• Journal of The Korean Dental Society of Anesthesiology
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• v.3 no.1 s.4
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• pp.34-37
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• 2003

Postoperative stroke is uncommon even in elderly patients, who have a higher incidence of all types of postoperative complications. The mechanism of postoperative stroke is not certain, but can be explained by intravascular clottings originated from thrombus or embolus or by intracranial hemorrhage. In a 66-year-old male patient with current hypertension medication, who underwent both neck dissection for malignancy metastasis under general anesthesia, the left hemiparesis and delayed emergency were found postoperatively. After transferred to intensive care unit, he got the thrombolytic therapy and then the therapies to decrease the swelling of the brain on the diagnosis of cerebral infarction in the vascular distribution of the middle cerebral artery. A brain MRI definitely showed the midline deviation to the left of the right brain hemisphere due to the progressing edematous changes. As he got worse, the emergency neurosurgical operation was proposed but rejected by his family. He died at postoperative 3 days. In this hypertensive patient. perioperative stroke could be originated from the surgical stimuli on major vessels, which were inevitable in neck dissection during the operation. We report this case of the postoperative stroke, which could be highly possible to be associated with extensive head and neck surgery.

• Journal of The Korean Dental Society of Anesthesiology
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• v.8 no.1
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• pp.1-9
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• 2008

Common dental procedures (local anesthesia and dental treatment) are potentially stress-inducing in many patients, especially medically compromised patients. The body response to dental stress involves the cardiovascular system (an increase in cardiovascular workload), the respiratory organ and the endocrine system (change in metabolism). To minimize the stress to the medical risk patient, the stress reduction protocol was established. The obtained contents were as follows: (1) Recognize the patient's degree of medical risk (2) Complete medical consultation before dental therapy (3) Schedule the patient's appointment in the morning (4) Monitor and record preoperative, perioperative and postoperative vital signs (5) Use psychosedation during therapy (6) Use adequate pain control during therapy (7) Short length of appointment: do not exceed the patient's limits of tolerance (8) Follow up with postoperative pain/anxiety control (9) Telephone the higher medical risk patient later on the same day that treatment was given. This protocol is predicated on the belief that the prevention of or reduction of stress ought to begin before the start of an appointment, continue throughout treatment, and, if indicated, into the postoperative period. The authors used the stress reduction protocol in the care of local anesthesia infected teeth in medically compromised patients. The final prognosis was comfortable without any complications.

• Journal of Chest Surgery
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• v.45 no.5
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• pp.301-307
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• 2012

Background: Perioperative transfusion of red blood cell (RBC) may cause adverse effects. Bloodless-cardiac surgery has been spotlighted to avoid those problems. Off pump coronary artery bypass (OPCAB) surgery can decrease the transfusion. However, the risk factors of transfusions in OPCAB have not been investigated properly. Materials and Methods: One hundred and thirteen patients (male:female=35:78, mean age=$66.7{\pm}9.9$ years) who received isolated OPCAB were retrospectively analyzed from March 2006 to September 2007. The threshold of RBC transfusion was 28.0% of hematocrit. Bilateral internal thoracic arteries graft were used for 99 patients (87.6%). One hundred and three (91.1%) and 35 patients (31.5%) took aspirin and clopidogrel just before surgery. Results: Sixty-five patients (47.5%) received the RBC transfusion (mean $2.2{\pm}3.2$ units). Mortality and major complications were not different between transfusion and no-transfusion group. But, ventilator support time, intensive care unit stay and hospitalization period had been reduced in no-transfusion group (p<0.05). In multivariate analysis, patients risk factors for RBC transfusion were preoperative low hematocrit (<37.5%) and clopidogrel medication. Surgical risk factors were longer graft harvesting time (<75 minutes) and total operation time (<5.5 hours, p <0.05). Conclusion: We performed the transfusion according to transfusion guideline; over 40% cases could conduct the OPCAB without transfusion. There were no differences in major clinical results between transfusion and non-transfusion group. In addition, when used together with accurate understanding of transfusion risk factors, it is expected to increase the proportion of patients that do not undergo transfusions.

