BACKGROUNDS/AIMS: Common bile duct (CBD) exploration has been a procedure necessary to remove stones which are not removable by endoscopic sphincterotomy (EST). T-tube was installed mainly in the concern of bile leakage after procedure. But T-tube itself can only cause bile peritonitis and thus, prolonged discomfort and care after operation. In addition, in the era of laparoscopy, T-tube insertion adds much operation time and is technically difficult for installation during the procedure. METHODS: Our case of open cholecystectomy and primary closure of CBD not leaving T-tube (n=28, group I) with reports dating from July 1998 to June 2007 is presented here to see whether primary closure without T-tube is safe as compared with T-tube inserted cases performed at the same center (n=15, group II). Operative cholangiography, CT scan, ultrasound and biochemical data were followed up for both groups and surveyed on operative complications as well to determine the outcomes. RESULTS: Bile leakage in 1, recurrent stone in 2 and obstructive jaundice in 1 were all considered during the follow up period among 28 group I patients (n=6), when compared to T-tube inserted group II patients with 2 bile peritonitis, 1 residual stones and 1 pancreatitis (n=4), showing no meaningful differences (p=0.07). CONCLUSIONS: CBD exploration and direct primary closure not leaving T-tube is an acceptable operational option as recently tried in many choledochotomies.
Bile ; Cholangiography ; Cholecystectomy ; Common Bile Duct ; Follow-Up Studies ; Humans ; Jaundice, Obstructive ; Laparoscopy ; Pancreatitis ; Peritonitis ; Sphincterotomy, Endoscopic

BACKGROUNDS/AIMS: The fate of gallstones that remain in the peritoneal cavity due to perforation of the gallbladder during laparoscopic cholecystectomy (LC) has been studied vigilantly since the early 1990s when this surgical procedure started to be used. But the complication statistics vary with each report. So we reviewed our 47 cases of lost stones that were traceable from 1998 to 2007. METHODS: Stones entered the peritoneal cavity through the perforation site during dissection of the body or Hartmann's pouch of gallbladder from the liver bed, despite trials of stone removal like irrigation and using a glove finger pouch especially in the case of numerous small stones. There were nine cases of lost stones that were caused by fragments of stone breaking from a large stone during its retrieval. RESULTS: No patient was forced into revision surgery or intervention for the missing stones but only negative suction drains were inserted, and information to the patients was given. Most of the stones (N=42, 89.4%) remained silent during the follow-up period of 10.4+/-3.6 years, and 5 patients (10.6%) developed inflammatory complications in the peritoneal cavity and abdominal wall. Two intraperitoneal abscesses were found in the right subhepatic area and a cul-de-sac and these were managed by laparotomy. Subhepatic abscess was later associated with intestinal obstruction. Two patients suffered an umbilical portal site fistula and a right flank portal fistula respectively, requiring prolonged wound care. One patient suffered immediate postoperative peritonitis that was cured by antibiotics. CONCLUSIONS: Lost stones should be retrieved or fragmented as much as possible for removal through a drain, and caution should be exercised during dissection of the gallbladder to avoid perforating the gallbladder. Considering the approximately 10% incidence of serious inflammatory complications of lost stones, the complications should be explained to patients to allow for earlier diagnosis of complications later.
Abdominal Wall ; Abscess ; Cholecystectomy, Laparoscopic ; Fingers ; Fistula ; Follow-Up Studies ; Gallbladder ; Gallstones ; Humans ; Incidence ; Intestinal Obstruction ; Laparotomy ; Liver ; Peritoneal Cavity ; Peritonitis ; Suction

