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Purpose@#Ductal carcinoma In Situ (DCIS) is common in South Korea. We evaluated the patterns of axillary surgery among patients with DCIS to highlight the need for compliance with the updated national guidelines. We also evaluated whether sentinel lymph node biopsy (SLNB) was performed in accordance with the national guidelines. @*Methods@#The Korean Health Insurance Review and Assessment Service-National Inpatient Sample database was searched for patients with DCIS (2009–2015) to identify axillary surgery patterns by breast surgery type, year of diagnosis, age at diagnosis, and the location and volume of surgeries for DCIS at the hospital. The rates of SLNB and axillary dissection were compared using descriptive statistics and univariate analyses. Analyses were also conducted using the chi-squared test and multiple logistic regression analysis. @*Results@#We identified 16,315 Korean women who underwent surgery for DCIS, including 11,292 cases of SLNB (69.2%) and 131 cases of axillary lymph node dissection (0.8%).Breast-conserving surgery (BCS) was performed in 10,323 patients (63.3%) with an SLNB rate of 56.0%, while total mastectomy (TM) was performed in 5,992 patients (36.7%), with an SLNB rate of 92.0%. During 2009–2015, the SLNB rate during TM increased from 88.23% to 92.80%. SLNB was influenced by hospital region and surgical volume, and hospitals performing low volumes of surgeries were significantly more likely to perform SLNB regardless of the surgery type (odds ratio, 1.372; 95% confidence interval, 1.265–1.488). @*Conclusion@#Although the Korean guidelines recommend SLNB for all TM procedures and select BCS procedures for DCIS, relatively high rates of SLNB were performed for BCS, and there was inter-hospital variability in performing SLNB. Improved compliance with the guidelines by the surgeons is critical for Korean patients with DCIS.

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Purpose@#Ductal carcinoma In Situ (DCIS) is common in South Korea. We evaluated the patterns of axillary surgery among patients with DCIS to highlight the need for compliance with the updated national guidelines. We also evaluated whether sentinel lymph node biopsy (SLNB) was performed in accordance with the national guidelines. @*Methods@#The Korean Health Insurance Review and Assessment Service-National Inpatient Sample database was searched for patients with DCIS (2009–2015) to identify axillary surgery patterns by breast surgery type, year of diagnosis, age at diagnosis, and the location and volume of surgeries for DCIS at the hospital. The rates of SLNB and axillary dissection were compared using descriptive statistics and univariate analyses. Analyses were also conducted using the chi-squared test and multiple logistic regression analysis. @*Results@#We identified 16,315 Korean women who underwent surgery for DCIS, including 11,292 cases of SLNB (69.2%) and 131 cases of axillary lymph node dissection (0.8%).Breast-conserving surgery (BCS) was performed in 10,323 patients (63.3%) with an SLNB rate of 56.0%, while total mastectomy (TM) was performed in 5,992 patients (36.7%), with an SLNB rate of 92.0%. During 2009–2015, the SLNB rate during TM increased from 88.23% to 92.80%. SLNB was influenced by hospital region and surgical volume, and hospitals performing low volumes of surgeries were significantly more likely to perform SLNB regardless of the surgery type (odds ratio, 1.372; 95% confidence interval, 1.265–1.488). @*Conclusion@#Although the Korean guidelines recommend SLNB for all TM procedures and select BCS procedures for DCIS, relatively high rates of SLNB were performed for BCS, and there was inter-hospital variability in performing SLNB. Improved compliance with the guidelines by the surgeons is critical for Korean patients with DCIS.

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BACKGROUND: Infection, one of the complications associated with procedures, can cause fatal outcomes for patients. Although the local anesthetic agent we use is less susceptible to infection due to its antibacterial action, we performed this study to check the change in the antibacterial effect of lidocaine in various clinical conditions. METHODS: After exposing lidocaine to five contaminated environments, we checked on whether the bacteria could be cultured in blood agar plate (BAP) media. In each contaminated environment, lidocaine was exposed for 4 h (n = 9) and 8 h (n = 9), and the results were compared. Lidocaine was swabbed with chlorhexidine (group A), brought into contact with saliva (group B), skin (group C), an operating room floor and an outpatient room floor (group D), operating room air for 24 h (group A-a), and outpatient room air for 24 h (group A-b). After exposure, the culture was initiated. RESULTS: In 2 of 9 BAP media where lidocaine was exposed to saliva (group B) for 8 h, growth of a colony was observed. In gram staining, it was found to be Streptococcus viridans. No bacteria were found in any other groups. CONCLUSIONS: Though lidocaine has strong antibacterial activity, it has been found that long-term exposure to a contaminated environment reduces its antibacterial activity and that drug contamination can be heavily affected not only by environmental but also human effects. Therefore, the use of aseptic drugs is necessary, and stopping the reuse of the drug is a way to prevent complications, including infection.

