Background: The prognostic consequences of transient hemodynamic deterioration due to cardiac displacement, which is most severe during left circumflex artery (LCX) grafting in off-pump coronary artery bypass surgery (OPCAB) are unknown. This study aimed to investigate the association between mixed venous oxygen saturation (SvO2) < 60% during LCX grafting and the occurrence of composite of morbidity endpoints. Methods: Data of patients who underwent elective OPCAB between January 2010 and December 2019 were reviewed. Logistic regression analysis was performed to detect risk factors for the composite of morbidity endpoints, defined as 30-day or in-hospital mortality, postoperative myocardial infarction, prolonged mechanical ventilation > 24 h, cerebrovascular accident, and acute kidney injury. Results: Among 1,071 patients, the composite of morbidity endpoints occurred in 303 (28%) patients. SvO2 < 60% during LCX grafting was significantly associated with the composite of morbidity (OR: 2.72, 95% CI [1.60, 4.61], P < 0.001) along with advanced age, chronic kidney disease, ratio of early mitral inflow velocity to mitral annular early diastolic velocity, and EuroSCORE II. Other major hemodynamic variables including the cardiac index were not associated with the outcome. Additional regression analysis revealed pre-operative anemia as a predictor of SvO2 < 60% during LCX grafting (OR: 2.09, 95% CI [1.33, 3.29], P = 0.001). Conclusions A decrease in SvO2 < 60%, albeit confined to the period of cardiac displacement, was associated with a 2.7-fold increased risk of detrimental outcomes after OPCAB, implying the prognostic importance of this transient deterioration in oxygen supply-demand balance.

Off-pump coronary surgery requires mechanical cardiac displacement, which results in bi-ventricular systolic and diastolic dysfunction. Although transient, subsequent hemodynamic deterioration can be associated with poor prognosis and, in extreme cases, emergency conversion to on-pump surgery, which is associated with high morbidity and mortality. Thus, appropriate decision-making regarding whether the surgery can be proceeded based on objective hemodynamic targets is essential before coronary arteriotomy. For adequate hemodynamic management, avoiding myocardial oxygen supply-demand imbalance, which includes maintaining mean arterial pressure above 70 mmHg and preventing an increase in oxygen demand beyond the patient’s coronary reserve, must be prioritized. Maintaining mixed venous oxygen saturation above 60%, which reflects the lower limit of adequate global oxygen supply-demand balance, is also essential. Above all, severe mechanical cardiac displacement incurring compressive syndromes, which cannot be overcome by adjusting major determinants of cardiac output, should be avoided. An uncompromising form of cardiac constraint can be ruled out as long as the central venous pressure is not equal to or greater than the pulmonary artery diastolic (or occlusion) pressure, as this would reflect tamponade physiology. In addition, transesophageal echocardiography should be conducted to rule out mechanical cardiac displacement-induced ventricular interdependence, dyskinesia, severe mitral regurgitation, and left ventricular outflow tract obstruction with or without systolic motion of the anterior leaflet of the mitral valve, which cannot be tolerated during grafting. Finally, the ascending aorta should be carefully inspected for gas bubbles to prevent hemodynamic collapse caused by a massive gas embolism obstructing the right coronary ostium.

Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.