BACKGROUNDS/AIMS: There is debate on the timing of cholecystectomy in acute cholecystitis. Although there is a recent trend toward early laparoscopic cholecystectomy (eLC), that is, within 72 hours of symptom onset, some surgeons still prefer delayed operations, or operations after several weeks, expecting subsidence of the inflammation and therefore a higher chance of avoiding open conversion and minimizing complications. Our experience of LC for 10 years was reviewed retrospectively for the timing of the operation and perioperative outcomes, focusing on evaluating the feasibility of delayed LC (dLC). METHODS: The severity of the acute cholecystitis was classified into three grades: easily responding to antibiotics and mostly symptom-free (mild, grade I), symptoms persisting during the treatment (moderate, grade II), and worsening into a septic state (severe, grade III). RESULTS: Among 353 cholecystectomy patients, grade I (N=224) patients had eLC in 152 cases and dLC in 72 cases. Grade II (N=117) patients had eLC in 103 cases and 12 had dLC. All grade III patients (N=12) underwent open cholecystectomy. In Grade I patients, when the operation was delayed, there were fewer open conversion cases compared to eLC patients (20.45% vs 7.69%) (p<0.05), and complications also were decreased (p>0.05). Grade II patients' rate of open conversions (58.3% vs 44.2%) and complications (25.0% vs 19.5%) increased when the operations were delayed compared with eLC patients (p<0.05). In grade I and II patients, the most common reason for open conversion was bleeding, and the most common complication was also bleeding. CONCLUSIONS: For patients with cholecystits that easily responds to antibiotics (grade I), dLC showed a higher laparoscopic success rate than eLC at the expense of prolonged treatment time and examinations, With moderate to severe cholecystitis (grade II, III), however, there was no room for delayed operations.
Anti-Bacterial Agents ; Cholecystectomy ; Cholecystectomy, Laparoscopic ; Cholecystitis ; Cholecystitis, Acute ; Hemorrhage ; Humans ; Inflammation ; Laparoscopy ; Retrospective Studies

Purpose: This study evaluated the surgical volumes and types of specific surgical procedures in a single trauma center for 3 consecutive years. Methods: From January 2014 to December 2016 there were 9,530 injury cases in the trauma registry that were reviewed. Results: There were 1,502 patients (15.8%) with an injury severity score over 15, of which 426 (28.4%) underwent an emergency operation or had an interventional radiology procedure. There were 186 craniotomies, 87 laparotomies, and 74 interventional radiology procedures performed. Conclusion The number of emergency operations by each dedicated trauma surgeon was very low therefore implementation of an acute-care surgery model is appropriate to consider together with changes to the training program for trauma surgeons.

Purpose: This study evaluated the surgical volumes and types of specific surgical procedures in a single trauma center for 3 consecutive years. Methods: From January 2014 to December 2016 there were 9,530 injury cases in the trauma registry that were reviewed. Results: There were 1,502 patients (15.8%) with an injury severity score over 15, of which 426 (28.4%) underwent an emergency operation or had an interventional radiology procedure. There were 186 craniotomies, 87 laparotomies, and 74 interventional radiology procedures performed. Conclusion The number of emergency operations by each dedicated trauma surgeon was very low therefore implementation of an acute-care surgery model is appropriate to consider together with changes to the training program for trauma surgeons.

BACKGROUND: As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe outcomes from injuries compared with the young. In this study, we examined the relationship between mortality and complications with age. METHODS: This study was a retrospective review of 256 major trauma patients (Injury Severity Score > 15) admitted to an emergency center over a two-year period. Age-dependent mortality and complications were evaluated. RESULTS: Of 256 patients, 209 (81.6%) were male and the mean age was 47.2 years. There was a trend between increasing age and increasing mortality, but this was not statistically significant. Increasing age was correlated with frequency of complications. CONCLUSIONS: Age was confirmed to be an independent predictor of mortality in major trauma. We documented that elderly trauma patients suffer from complications more frequently compared with their younger counterparts. Appropriate and specific triage and management guidelines for elderly trauma patients are needed.
Aged* ; Emergencies ; Humans ; Male ; Mortality* ; Retrospective Studies ; Triage