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Gastric metastasis from invasive lobular breast carcinoma is rare. Mostly gastrointestinal metastasis presents as one among multiple metastases, several years after primary diagnosis of breast carcinoma. Herein, we report a synchronously diagnosed gastric metastasis from invasive lobular carcinoma, mimicking primary gastric linitis plastica with pyloric obstruction. We reviewed clinical and pathological findings of gastric carcinoma metastatic from the breast. In particular, we focused on immunohistochemical studies of selected antibodies, including those for estrogen receptors, gross cystic disease fluid protein-15, and caudal-type homeobox transcription factor 2, for accurate differential diagnosis. Clinical suspicion, repeat endoscopic biopsy, and detailed histological analysis including immunohistochemistry are necessary for diagnosis of gastric carcinoma metastatic from the breast.

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Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.

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Many sedatives are used clinically and include benzodiazepines, barbiturates, antihistamines, propofol, and alpha-2-agonist. Benzodiazepines activate GABA neuronal receptors in the brain and present sedating, hypnotic, anxiolytic, amnestic, and anticonvulsant effects, but low analgesic effects. Propofol induce sedative, anxiolytic, and amnestic effects but no analgesic effects. However, risks such as cardiopulmonary instability and hypotension must be considered during administration. Dexmedetomidine is a high selective alpha-2 agonist and has many advantages as a sedative. Patients under dexmedetomidine sedation awaken easily and are more likely to be cooperative. Risk of respiratory depression and cardiopulmonary instability is low as well. Additionally, dexmedetomidine decreases amount of analgesic needed during and after surgery, presenting analgesic effects. Dexmedetomidine also decreases risk of delirium. However, bradycardia may occur and biphasic effects on blood pressure may be observed during beginning of administration. Because of lengthy symptom onset and offset time, physicians should carefully control administration at the beginning and end of dexmedetomidine administration. The purpose of this review is to evaluate the efficacy and availability of dexmedetomidine in various clinical fields including sedation for critically ill patients, regional anesthesia, monitored anesthesia care for some invasive procedures, stabilization of heart in cardiac surgery or endoscopic procedures.

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BACKGROUND: As the number of elder patients grows, spinal anesthesia for such patients are increasing significantly. Any effort is needed to use the least anesthetic drug for maintaining the anesthesia while avoiding hazards of cardio-pulmonary complications. METHODS: American Society of Anesthesiologists physical status classification I and II, Forty five elderly patients (> or = 60 years) who received transurethral resection of the prostate or transurethral resection of the bladder tumor were allocated randomly into three treatment groups. The DMT 0.5 group was designed as with dexmedetomidine 0.5 microg/kg while the DMT 1.0 group has a 1 microg/kg intravenous injection over 10 min before anesthetic induction. The Control group was designed to get a normal saline. Each group was compared regarding the maximum sensory block level, extension of anesthesia, degree of motor block, level of sedation, VAS score and complications. RESULTS: There were no significant differences among the 3 treatment groups regarding the maximum level of sensory block and motor block. However, the duration of sensory block was significantly longer in DMT 1.0 group than in the control group (P = 0.045). Both DMT 1.0 group (median = 3, range = 2-6) and DMT 0.5 group (median = 3, range = 1-6) showed a mean value of 3-4 Ramsay sedation score, which resulted in more excessive sedation and significantly greater incidence of bradycardia compared to the control group. No complications such as hypotension, nausea, tremor, and hypoxia were found during this investigation. CONCLUSIONS: In elder patients, the DMT 1.0 group is effective in duration of sensory block and is superior in the aspect of prolonged duration of sensory block compared to the DMT 0.5 group.

