Methods: This study included 138 patients who underwent PLIF, with a mean age of 67 years and a follow-up period of 12 months. At 12 months postoperatively, lumbar computed tomography (CT) was performed to assess SL, and patients were categorized into SL and nonloosening (NL) groups accordingly. A propensity score-matched model was used to adjust for age, sex, and body mass index (BMI). Propensity score matching was performed to compare outcomes between the SL and NL groups. Results: Among the 138 patients, 29 (21%) developed SL following PLIF. Preliminary analysis revealed that the patients in the SL group were older and exhibited decreased femoral neck bone mineral density, preoperative pelvic retroversion, poor whole spine alignment, and lesser improvement in HRQOL compared with the NL group. Using propensity score matching, 22 patients were selected from each group (mean age, 72 years) (C-statistic=0.78). The propensity score-matched analysis demonstrated significant differences in the preoperative pelvic tilt (25.9° vs. 17.8°, p=0.010) between the matched SL and NL groups. Furthermore, the Oswestry Disability Index scores indicated poorer improvements in the matched SL group than in the matched NL group at 9 months postoperatively (p=0.025). Conclusions After matching, pre- and postoperative pelvic retroversion were significantly associated with SL. Patients with SL experienced significantly poorer improvement in HRQOL at 9 months postoperatively. Therefore, implementing strategies for preventing SL may enhance early postoperative HRQOL.

A woman in her 80s who had difficulty walking due to back pain was admitted to our hospital. Until two months earlier, she had been able to live independently in daily life. She was not severely constipated, did not take laxatives, and had not received an enema or undergone stool extraction. She had no abdominal symptoms, such as abdominal pain or distension. Surprisingly, however, computed tomography showed lower rectal perforation with subcutaneous emphysema in the pelvic retroperitoneum, hip, and left inguinal region. Therefore, we urgently performed abdominoperineal resection to save her. The lower rectum is a relatively uncommon site of perforation in the large intestine, and nontraumatic cases are rare. Elderly patients in particular may have only atypical symptoms and thus require careful attention.

We reevaluated our heparin and protamine administration protocol during and after cardiopulmonary bypass (CPB). In 12 patients who underwent cardiac surgery using a heparin-coated circuit under mild hypothermia, heparin concentration was measured with the Hepcon^®/HMS. Before initiating CPB, 1.5mg/kg of heparin was given to maintain the activated clotting time (ACT) at more than 400sec. Patients were divided into two groups. In group I (n=6), heparin was neutralized with an empirical dose of protamine (1.5mg protamine/mg initial heparin). In group II (n=6), the protamine dose was determined by the residual heparin concentration, measured with the Hepcon^®. Patients in group II received a lower dosage of protamine than group I (1.7±0.0 vs. 3.6±0.4mg/kg, p<0.001). There were no significant differences in the intraoperative bleeding, postoperative bleeding and activated clotting time between the groups. By determining the appropriate protamine dosage, this heparin analysis system may be useful in managing CPB.

We report two emergency mitral valve replacements performed successfully on 16-week and 29-week pregnant women for infective endocarditis in the active phase. The first patient was in severe acute heart failure on admission, and the fetus was already dead. Induced abortion was performed uneventfully 6 days after mitral valve replacement. The second patient presented with several episodes of systemic embolization. An echocardiography revealed giant movable vegetation on the mitral valve. The patient had emergency mitral valve replacement just after the Caesarian section. Both the patient and her baby weighting 1, 374g had an uneventful good courses with no complication. We concluded that in emergency operations in pregnancy, saving the mother's life should have priority over all else, but we should find the way to rescue the fetus life if at all possible. Therefore, depending on the situation, we should not hesitate about doing a simultaneous operation, Caesarian section and heart surgery, for that purpose.

Between January 1981 and December 1996, we performed valve replacement in 281 patients using bileaflet prosthetic valves in mitral and/or tricuspid positions. Thrombosed valve were seen in 10 patients (7 in mitral, 3 in tricuspid positions). In 5 patients, coumadin had been stopped for several reasons (pacemaker implantation, melena, drug allergy), but in the other 5 patients, anticoagulation was within the therapeutic range at the time of presentation. For thrombolytic therapy urokinase or tissue plasminogen activator were used. The treatment was successful in 5 patients (4 mitral, 1 tricuspid), and unsuccessful in 5 patients (3 mitral, 2 tricuspid). Three of the 5 unsuccessful patients were treated surgically (3 with re-mitral valve replacement, 1 with thrombectomy). Prompt surgical treatment can be used as the first line of therapy for thrombosed valves. Thrombolytic therapy may be useful in some cases of bileaflet valve thrombosis without critical hemodynamic collapse. Doppler echocardiographic assessment of increasing peak velocity and pressure half time is useful for detecting thrombosed valves.