OBJECTIVES: Many factors influence the outcome of endoscopic dacryocystorhinostomy (DCR). One of the most important prognostic factors is the level of obstruction in the lacrimal drainage system. The main objective of this report is to evaluate both the frequency of obstruction by anatomical region of the lacrimal drainage system on dacryocystography (DCG) and the surgical outcome of endoscopic DCR according to the obstruction level. METHODS: A retrospective series of 48 patients (60 eyes) who had undergone endoscopic DCR from January 2005 to November 2007 were enrolled. Preoperative evaluation consisted of a standard examination which included lacrimal irrigation, probing, DCG and osteomeatal unit (OMU) computed tomography. Patients were classified into four groups according to the obstruction level on DCG. Surgical outcome was evaluated postoperatively by subjective improvement of epiphora and patent rhinostomy opening on nasal endoscopic exam. RESULTS: Of 60 eyes, the levels of obstruction were the common canaliculus in 14 eyes (23.3%), the lacrimal sac in 13 eyes (21.7%), the duct-sac junction in 13 eyes (21.7%) and the nasolacrimal duct (NLD) in 20 eyes (33.3%). The ductsac junction obstruction was treated most successfully (100%), followed by NLD obstruction (90%), common canaliculus obstruction (78.6%) and saccal obstruction (69.2%). CONCLUSION: In patients with lacrimal drainage system obstruction, preoperative evaluation of obstruction level using DCG may be helpful for predicting the surgical outcome of endoscopic DCR. The saccal obstruction may have a worse prognosis than the other obstruction levels.
Dacryocystorhinostomy ; Drainage ; Eye ; Humans ; Lacrimal Apparatus Diseases ; Lacrimal Duct Obstruction ; Nasolacrimal Duct ; Prognosis ; Retrospective Studies

Carotid body tumor is a manifestation of paraganglioma, a systemic disease, in the head and neck region. Bilateral presentation is rare, and it may or may not be functional. In symptomatic cases, it is important to evaluate the patient thoroughly through the whole body for the causative lesion. We experienced an unusual patient who had a history of resection for a carotid body tumor presenting with fluctuating hypertension. Work up revealed contralateral carotid body tumor and increased levels of catecholamine. He underwent resection of the contralateral carotid body tumor, but his symptoms persisted. Further studies led to detection of extraadrenal retroperitoneal paraganglioma with liver infiltration, for which he had an operation. His hypertension and catecholamine levels returned to normal.
Carotid Body Tumor* ; Carotid Body* ; Head ; Humans ; Hypertension ; Liver ; Neck ; Paraganglioma*

Pneumocystis carinii pneumonia (PCP) is one of the most common causes of infection in patients with HIV infection. With the development of effective prophylactic agent, the incidence of PCP in patients with HIV infection has been declining. On the other hand, however, the incidence of PCP has been increasing in immunocompromised hosts without HIV infection, such as rheumatoid arthritis, bone marrow transplantaion and Behcet syndrome. The increased occurrence of PCP in non-HIV- infected subjects has been attributed to several factors, such as use of stronger immunosuppressive regimens, higher awareness of PCP, advanced diagnostic technology and nosocomial spread of P. carinii. The occurrence of PCP in patients who receive immunosuppressive drugs for autoimmune disease has not been well known in Korea. We report a patient with Behcet syndrome who suffered from PCP after immunosuppressive drugs.
Arthritis, Rheumatoid ; Autoimmune Diseases ; Behcet Syndrome* ; Bone Marrow ; Hand ; HIV Infections ; Humans ; Immunocompromised Host ; Incidence ; Korea ; Pneumocystis carinii* ; Pneumocystis* ; Pneumonia, Pneumocystis*

Pneumocystis carinii pneumonia (PCP) is one of the most common causes of infection in patients with HIV infection. With the development of effective prophylactic agent, the incidence of PCP in patients with HIV infection has been declining. On the other hand, however, the incidence of PCP has been increasing in immunocompromised hosts without HIV infection, such as rheumatoid arthritis, bone marrow transplantaion and Behcet syndrome. The increased occurrence of PCP in non-HIV- infected subjects has been attributed to several factors, such as use of stronger immunosuppressive regimens, higher awareness of PCP, advanced diagnostic technology and nosocomial spread of P. carinii. The occurrence of PCP in patients who receive immunosuppressive drugs for autoimmune disease has not been well known in Korea. We report a patient with Behcet syndrome who suffered from PCP after immunosuppressive drugs.
Arthritis, Rheumatoid ; Autoimmune Diseases ; Behcet Syndrome* ; Bone Marrow ; Hand ; HIV Infections ; Humans ; Immunocompromised Host ; Incidence ; Korea ; Pneumocystis carinii* ; Pneumocystis* ; Pneumonia, Pneumocystis*

