous epidural infusion containing 3 mg morphine in 100 ml bupivacaine 0.125% with either no naloxone (control group, n = 18) or a calculated dose of 0.208 microg x kg(-1) x hr(-1) of naloxone (experimental group, n = 25) for 48 hr. We measured the time to the first postoperative passage of flatus and feces to evaluate the restoration of bowel function, and visual analog scales (VAS) for pain during rest and movement. Scores were assessed at 2, 4, 8, 16, 24, 36 and 48 hr postoperatively.

RESULTS

The experimental group had a shorter time to the first postoperative passage of flatus (5 1.9 +/- 1 6.6 hr vs 87.0 +/- 19.5 hr, P < 0.001 ) and feces (95.3 +/- 25.0 hr vs 132.9 +/- 29.4 hr, P < 0.001). No differences were found in either resting or active VAS between the two groups.

CONCLUSION

Epidural naloxone reduces epidural morphine-induced intestinal hypomotility without reversing its analgesic effects.

Effect of BL-21 (Wei-Yu) acupoint stimulation on gastric motility following preanesthetic treatment in dogs

In acupuncture practice of animals, preanesthetics sometimes are needed. The purpose of this study was to select the ideal chemical restraint at acupuncture for gastric motility. Nine healthy mixed breed dogs weighed 10-21 kg and aged 1-3 years old were used in this study. Two EMG surface electrodes were placed between the seromuscular and the mucosal layer of pylorus. Twenty minutes after feeding normal gastric motility was recorded for 60 minutes using physiograph (Narco-Biosystem). Then preanesthetic treated-gastric motility was observed for 30 minutes. Preanesthetics used were xylazine, diazepam, and acepromazine. Acupuncture needles were inserted to BL-21 (Wei-Yu) acupoint, and then changes of gastric motility were recorded for 60 minutes. The gastric motility following xylazine administration (1 mg/kg, IV) was markedly decreased. BL-21 (Wei-Yu) acupoints stimulation did not alter xylazine-induced depression of gastric motility. The diazepam (1 mg/kg IV) treated-gastric motility was increased mildly 20 minutes after drug administration. BL-21 (Wei-Yu) acupoint stimulation after diazepam administration enhanced gastric motility significantly. The gastric motility following acepromazine (0.3 mg/kg, IM) administration was not changed compared with normal gastric motility. Application of traditional acupuncture at BL-21 (Wei-Yu) significantly increased the gastric motility. Based on these results, acepromazine and diazepam could be acceptable chemical restraints for acupuncture therapy of gastric motility, but xylazine couldn't be.

Palliatively treated cerebral arteriovenous malformations: follow-up results

The purpose of this study was to evaluate the benefits of palliative embolisation of patients with inoperable intracranial AVMs. It involved the analysis of the long-term clinical follow-up results of 27 patients with inoperable intracranial AVMs. Sixteen patients were treated medically and 11 patients received partial embolisation. The mean size of the lesions was 7.2 +/- 2.6 cm, and the mean follow-up period was 99 +/- 44 months (range 52-192 months). There were no significant statistical differences in the sex, age, size, venous drainage pattern, location of the lesions or presented symptoms. The analysis of the long-term clinical follow-up results showed no significant difference in either the risk of haemorrhage or clinical status of the patients in the two treatment groups. Of the 16 patients in the medical treatment group, 8 (50%) showed a clinical improvement, 3 no improvement and 5 (31%) deterioration. Of the 11 patients in the embolisation group, 5 (45.5%) showed clinical improvement, 3 no improvement and 3 (27.3%) deterioration (P = 0.871). Twenty-five percent (4 cases) of patients in the medical group and 45.5% (5 cases) of patients in the embolisation group suffered from haemorrhage during the follow-up period (P = 0.270). Complications related to embolisation occurred in three cases. This comparative study shows that palliative partial embolisation of intracranial AVMs, in all probability does not produce better clinical results than medical treatment.

General pharmacology studies on beta-domain deleted recombinant factor VIII

beta-Domain deleted recombinant factor VIII (GC-rAHF), newly developed by Korea Green Cross Co., is a novel therapeutic for hemophiliacs and is currently under clinical evaluation. The general pharmacological properties of this drug were evaluated using mice, rats, guinea pigs and rabbits. Intravenous doses of 5 to 500 IU/kg were assayed in several tests to analyze their effects in vivo on various systems. The effect of the substance under study was also tested in vitro on isolated guinea pig ileum preparations at final concentrations of 5 to 50 IU/kg. The result of this study showed that GC-rAHF did not affect general behavior in the Irwin test. Similarly the drug was not found to affect neither normal body temperature nor the spontaneous activity in mice. In addition, it was not found to induce pharmacologically significant alterations of the cardiovascular and respiratory parameters in rats. No effects were observed either in the pentobarbital sodium-induced sleep-induction time and duration, in writhing test or in the test of pentetrazole-induced convulsion. Finally, the tested drug did not modify the gastrointestinal motility, acetylcholine or histamine-induced contraction of the isolated guinea pig ileum, nor gastric secretion. The results demonstrated that GC-rAHF has no effects on the central nervous, cardiovascular, respiratory and digestive systems in the doses of 5, 50 and 500 IU/kg in vivo and 5, 10, 50 and 100 IU/kg in vitro.

