A 71-year-old diabetic male who had undergone coronary artery bypass surgery 8-years ago due to coronary artery disease, complained of hiccups for 3 days and worsening of anginal symptoms, which was proven to be with Staphylococcus hominis bacteremia. The patient was finally diagnosed with a mycotic aneurysm of the ascending aorta. All of the branches originating from the ascending aorta were narrowed due to the aortitis, including the origin of the left subclavian artery, which was supplying the left anterior descending artery as a result of bypass surgery. This might have been the cause of the chest pain and hiccups, since the vagus nerve is near the left subclavian artery. Three-dimensional chest computed tomography examination revealed a massive extension of the aortitis.
Aged ; Aneurysm ; Aneurysm, Infected ; Angina, Unstable ; Aorta ; Aortitis ; Arteries ; Bacteremia ; Chest Pain ; Coronary Artery Bypass ; Coronary Artery Disease ; Hiccup ; Humans ; Male ; Staphylococcus hominis ; Subclavian Artery ; Thorax ; Vagus Nerve

A 50-year-old man with bladder cancer had spinal anesthesia for transurethral resection of bladder. After he had spinal block at the T8 level, he developed a persistent penile erection, making it impossible to introduce the 24 French cystoscope. To treat a persistent penile erection, intravenous glycopyrrolate was incrementally given for a total of 0.4 mg. A persistent penile erection was markedly subsided 5 minutes after last 0.2 mg glycopyrrolate was given. Then corpus cavernosum blood was aspirated. The cystoscope was easily introduced, and transurethral resection of bladder proceeded without further complication.
Anesthesia, Spinal* ; Cystoscopes ; Glycopyrrolate ; Humans ; Male ; Middle Aged ; Penile Erection* ; Urinary Bladder ; Urinary Bladder Neoplasms

Acute necrotizing esophagitis (AEN), also called "black esophagus," is a rare disorder with an unknown pathogenesis. Endoscopic findings generally show black pigmentation throughout the esophagus. This case also offered rare views of the gross anatomy of this disorder. Histological examination revealed that the mucosal and submucosal layers of the esophagus were involved in the severe necrotizing inflammation. The chief manifestation of this disease is hematemesis from hemorrhage of the upper gastrointestinal tract with a typically multifactorial etiology. AEN is also characterized by a clear boundary at the gastroesophageal junction where the necrosis stops. In this study, we report an autopsy case of a 61-year-old man with necrotizing inflammation throughout the esophagus and esophageal necrosis from the laryngopharynx to the gastroesophageal junction. The patient was a disabled person with a history of alcohol abuse who was also diagnosed with mild coronary arteriosclerosis and fatty liver on the basis of the underlying diseases. In this case, the main etiology for poor perfusion from the distal esophageal area was likely underlying illness, history of alcoholism, and malnutrition.
Alcoholism ; Autopsy* ; Coronary Artery Disease ; Disabled Persons ; Esophagitis* ; Esophagogastric Junction ; Esophagus ; Fatty Liver ; Hematemesis ; Hemorrhage ; Humans ; Hypopharynx ; Inflammation ; Malnutrition ; Middle Aged ; Necrosis ; Perfusion ; Pigmentation ; Upper Gastrointestinal Tract

General anesthesia is the main strategy for almost all thoracic surgeries. However, a growing body of literature has reported successful cases of non-intubated thoracic surgery with regional anesthesia. This alternative strategy not only prevents complications related to general anesthesia, such as lung injury, incomplete re-expansion and intubation related problems, but also accords with trends of shorter hospital stay and lower overall costs. We experienced a successful case of non-intubated thoracoscopic decortication for a 68-year-old man who was diagnosed as empyema while the patient kept spontaneously breathing with moderate sedation under thoracic epidural anesthesia. The patient showed a fast recovery without concerns of general anesthesia related complications and effective postoperative analgesia through thoracic epidural patient-controlled analgesia device. This is the first report of non-intubated thoracoscopic surgery under thoracic epidural anesthesia in Korea, and we expect that various well designed prospective studies will warrant the improvement of outcomes in non-intubated thoracoscopic surgery.
Aged ; Analgesia ; Analgesia, Patient-Controlled ; Anesthesia, Conduction ; Anesthesia, Epidural* ; Anesthesia, General ; Conscious Sedation ; Empyema* ; Humans ; Intubation ; Korea ; Length of Stay ; Lung Injury ; Prospective Studies ; Respiration ; Thoracic Surgery ; Thoracoscopy*

Background: : Since primary emergency treatment should be performed appropriately and promptly, efficient and accurate communication between paramedics and medical staff is paramount to a successful primary emergency treatment and patient handover. The problem of the training program in Korea is that it concentrates more on in-class lectures, often delivered by non-medical specialists, who may lack in practical experience and without proper communication training. To solve this problem, we have devised a simulation based training that focuses on event debriefings and two-way communication. Methods: : 62 paramedics from 3 stations enrolled in the study. 4 different courses with different emergency situations were created and each course was taken twice resulting in a total of 8 classes. All courses were based on actual cases. The curriculum consisted of subject lectures with guidelines, skill practice courses, and simulation courses based on hands-on method. In simulation courses, paramedics use standardized check list to communicate with medical specialists. All curriculums except subject lectures include debriefing, which allows free talking with educators comprised of medical specialists. In order to measure the educational impact, all students performed self-assessment through a structured questionnaire before and after the training. Results: : Regardless different situations and paramedics’ education level, their performance and communication skills have improved after simulation training course. Paramedics mentioned learning skills in simulation course through communication with medical staffs as the biggest advantage. Conclusion : Receiving the simulation training with standardized communication tools is effective at enhancing the communication between the paramedics and medical staff.