• Journal of Yeungnam Medical Science
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• v.39 no.2
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• pp.133-140
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• 2022

Background: Despite advances in surgery and intensive perioperative care, fecal peritonitis secondary to colonic perforation is associated with high rates of morbidity and mortality. This study was performed to review the outcomes of patients who underwent colonic perforation surgery and to evaluate the prognostic factors associated with mortality. Methods: A retrospective analysis was performed on 224 consecutive patients who underwent emergency colonic perforation surgery between January 2008 and May 2019. We divided the patients into survivor and non-survivor groups and compared their surgical outcomes. Results: The most common cause of colon perforation was malignancy in 54 patients (24.1%), followed by iatrogenic perforation in 41 (18.3%), stercoral perforation in 39 (17.4%), and diverticulitis in 37 (16.5%). The sigmoid colon (n=124, 55.4%) was the most common location of perforation, followed by the ascending colon, rectum, and cecum. Forty-five patients (20.1%) died within 1 month after surgery. Comparing the 179 survivors with the 45 non-survivors, the patient characteristics associated with mortality were advanced age, low systolic blood pressure, tachycardia, organ failure, high C-reactive protein, high creatinine, prolonged prothrombin time, and high lactate level. The presence of free or feculent fluid, diffuse peritonitis, and right-sided perforation were associated with mortality. In multivariate analysis, advanced age, organ failure, right-sided perforation, and diffuse peritonitis independently predicted mortality within 1 month after surgery. Conclusion: Age and organ failure were prognostic factors for mortality associated with colon perforation. Furthermore, right-sided perforation and diffuse peritonitis demonstrated a significant association with patient mortality.

• Journal of Gastric Cancer
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• v.23 no.1
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• pp.207-223
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• 2023

Gastric cancer (GC) is the fourth leading cause of cancer-related deaths worldwide. Under the standard of care, patients with advanced GC (AGC) have a median survival time of approximately 12-15 months. With the emergence of immunotherapy as a key therapeutic strategy in medical oncology, relevant changes are expected in the systemic treatment of GC. In the phase III ATTRACTION-2 trial, nivolumab, a monoclonal anti-programmed cell death 1 (PD-1) antibody, as a third- or later-line treatment improved overall survival (OS) compared with placebo in patients with AGC. Furthermore, nivolumab in combination with 5-fluorouracil and platinum as a first-line treatment improved OS in patients with human epidermal growth factor receptor-2 (HER2)-negative AGC in the global phase III CheckMate-649 study. Another anti-PD-1 antibody, pembrolizumab, in combination with trastuzumab and cytotoxic chemotherapy as a first-line treatment, significantly improved the overall response rate in patients with HER2-positive AGC. Therefore, immune checkpoint inhibitors (ICIs) are essential components of the current treatment of GC. Subsequent treatments after ICI combination therapy, such as ICI rechallenge or combination therapy with agents having other modes of action, are being actively investigated to date. On the basis of the success of immunotherapy in the treatment of AGC, various clinical trials are underway to apply this therapeutic strategy in the perioperative and postoperative settings for patients with early GC. This review describes recent progress in immunotherapy and potential immunotherapy biomarkers for GC.

• Journal of Trauma and Injury
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• v.36 no.4
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• pp.354-361
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• 2023