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I think endoscopic retrograde cholangiopancreatography (ERCP) is a very highly advanced upper endoscopic procedure, and is an uncomfortable procedure that requires adequate sedation for its successful conduction. But, The optimum method for sedation for endoscopic procedures is not known. Propofol has a faster recovery time than traditional sedative agents, but may be associated with increased complication rates. Dexmedetomidine is a highly selective alpha2 adrenoceptor agonist that has many advantages over other sedatives. In addition to producing sedative, analgesic, and anxiolytic effects, it provides respiratory stability. When patients are treated with appropriate analgesics, sedation with dexmedetomidine for ERCP would be safe and associated with better outcomes than sedation with other sedatives.

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BACKGROUND: During nasotracheal intubation it is important to have proper pretreatment for nasal mucosa constriction and nasal cavity expanding. Nasal packing of epinephrine gauze is widely used as well as xylometazoline. The aim of this study was to compare and evaluate the efficacy of prophylactic intranasal spray of xylometazoline against epinephrine gauze packing in expanding the nasal cavity. METHODS: Volunteers (n = 32) in their twenties without nasal disease such as septal deviation or rhinitis were enrolled in the study. The more patent nostril in each subject was measured by acoustic rhinometry as the base value. After intranasal spray of xylometazoline, the same nostril was remeasured by same method. Twenty four hours later, intranasal packing of epinephrine gauze was done and the same treatment was done. Subject preferences about the procedures were asked. RESULTS: There were significant difference among treatments (base value: 0.582 +/- 0.164 cm2, xylometazoline spray: 0.793 +/- 0.165 cm2, epinephrine gauze packing: 0.990 +/- 0.290 cm2) in acoustic rhinometry. While the epinephrine gauze packing showed more efficient mucosa constriction, subjects preferred xylometazoline spray. CONCLUSIONS: Even though xylometazoline spray was less effective than epinephrine gauze packing, the simplicity and convenience compensated. In patients undergoing nasotracheal intubation, xylometazoline spray can be an alternative to epinephrine gauze packing.

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Every operation could have a fire emergency, especially in the case of a tracheostomy. When a flammable gas meets a source of heat, the danger of fire is remarkable. A tracheal tube filled with a high concentration of oxygen is also a great risk factor for fire. Intra-tracheal tube fire is a rare, yet critical emergency with catastrophic consequences. Thus, numerous precautions are taken during a tracheostomy like, use of a special tube to prevent laser damage, ballooning of the tube with normal saline instead of air, and dilution of FiO2 with helium or nitrogen. Since the first recorded cases on tube fires, most of the fires were initiated in the balloon and the tip. In the present case report, however, we came across a fire incidence, which originated from the wire.

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PURPOSE: There have been recent studies of the 18F-fluorodeoxyglucose positron emission tomography and computed tomography (18F-FDG PET/CT) in the staging, detection, and follow-up of the breast cancer occurrence and recurrence. There was controversy concerning the use of 18F-FDG PET/CT for staging primary breast cancer. In this study, we investigated the potential effects of 18F-FDG PET/CT in the initial assessment of patients with primary breast cancer. METHODS: From January 2008 to December 2009, 154 consecutive biopsy-proven invasive breast cancer patients were enrolled in this study. Patients underwent conventional imaging studies including mammography, breast ultrasonography (USG), and magnetic resonance imaging for local assessment, and plain chest X-ray, liver USG, and bone scan to rule out distant metastasis. All 154 patients underwent 18F-FDG PET/CT in the initial assessment. RESULTS: 18F-FDG PET/CT did not detect primary breast lesions in 16 patients with a sensitivity of 89.6% and detected only 5 multiple lesions (12.5%) out of 40 cases. Histologically confirmed axillary lymph node (LN) metastases were in 51 patients, and the sensitivity and specificity of 18F-FDG PET/CT to detect metastatic axilla were 37.3% and 95.8%, respectively; whereas the corresponding estimates of USG were 41.2% and 93.7%, respectively. Eleven extra-axillary LN metastases were found in eight patients, and seven lesions were detected by 18F-FDG PET/CT only. The sensitivity and specificity of 18F-FDG PET/CT in detecting distant metastasis were 100% and 96.4%, respectively; whereas the sensitivity and specificity of the conventional imaging were 61.5% and 99.2%, respectively. CONCLUSION: 18F-FDG PET/CT cannot be recommended as a primary diagnostic procedure in breast cancer, but it has the potential to be used as an additional imaging tool for the detection of axillary metastasis, distant metastasis, and extra-axillary LN metastasis. 18F-FDG PET/CT cannot solely replace the conventional diagnostic procedure in primary breast cancer. The best approach may be the combination of different imaging modalities.

