Laparoscopic Cholecystectomy in a Hemophiliac Patient with Factor VIII Inhibitor

Hemophilia A is a severe bleeding disorder resulting from the lack of functional blood coagulation factor VIII. Accordingly, operations on patients with hemophilia A, except in a few cases, are performed with the administration of factor VIII. However, in those hemophilia A patients administered factor VIII inhibitor, factor VIII replacement therapy is ineffective. The treatment of hemophilic patients with factor VIII inhibitor is undertaken to utilize the hemostatic capacity of the activated forms of FVII, FIX and FX contained within prothrombin complex concentrates, which are purposely manufactured to contain Factor Eight Inhibitor Bypassing Activity (FEIBA) during surgery. Further, in the last few years, a new product, recombinant activated FVII (FVIIa, Novo-VII), which is thought to ensure hemostasis by binding, directly or in complex with tissue factor, to negatively charged phospholipids on the surface of activated platelets, has been licensed. Recently, we experienced a GB stone, with acute cholecystitis, in a fifty year old hemophilia A man treated with factor VIII inhibitor. Under medication with FEIBA and Novo-VII, a laparoscopic cholecystectomy was performed. Here, this case is reported, with a review of the literature.ope

Prognostic Factors and Survival Rate of Pancreatic Adenocarcinoma after Curative Surgery

Purpose: This retrospective study aimed to identify the outcomes of resected pancreatic cancers and determine the prognostic factors for long term survival based on a single hospital experience. Methods: Between January 1990 and February 2004, patients with a pancreatic ductal adenocarcinoma who had undergone resection at Severance hospital, Yonsei University, were analyzed retrospectively. Results: Ninety-five patients underwent resection with curative intents for pancreatic adenocarcinoma. Sixty-seven (70.5%) patients had pancreatic head cancer, 27 (28.4%) cancers in the body and tail of the pancreas, and 1 had a diffusely spread type of pancreatic cancer. Procedures employed include Whipple resection (35.8%), pylorus preserving pancreaticoduodenectomy (33.7%), distal pancreatectomy (28.4%), and total pancreatectomy (2.1%). Stage Ia, Ib, IIa, IIb and III were present in 3.2, 4.2, 45.3, 44.2, and 3.2%, respectiely. The overall 5-year survival rate was 20.7%. Only low tumor stage was a significant predictive predictor of survival in univariate analysis (P＜0.05). Conclusion: Long-term survival in patients with pancreatic adenocarcinoma is determined by the disease stage. This result suggests that early detection would be necessary to improve the survival of patients with pancreatic adenocarcinoma.ope

Thoracoscopic Splanchnicectomy for Intractable Abdominal Pain

Purpose: In patient with intractable abdominal pain due to cancer, with respect to the quality of life, it is often insufficient to relieve pain with the use of analgesics. The development of laparoscopic surgery has made a thoracoscopic splanchnicectomy possible, but the results by using several different methods have varied between different authors. Herein, we introduce a modified method of thoracoscopic splanchnicectomy on the basis of anatomical background from cadaver dissection. Methods: Sixteen thoracoscopic splanchnicectomies were performed, with the Numerical rating scale (NRS) used for the assessment of pain. The procedure was performed, under general anesthesia, using a double lumen catheter to deflate the lung on the operation side with the patient in the lateral decubitus position. Openings were made in the 7th intercostal space at the postaxillary line for a 12 mm trocar and in the 4th and 5th intercostals spaces for 5 and 2 mm trocars, respectively. The terminal branch of the greater splanchnic nerve ends In 5th intercostal space. Six or seven branches of the splanchnic nerve were cut, dissected downward to just above the diaphragm and then cut. The sympathetic trunk was also cut in this level if the patient suffered from constipation. Results: A splanchicectomy appeared to result in significant reduction of abdominal pain in all cases. The average reduction in the pain score was 78%. There were no postoperative complications. Conclusion: A thoracoscopic splanchnicectomy is the treat-ment of choice for intractable intraabdominal cancer pain, helping with drug cessation or the reduction and recovery of daily activity in most patients.ope