Purpose: Ketamine has historically been contraindicated in traumatic brain injury (TBI) due to concern for raising intracranial pressure. However, it is increasingly being used in TBI due to the favorable respiratory and hemodynamic properties. To date, no studies have evaluated whether ketamine administered in subjects with TBI is associated with patient survival or disability. Methods: We performed a retrospective analysis of data from the multicenter Prehospital Tranexamic Acid Use for Traumatic Brain Injury trial, comparing ketamine-exposed and ketamine-unexposed TBI subjects to determine whether an association exists between ketamine administration and mortality, as well as secondary outcome measures. Results: We analyzed 841 eligible subjects from the original study, of which 131 (15.5%) received ketamine. Ketamine-exposed subjects were younger (37.3±16.9 years vs. 42.0±18.6 years, P=0.037), had a worse initial Glasgow Coma Scale score (7±3 vs. 8±4, P=0.003), and were more likely to be intubated than ketamine-unexposed subjects (88.5% vs. 44.2%, P<0.001). Overall, there was no difference in mortality (12.2% vs. 15.5%, P=0.391) or disability measures between groups. Ketamine-exposed subjects had significantly fewer instances of elevated intracranial pressure (ICP) compared to ketamine-unexposed subjects (56.3% vs. 82.3%, P=0.048). In the very rare outcomes of cardiac events and seizure activity, seizure activity was statistically more likely in ketamine-exposed subjects (3.1% vs. 1.0%, P=0.010). In the intracranial hemorrhage subgroup, cardiac events were more likely in ketamine-exposed subjects (2.3% vs. 0.2%, P=0.025). Ketamine exposure was associated with a smaller increase in TBI protein biomarker concentrations. Conclusions: Ketamine administration was not associated with worse survival or disability despite being administered to more severely injured subjects. Ketamine exposure was associated with reduced elevations of ICP, more instances of seizure activity, and lower concentrations of TBI protein biomarkers.

• Journal of Chest Surgery
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• v.56 no.6
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• pp.374-386
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• 2023

Background: The heightened morbidity and mortality associated with repeat cardiac surgery are well documented. Redo median sternotomy (MS) and minimally invasive valve surgery are options for patients with prior cardiac surgery who require mitral valve surgery (MVS). We conducted a systematic review and meta-analysis comparing the outcomes of redo MS and minimally invasive MVS (MIMVS) in this population. Methods: We searched PubMed, EMBASE, and Scopus for studies comparing outcomes of redo MS and MIMVS for MVS. To calculate risk ratios (RRs) for binary outcomes and weighted mean differences (MDs) for continuous data, we employed a random-effects model. Results: We included 12 retrospective observational studies, comprising 4157 participants (675 for MIMVS; 3482 for redo MS). Reductions in mortality (RR, 0.54; 95% confidence interval [CI], 0.37-0.80), length of hospital stay (MD, -4.23; 95% CI, -5.77 to -2.68), length of intensive care unit (ICU) stay (MD, -2.02; 95% CI, -3.17 to -0.88), and new-onset acute kidney injury (AKI) risk (odds ratio, 0.34; 95% CI, 0.19 to 0.61) were statistically significant and favored MIMVS (p<0.05). No significant differences were observed in aortic cross-clamp time, cardiopulmonary bypass time, or risk of perioperative stroke, new-onset atrial fibrillation, surgical site infection, or reoperation for bleeding (p>0.05). Conclusion: The current literature, which primarily consists of retrospective comparisons, underscores certain benefits of MIMVS over redo MS. These include decreased mortality, shorter hospital and ICU stays, and reduced AKI risk. Given the lack of high-quality evidence, prospective randomized control trials with adequate power are necessary to investigate long-term outcomes.

• Korean Journal of Radiology
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• v.25 no.1
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• pp.24-32
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• 2024

Despite improvements in operative techniques and perioperative care, post-hepatectomy liver failure (PHLF) remains the most serious cause of morbidity and mortality after surgery, and several risk factors have been identified to predict PHLF. Although volumetric assessment using imaging contributes to surgical simulation by estimating the function of future liver remnants in predicting PHLF, liver function is assumed to be homogeneous throughout the liver. The combination of volumetric and functional analyses may be more useful for an accurate evaluation of liver function and prediction of PHLF than only volumetric analysis. Gadoxetic acid is a hepatocyte-specific magnetic resonance (MR) contrast agent that is taken up by hepatocytes via the OATP1 transporter after intravenous administration. Gadoxetic acid-enhanced MR imaging (MRI) offers information regarding both global and regional functions, leading to a more precise evaluation even in cases with heterogeneous liver function. Various indices, including signal intensity-based methods and MR relaxometry, have been proposed for the estimation of liver function and prediction of PHLF using gadoxetic acid-enhanced MRI. Recent developments in MR techniques, including high-resolution hepatobiliary phase images using deep learning image reconstruction and whole-liver T1 map acquisition, have enabled a more detailed and accurate estimation of liver function in gadoxetic acid-enhanced MRI.