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PURPOSE: After shoulder arthroscopy via general anesthesia, most patients complain of severe pain during the early post operative period. In this study, the efficacy of pain control during the early post operative period with interscalene block anesthesia for shoulder arthroscopy was investigated and compared with general anesthesia. MATERIALS AND METHODS: A prospective randomized controlled study was conducted on 40 patients who underwent shoulder arthroscopy between September 2008 and March 2009. The patients were grouped according to the method of anesthesia. The visual analogue scale (VAS) at the preoperative and early postoperative periods was checked and compared. In addition, the duration of patient controlled analgesia (PCA) usage and additional pain killer injections were examined. RESULTS: There was no significant difference between the two groups for the VAS score before surgery, but the interscalene block group showed a significantly lower VAS score. The duration of PCA usage was also significantly longer for the interscalene block group, which implies less pain. The number of additional pain killer injections was significantly less in the interscalene block group. CONCLUSION: The patients who underwent shoulder arthroscopy with interscalene block had significantly less pain during the immediately post operative period for up to 48 hours. So patients could conduct initial rehabilitation and experience minimized side effects caused by analgesics due to the decreased use of pain killer. Therefore, interscalene block is considered a good method of anesthesia for the immediate postoperative pain control after shoulder arthroscopy.

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BACKGROUND: The transversus abdominis plane block is recently described peripheral block to providing analgesia to the anterior abdominal wall. The goal of this study is to evaluate the analgesic efficacy of the ultrasound-guided transversus abdominis plane block (US-TAP block) in patients undergoing gynecologic surgery via a transverse lower abdominal skin incision. METHODS: Thirty-two patients undergoing gynecologic surgery were randomized to undergo standard care such as PCA, or to receive additional US-TAP block with standard care. After general anesthesia induction, a bilateral US-TAP block was performed using 0.375% ropivacaine 20 ml on each side. Postoperative demand of rescue analgesics in PACU and ward were recorded. Each patient was assessed postoperatively by a blinded investigator in the postanesthesia care unit (PACU) and at 2, 6, 10, 24, 48 hr postoperatively to investigate pain, drowsiness, nausea and itch. RESULTS: The US-TAP block reduced pain intensity compared to standard care in the PACU (5.2 +/- 3.1 vs 8.4 +/- 1.3) and at 2, 24 postoperative hours (3.0 +/- 2.4 vs 5.2 +/- 2.4, 0.9 +/- 1.5 vs 2.2 +/- 1.9). Fentanyl requirements in PACU was reduced (20.3 +/- 20.9 vs 62.5 +/- 35.4 microg, P < 0.05). In ward, pethidine requirements was reduced (21.9 +/- 28.7 vs 56.3 +/- 34.8 mg, P < 0.05). CONCLUSIONS: The US-TAP block with standard care provide more effective analgesia after gynecologic surgery via a transverse lower abdominal skin incision.

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BACKGROUND: The hemodynamic changes associated with orotracheal intubation may result from direct laryngoscopy and the endotracheal intubation. This study was designed to compare the hemodynamic changes after the endotracheal intubation with either the Levitan FPS scope or Macintosh laryngoscope. METHODS: Sixty patients, aged 20 to 60 years, were randomly allocated into two groups, the Levitan FPS scope group (LF group, n = 30) and the Macintosh group (M group, n = 30). The endotracheal intubation with the Levitan FPS scope or Macintosh blade was performed after inducing anesthesia. The heart rate and arterial pressure were measured before induction, just before intubation and at 1, 3 and 5 min after intubation. RESULTS: There were no significant differences in the arterial pressure and heart rate responses to tracheal intubation with the Levitan FPS scope and the Macintosh laryngoscope. In both groups, the arterial pressures at 1 and 3 and 5 min after intubation were increased significantly compared with the preintubation values, and the heart rates at 1 and 3 min after intubation were increased significantly compared with the preintubation values. CONCLUSIONS: The Levitan FPS scopic intubation does not attenuate the hemodynamic responses associated with endotracheal intubation compared with the Macintosh laryngoscopy.