PURPOSE: Acute lymphoblastic leukemia (ALL) accounts for approximately 75% of all cases of childhood leukemia. We investigated epidemiology, clinical and laboratory features and treatment outcome of the children with ALL in Korea during recent 5 years. METHODS: One thousand forty nine patients were enrolled between January 1994 and December 1998 from 37 major hospitals in Korea. The data regarding the clinical and laboratory features including age, WBC counts at diagnosis, immunophenotype, morphology, cytogenetics and treatment outcome of patients were analyzed retrospectively by review of patient's medical records. Kaplan-Meier survival curves were constructed. The differences between groups analyzed by log-rank test. RESULTS: There were 597 males and 452 females. The distribution between the age 2 and 5 years is most common in 46.1%. The annual incidence rate per 100,000 population varied from 1.6 to 2.2. The 5 year event free survival (EFS) rates according to good prognostic factors were as follows: 67% bet ween 1-9 year of age at diagnosis, 69% in under 10,000/mm3of initial WBC count, 74% in early pre-B cell CALLA ( ) immunophenotype, 65% in L3 morphology, 68% in no CNS invasion. Most of patients were treated by CCG treatment protocol. The 5 year EFS was 63%. Main complications were sepsis (21.8%) and hemorrhage (12.5%). The relapse rate was 15.6%. The common causes of death were sepsis, DIC, pneumonia, relapse. CONCLUSION: Our results could provide the most recent and important information about acute lymphoblastic leukemia of children in Korea.
Cause of Death ; Child ; Clinical Protocols ; Cytogenetics ; Dacarbazine ; Diagnosis ; Disease-Free Survival ; Epidemiology* ; Female ; Hemorrhage ; Humans ; Incidence ; Kaplan-Meier Estimate ; Korea* ; Leukemia ; Male ; Medical Records ; Pneumonia ; Precursor Cell Lymphoblastic Leukemia-Lymphoma* ; Precursor Cells, B-Lymphoid ; Recurrence ; Retrospective Studies ; Sepsis ; Treatment Outcome

PURPOSE: Establishing the preoperative stage of colorectal cancer is of primary importance in determining the management and the operative procedure. A comparative study of preoperative evaluation of colorectal cancer is necessary for proper management. METHODS: This study reports a 7 years' experience using another two species of CT for preoperative staging. One species of CT (1989, Delta 2060, Technicare, USA) was used from January 1990 to December 1992; the other species of CT (1992, Highlight Advantage, General Electric Company, USA) was used from January 1993 to December 1997. This study included retrospective analysis of 237 cases of colorectal cancer from January 1990 to December 1997. In first group, the preoperative stage evaluation was done with a much older species of CT from January 1990 to December 1992; in the other group, the preoperative stage evaluation was done with a newer species of CT from January 1993 to December 1997. RESULT: The accuracy & sensitivity of preoperative staging between the two groups showed no significant differences. CONCLUSION: CT is recommended in the preoperative staging of rectal cancer and as an aid in choosing the appropriate therapy. In addition to CT, transrectal ultrasonography and MRI are recommend for improving the accuracy of preoperative staging in assessing local invasion by cancer.
Colorectal Neoplasms* ; Magnetic Resonance Imaging ; Rectal Neoplasms ; Retrospective Studies ; Surgical Procedures, Operative ; Ultrasonography

Carcinogens ; Cytochrome P-450 CYP1A1 ; Cytochrome P-450 CYP2E1 ; Cytochrome P-450 Enzyme System ; Cytochromes ; DNA Repair ; Exons ; Genes, Suppressor ; Genetic Predisposition to Disease ; Genotype ; Head and Neck Neoplasms ; Head ; Humans ; Metabolism ; Neck ; Negotiating ; Oncogenes ; Polymorphism, Genetic ; Xenobiotics