PURPOSE: Alagille syndrome is a complex hereditary disorder that is associated with cardiac, hepatic, skeletal, ocular, and facial abnormalities. Mutations in the Notch signaling pathway, such as in JAG1 and NOTCH2, play a key role in embryonic development. A cardiac or hepatic presentation is a critical factor for determining the prognosis. METHODS: We conducted a retrospective study of 41 patients with Alagille syndrome or a JAG1 mutation between 1983 and 2013. RESULTS: The first presentations were jaundice, murmur, cyanosis, and small bowel obstruction at a median age of 1.0 months (range, 0-24 months). The JAG1 mutation was found in 27 of the 28 genetically-tested patients. Cardiovascular anomalies were identified in 36 patients, chronic cholestasis was identified in 34, and liver transplantation was performed in 9. There was no significant correlation between the severity of the liver and cardiac diseases. The most common cardiovascular anomaly was peripheral pulmonary stenosis (83.3%), with 13 patients having significant hemodynamic derangement and 12 undergoing surgical repair. A total bilirubin level of >15 mg/dL with a complex surgical procedure increased the surgical mortality (P=0.022). Eight patients died after a median period of 2.67 years (range, 0.33-15 years). The groups with fetal presentation and with combined severe liver and heart disease had the poorest survival (P<0.001). CONCLUSION: The group with combined severe liver and heart disease had the poorest survival, and a multidisciplinary approach is necessary to improve the outcome.
Alagille Syndrome* ; Bilirubin ; Cardiovascular Diseases ; Cholestasis ; Cyanosis ; Embryonic Development ; Female ; Heart Diseases ; Hemodynamics ; Humans ; Jaundice ; Labor Presentation ; Liver ; Liver Transplantation ; Mortality ; Pregnancy ; Prognosis ; Pulmonary Valve Stenosis ; Retrospective Studies

Endoscopic submucosal dissection (ESD) is widely performed these days as the standard procedure for the treatment of early gastric cancer. During ESD, insertion and rotation of the scope, air insufflation, incision and hemostasis may provoke pain, which commonly requires either general anesthesia or moderate to deep sedation. Deep sedation precludes the need for general anesthesia, and can help endoscopists speed up the procedure compared to light sedation. But, there are risks of respiratory complication. We report a case of respiratory compromise caused by pneumoperitoneum from unrecognized gastric perforation during ESD under deep sedation.
Anesthesia, General ; Deep Sedation* ; Hemostasis ; Insufflation ; Pneumoperitoneum ; Respiratory Insufficiency* ; Stomach Neoplasms

Endoscopic submucosal dissection (ESD) is widely performed these days as the standard procedure for the treatment of early gastric cancer. During ESD, insertion and rotation of the scope, air insufflation, incision and hemostasis may provoke pain, which commonly requires either general anesthesia or moderate to deep sedation. Deep sedation precludes the need for general anesthesia, and can help endoscopists speed up the procedure compared to light sedation. But, there are risks of respiratory complication. We report a case of respiratory compromise caused by pneumoperitoneum from unrecognized gastric perforation during ESD under deep sedation.
Anesthesia, General ; Deep Sedation* ; Hemostasis ; Insufflation ; Pneumoperitoneum ; Respiratory Insufficiency* ; Stomach Neoplasms

OBJECTIVE: To explore the features that predict size increase and development of potential malignant features in incidentally detected, unilocular cystic pancreatic lesions (CPLs) less than 3 cm in diameter, during subsequent follow-up. MATERIALS AND METHODS: We retrieved data of patients diagnosed with unilocular CPLs less than 3 cm in diameter during the period from November 2003 through December 2014, using a computerized search. All serial CT and MR images were analyzed to identify the number, size, and location of CPLs; dilatation of the main pancreatic duct; and occurrence of worrisome features and high-risk stigmata of malignancy in the lesion. The characteristics of CPLs were compared between the increase (i.e., size increase during subsequent follow-up) and no-increase groups. For CPLs in the increase group, subgroup analysis was performed according to the lesion size at the last follow-up (< 3 cm vs. ≥ 3 cm). RESULTS: Among 553 eligible patients, 132 (23.9%) had CPLs that increased in size, and 421 (76.1%) had CPLs that did not, during follow-up. Of the 132, 12 (9.1%) CPLs increased to diameters ≥ 3 cm at the final follow-up. Among the various factors, follow-up duration was a significant independent factor for an interval size increase of CPLs (p < 0.001). In the increase group, initial cyst size was a significant independent factor to predict later size increase to or beyond 3 cm in diameter (p < 0.001), and the initial cyst diameter ≥ 1.5 cm predicted such a growth with a sensitivity and specificity of 83% and 72%, respectively. No significant factors to predict the development of potential malignant features were identified. CONCLUSION: Follow-up duration was associated with an interval size increase of CPLs. Among the growing CPLs, initial cyst size was associated with future lesion growth to and beyond 3 cm.
Christianity ; Dilatation ; Follow-Up Studies ; Humans ; Pancreas ; Pancreatic Cyst* ; Pancreatic Ducts ; Risk Factors ; Sensitivity and Specificity