• Journal of Chest Surgery
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• v.57 no.3
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• pp.263-271
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• 2024

Background: Delirium is a recognized neurological complication following cardiac surgery and is associated with adverse clinical outcomes, including elevated mortality and prolonged hospitalization. While several clinical risk factors for post-cardiac surgery delirium have been identified, the pathophysiology related to the immune response remains unexamined. This study was conducted to investigate the immunological factors contributing to delirium in patients after thoracic aortic surgery. Methods: We retrospectively evaluated 43 consecutive patients who underwent thoracic aortic surgery between July 2017 and June 2018. These patients were categorized into 2 groups: those with delirium and those without it. All clinical characteristics were compared between groups. Blood samples were collected and tested on the day of admission, as well as on postoperative days 1, 3, 7, and 30. Levels of helper T cells (CD4), cytotoxic T cells (CD8), B cells (CD19), natural killer cells (CD56+CD16++), and monocytes (CD14+CD16-) were measured using flow cytometry. Results: The median patient age was 71 years (interquartile range, 56.7 to 79.0 years), and 21 of the patients (48.8%) were male. Preoperatively, most immune cell counts did not differ significantly between groups. However, the patients with delirium exhibited significantly higher levels of interleukin-6 and lower levels of tumor necrosis factor-alpha (TNF-α) than those without delirium (p<0.05). Multivariate analysis revealed that lower TNF-α levels were associated with an increased risk of postoperative delirium (p<0.05). Conclusion: Postoperative delirium may be linked to perioperative changes in immune cells and preoperative cytokine levels. Additional research is required to elucidate the pathophysiological mechanisms underlying delirium.

• Archives of Reconstructive Microsurgery
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• v.9 no.1
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• pp.1-5
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• 2000

The microsurgical reconstruction is necessary for elderly patients to treat severe trauma and head and neck tumor. The aim of this study is to analyze the risks of microvascular surgery and whether or not happening of more complication in elderly patients who are older than 60 years old and to suggest the solution of the complication. The retrospective study included 41 elderly patients who underwent treatment of 44 microsurgical reconstructions among total 271 cases of microsurgical reconstruction from July, 1988 to December, 1998. Their ages ranged from 61 years to 79 years. There were 26 males and 15 females. The involved sites were 23 head and necks, 13 upper gastrointestinal tracts, 3 lower extremities, 1 chest and 1 sacral region. The causes of microsurgical reconstruction were 36 head and neck tumors, 2 radionecrosis, 2 traumas and 1 melanoma in lower limb. The used flaps were 14 radial forearm flaps, 13 jejunal flaps, 10 latissimus dorsi muscle flaps, 3 rectus abdominis muscle flaps, 2 lateral arm flaps, 1 scapular flap, and 1 iliac osteocutaneous flap. They had medical problems which were 29 tobacco abuse, 14 hypertensions, 13 alcohol abuse, 10 chronic obstructive pulmonary diseases, 7 diabetes mellituses, 3 ischemic heart diseases. All patients have had successful results without specific complications except 3 cases of free flap failure and 3 perioperative death. The causes of 3 flap failures were 2 flap necrosis due to arterial insufficiency and 1 flap loss due to secondary infection. All of these cases were treated with secondary free flap surgery. However 3 patients died perioperatively due to 2 respiratory arrests and 1 sepsis. It was not related to operate microsurgical reconstruction itself, but was correlated with the complication of postoperative care after head and neck surgery. We conclude that plastic surgeons consider the importance of prevention of expected complication as thorough analysis of operative risk factor and appropriate treatment. We had to select the donor and recipient vessel appropriately to perform successful microsurgery in elderly patients and consider vein graft and end-to-side anastomosis to reduce complication if necessary. In addition, we emphasize the importance of pre, peri and postoperative care in head and neck cancer patients to reduce postoperative complication and morbidity.