(The) development of microwave ablator, probe and animal experiment

의학과/석사[한글]간세포암은 조기에 발견하여 수술로 절제하는 것이 가장 효과적이지만 약 90%에서 간경변을 동반하며, 다발성으로 진행되어서 발견하여도 수술을 받을 수 없는 경우가 많다. 이러한 경우 비수술적 국소치료법으로 경피적 에탄올 주입술과 열을 이용한 고주파, 레이저, 또는 극초단파 치료법이 최근 관심이 높아지고 있다. 극초단파치료법은 특히 크기가 작고 절제 불가능한 간세포암에서 안전하고 효과적인 치료법으로 알려져 있다. 현재 임상 사용 중인 극초단파 응고기와 프로브는 제조사 마다 약간의 차이가 있지만 응고괴사 범위가 약 2cm정도이고 이 또한 수입에 의존하고 있다. 통신산업기술 발달에 따른 극초단파의 발전과 제어기술 그리고 방사용 안테나 제조기술들을 임상에 응용 하고자 국내에서 제작된 극초단파 응고기(SWM2500？, 세운메디칼(주), 서울, 한국)와 프로브(세운메디칼㈜, 서울, 한국)를 이용하여 정상 돼지 간에 응고괴사를 만들어, 이 조직을 육안적, 조직학적으로 조사하여 성능을 관찰하고, 임상적용의 가능성에 대해 알아보고자 하였다.새롭게 제작된 극초단파 응고기로 동물실험실에서 전신 마취된 돼지 10마리의 간을 대상으로 하였다. 모두 5종류의 안테나를 사용하였으며 각각 60W의 출력에 5분, 10분 총 20회의 조직응고 실험을 시행하였다. 급성기(시술직후)와 아급성기(시술 후 1주 후)에 동물을 희생시켜 응고 조직의 육안적 소견과 조직학적 소견(hematoxylin-eosin 염색)들을 비교 분석하였다. 응고 조직의 범위는 육안적 소견의 직경(R)과 길이(L), 그리고 이를 바탕으로 응고 괴사된 부피(4π(R)2L/3 )계산하였다.응고괴사 범위는 출력을 60W로 하였을 때, 시술 직후에는 적용시간과 괴사부위의 육안적 직경 (p=0.197)과 길이(p=0.276), 그리고 부피(p=0.138)에 있어 통계적 의미를 갖는 차이는 없었고, 시술 후 1주일 후 측정된 괴사부위의 육안적 직경과 길이, 부피를 비교해 볼 때, 괴사부위의 직경(p=0.043)과 부피(p=0.043)는 시간에 따른 괴사범위의 확장이 통계적으로 의미 있는 차이를 보였으나, 괴사부위의 육안적 길이는 증가하였으나 통계적 의미는 없었다(p=0.078).본 연구를 통해 새로 개발한 극초단파 응고기와 프로브는 돼지 간에서 안전하고 효과적으로 조직응고괴사를 만들 수 있었다. 그러나 앞으로 임상 적용을 위해서는 응고의 범위에 대한 정확한 예측을 위해 좀 더 많은 연구가 필요할 것으로 사료된다. [영문]Purpose : Microwave coagulation therapy has been widely used in the destruction of small, irresectable liver tumors of primary and secondary origin as an effective minimal invasive therapy. The purpose of this study was to evaluate the clinical implementation of microwave tissue ablator and probe engineered by domestic company through in vivo experiment in the normal porcine liver.Method : Multiple tissue ablations(20 ablations, two ablation per liver) were performed in vivo normal porcine liver with 2.45-GHz, 60 W microwave tissue ablators with 5 types of 3mm-diameter probe, while treatment duration was 5 and 10 minutes. 5 pigs were assigned to acute group (sacrifice right after ablation) and subacute group (sacrifice 7 days after ablation) respectively. Transverse (perpendicular to the probe axis) and longitudinal (parallel to the device axis) coagulation diameter were measured and volume was calculated. Wilcoxon sign rank test was performed to characterize the relationship between the size of coagulation necrosis and treatment duration in the two groups.Result : The maximum mean transverse diameter of lesion was 3.04±1.15 cm with 60 W, 10 minutes duration in subacute group. In the acute group, there was no relation between the size of coagulation necrosis and the treatment duration (p >0.05). But in the subacute group 10 minutes treatment had the longer transverse diameter and volume of coagulation necrosis than 5 minutes (p<0.05).Conclusion : Large zones of ablation can be achieved safely with the microwave tissue ablator and probe engineered by domestic company. For the longer treatment duration, larger zones of coagulation were achieved in subacute group.ope