Transposable elements are one of major sources to cause genomic instability through various mechanisms including de novo insertion, insertion-mediated genomic deletion, and recombination-associated genomic deletion. Among them is Alu element which is the most abundant element, composing ~10% of the human genome. The element emerged in the primate genome 65 million years ago and has since propagated successfully in the human and non-human primate genomes. Alu element is a non-autonomous retrotransposon and therefore retrotransposed using L1-enzyme machinery. The 'master gene' model has been generally accepted to explain Alu element amplification in primate genomes. According to the model, different subfamilies of Alu elements are created by mutations on the master gene and most Alu elements are amplified from the hyperactive master genes. Alu element is frequently involved in genomic rearrangements in the human genome due to its abundance and sequence identity between them. The genomic rearrangements caused by Alu elements could lead to genetic disorders such as hereditary disease, blood disorder, and neurological disorder. In fact, Alu elements are associated with approximately 0.1% of human genetic disorders. The first part of this review discusses mechanisms of Alu amplification and diversity among different Alu subfamilies. The second part discusses the particular role of Alu elements in generating genomic rearrangements as well as human genetic disorders.
Alu Elements* ; DNA Transposable Elements ; Genetic Diseases, Inborn ; Genome ; Genome, Human ; Genomic Instability ; Humans* ; Nervous System Diseases ; Primates ; Recombination, Genetic ; Retroelements

BACKGROUND: The dissemination of metallo-beta-lactamase (MBL) producing gram-negative bacilli is of great concern because MBL can hydrolyze carbapenem. We report herein the infection by VIM-2 type MBL producing Achromobacter xylosoxidans subsp. xylosoxidans. MATERIALS AND METHODS: For seven A. xylosoxidans subsp. xylosoxidans with reduced imipenem susceptibility, the detection for MBL was performed using EDTA double disk synergy test (EDTA- DDS) and the PCR for IMP-1, VIM-1 and VIM-2 genes. The minimal inhibitory concentration (MIC) of MBL producers were determined by microbroth dilution methods. The DNA fingerprinting analysis was performed by random amplified polymorphic DNA. RESULTS: All seven isolates were MBL producers when tested with EDTA-DDS test and these isolates were VIM-2 type confirmed by the PCR and DNA sequencing analysis. The MIC against imipenem ranged from 16 to 32 microgram/mL in these isolates. The DNA fingerprints of these isolates were identical. CONCLUSION: A. xylosoxidans subsp. xylosoxidans manifest resistance against imipenem by acquisition of VIM-2 type MBL. To our knowledge, this is the first report on the VIM-2 type MBL producing A. xylosoxidans subsp. xylosoxidans.
Achromobacter denitrificans* ; Achromobacter* ; DNA ; DNA Fingerprinting ; Edetic Acid ; Imipenem ; Polymerase Chain Reaction ; Sequence Analysis, DNA

BACKGROUND: The dissemination of metallo-beta-lactamase (MBL) producing gram-negative bacilli is of great concern because MBL can hydrolyze carbapenem. We report herein the infection by VIM-2 type MBL producing Achromobacter xylosoxidans subsp. xylosoxidans. MATERIALS AND METHODS: For seven A. xylosoxidans subsp. xylosoxidans with reduced imipenem susceptibility, the detection for MBL was performed using EDTA double disk synergy test (EDTA- DDS) and the PCR for IMP-1, VIM-1 and VIM-2 genes. The minimal inhibitory concentration (MIC) of MBL producers were determined by microbroth dilution methods. The DNA fingerprinting analysis was performed by random amplified polymorphic DNA. RESULTS: All seven isolates were MBL producers when tested with EDTA-DDS test and these isolates were VIM-2 type confirmed by the PCR and DNA sequencing analysis. The MIC against imipenem ranged from 16 to 32 microgram/mL in these isolates. The DNA fingerprints of these isolates were identical. CONCLUSION: A. xylosoxidans subsp. xylosoxidans manifest resistance against imipenem by acquisition of VIM-2 type MBL. To our knowledge, this is the first report on the VIM-2 type MBL producing A. xylosoxidans subsp. xylosoxidans.
Achromobacter denitrificans* ; Achromobacter* ; DNA ; DNA Fingerprinting ; Edetic Acid ; Imipenem ; Polymerase Chain Reaction ; Sequence Analysis, DNA

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU). METHODS: We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated. RESULTS: The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher. CONCLUSIONS: In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.
APACHE* ; Cardiovascular System ; Complement System Proteins ; Critical Care* ; Critical Illness ; Humans ; Injury Severity Score ; Intensive Care Units* ; Mortality ; Multiple Trauma ; Retrospective Studies ; Survival Rate ; Trauma Centers