Fluoroscopy-aided thoracoscopic resection of pulmonary nodule localized with contrast media

BACKGROUND

The pulmonary nodules have become the major indication of video-assisted thoracic surgery (VATS). Recently, several preoperative or intraoperative techniques for identifying small or deeply seated pulmonary nodules have facilitated thoracoscopic resection. We describe the new technique for detecting difficult lesions.

METHODS

Preoperatively, we marked the visceral pleura near the pulmonary nodules with dye, simultaneously injected contrast media (1 water-soluble Optiray [Mallinckrodt Medical Inc, Quebec, Canada], 18 barium sulfate, 11 Lipiodol [Laboratoire Guerbet, Aulnay-sous-Bois, France]) into or around the nodule under computed tomography (CT) guidance. During VATS, we were able to easily and accurately detect and resect all the nodules localized with contrast media, of which the radiopacity was visualized on the portable fluoroscopic monitor.

RESULTS

Between February 1996 and December 1998, we thoracoscopically resected 30 nodules in 28 patients (13 were women; age, 53 +/- 14 years). The resected nodules were 17 +/- 7.6 mm (range; 4 to 32 mm) in size, and 8.9 +/- 8 mm (range, 2 to 34 mm) in depth. The pathologic diagnosis of the nodules was benign in 20 and malignant in 10 (six primary cancers of lung and four metastatic cancers). There were only minor complications related CT localization.

CONCLUSIONS

This new technique can help the surgeons detect and resect the difficult lesions with safety and rapidity by VATS without thoracotomy.

Clinical characteristics of vertebrobasilar artery dissection

Sixteen patients with the diagnosis of vertebral or basilar artery dissection who were admitted at the Seoul National University Hospital from 1972 to 1996 are described. During the same period, we encountered 76 patients with posterior circulation aneurysms, so the vertebrobasilar artery dissection was 21% of posterior circulation aneurysms. The mean age was 44 years, and male predominated. Nine patients presented with subarachnoid hemorrhage (SAH) and seven with ischemic symptoms. The characteristic angiographic finding of patients with SAH was aneurysmal dilatation (pseudoaneurysm) in eight of nine cases. In cases of ischemic symptoms, only one case had aneurysmal dilatation. Some other angiographic findings were demonstrated such as string sign, tapered narrowing, complete occlusion, or double lumen. Clinical course of SAH group was much different from that of ischemic group. Rebleeding occurred in three patients of SAH group; immediately after the rebleeding all patients became comatose, but after extraventricular drainage, all patients with rebleeding recovered rapidly. In SAH group, four of nine cases died but there was no mortality in the ischemic group. These four patients showed signs of stem failure, when computed tomography (CT) demonstrated no evidence of additional bleeding and follow-up CT showed the infarction at a part of stem and/or cerebellum. Vasospasm or sudden extensive extension of dissection could be the cause of death. Surgical management was performed in three patients, endovascular intervention in four, and conservative management in two. The patients with incomplete embolization or conservative management had poor outcome. In ischemic group, all underwent conservative management including anticoagulation and/or antiplatelet therapy. On follow-up, most of the patients with ischemic symptoms made complete or very good recoveries.

Object matching algorithms using robust Hausdorff distance measures

A Hausdorff distance (HD) is one of commonly used measures for object matching. This work analyzes the conventional HD measures and proposes two robust HD measures based on m-estimation and least trimmed square (LTS) which are more efficient than the conventional HD measures. By computer simulation, the matching performance of the conventional and proposed HD measures is compared with synthetic and real images.

Primary intramedullary spinal cord primitive neuroectodermal tumor with intracranial seeding in an infant

Primary spinal cord primitive neuroectodermal tumor (PNET) is a rare entity. In all 13 cases have been reported in the literature, including 3 with intracranial seeding. A 3-month-old girl with involvement of the spinal cord below the mid-thoracic level is described. The brain MRI revealed findings indicative of seeding along the intracranial subarachnoid space. Biopsy, duraplasty and removal of laminotomy flap were done. In spite of a good response to the first cycle of postoperative "8-drugs-in-a-day' chemotherapy, further treatment was refused. She died 21 days after the onset of leg weakness, which reveals the rapid progression of untreated cases. To our knowledge, this is the first case of spinal cord PNET with parenchymal involvement that has been described in an infant.

[The effect of surfactant therapy associated with high frequency jet ventilation on oxygenation in canine lavaged lungs]

The effects of exogenous surfactant (SF) replacement therapy associated with high frequency jet ventilation (HFJV) on blood gas changes, pulmonary and hemodynamic variables were studied in canine lavaged lungs. The lungs were lavaged repeatedly with physiological saline until PaO2 decreased to 100 mmHg under intravenous pentobarbital anesthesia with 100% oxygen. SF (50 mg.kg-1) in the experimental group (n = 12) and saline in the control group (n = 8) were administered to the trachea using HFJV with a duration of 10 min. HFJV was further continued for 1 hour to make surfactant distribute evenly. Then respiration was controlled by the conventional mechanical ventilator for 3 hrs. During the administration of SF (10 min). PaCO2 was not altered. In the surfactant group, PaO2 improved significantly (200 mmHg) at the end of HFJV and was maintained for the next 3 hrs at this level, but it did not improve in the saline group. Therefore, we suggest that HFJV can be used safely for the treatment of acute respiratory failure and is an effective method for the administration of the pulmonary surfactant into the alveoli.