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Visual loss occurring after pediatric cardiac surgery employing cardiopulmonary bypass (CPB) is relatively rare but the risk is substantial. Compromised cerebral perfusion due to a CPB related micro-embolization and inflammatory vascular changes as well as reduced oxygen carrying capacity in hemodilution and hypothermia during CPB might be major contributing factors to the development of postoperative visual loss after cardiac surgery with CPB. A case of immediate but transient postoperative visual loss was encountered in a 21-month-old male who underwent tricuspid valve surgery. Despite routine intraoperative measures to maintain an adequate perfusion pressure throughout the procedure, postoperative computed tomography revealed a subacute infarct in his occipital lobe. Recovery began on postoperative day 28, and the patient's vision was restored by 31 days.

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BACKGROUND: Interscalene brachial plexus block (IS-BPB) offers many advantages over general anesthesia for both arthroscopic and open surgeries of the shoulder, including shorter hospital stay, reduced postoperative analgesia requirements, and avoidance of the risks and side effects of general anesthesia. The purpose of this study was to compare the effectiveness of postoperative pain control by IS-BPB to general anesthesia for performing arthroscopic shoulder surgery. METHODS: Sixty patients were divided into three groups: general anesthesia (group A, n=20), general anesthesia and suprascapular nerve block (SSNB) (group B, n=20), and only IS-BPB(group C, n=20). All patients received patient-controlled analgesia (PCA), and were instructed to rate their pain using a visual analogue scale (VAS) ranging from 0 to 10. VAS was measured at 1, 4, 8, 12, and 24 hours after surgery. Hospital stays were recorded. RESULTS: VAS decreased significantly with time in group A and B (P < 0.05) (Fig. 1), but not in group C. Group C had less pain at 1, 4, 8, 12, 24, hours postoperatively than the other groups (P < 0.05) (Fig. 1). Group C had shorter hospital stays than the other groups (P < 0.05) (Fig. 2). CONCLUSIONS: IS-BPB results in less postoperative pain and a shorter hospital stay than general anesthesia for arthroscopic shoulder surgery (P < 0.05).

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BACKGROUND: We introduce a new, simple portable inhalational induction device (PD) that provides co-operative inhalational induction of anaesthesia using N2O and subsequent sevoflurane in the preanaesthetic induction area in children. METHODS: Forty-five children (30 to 94 months old age, <35 kg) who were scheduled to undergo simple operations were assigned randomly to one of three regimens. Patients were encouraged by their parents to inhale N2O followed by sevoflurane (PD N2O-sevo group) or sevoflurane (PD sevo group) using a portable inhalational induction device in the preanaesthetic induction area until they were unable to respond to their names. They were then transferred to the operating room while maintaining inhalation of sevoflurane via the device. The control group underwent conventional inhalational induction in the operating room with the parents in attendance. RESULTS: Patients in the PD N2O-sevo group had a higher co-operative inhalation frequency than the patients in the PD sevo or the control group. Anaesthesia induction in the PD N2O-sevo and the PD sevo groups were faster than in the control group. Parent satisfaction score (0-100) was higher for the PD N2O-sevo group than for the control group. CONCLUSIONS: A new portable inhalational induction device allows faster induction in co-operation with parents present in the preanaesthetic induction area compared to conventional inhalational induction in the unfamiliar operating room with the parents in attendance.

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Intraoperative airway obstruction is usually manifested as high peak inflation pressures and decreased exhaled tidal volume. The simultaneous occurrence of increased peak inflation pressure and unchanging plateau pressure generally indicates a mechanical obstruction of the tracheal tube. We experienced a reinforced tube obstruction after intraluminal bulging of the tube. A 59 year-old woman was scheduled for a neck mass excision and ventral hernia repair. The patient was intubated with a 7.0 mm new reinforced tube without any problems. Three hours later, signs of airway obstruction presented, and passage of a suction catheter failed. Examination with the naked eye showed a partial obstruction by intraluminal bulging of the inner layer of the tube. We report this case of partial airway obstruction with a reinforced tube.

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BACKGROUND: The addition of remifentanil during propofol TCI (target controlled infusion) attenuates the hemodynamic changes induced by endotracheal intubation. This study examined the optimal effect-site concentration of remifentanil to minimize the cardiovascular changes to endotracheal intubation in elderly patients. METHODS: Fifty ASA 1 or 2 elderly patients scheduled for elective surgery under general anesthesia were assigned randomly to one of two groups according to the effect-site concentration of remifentanil. Each group was administered 4 microgram/ml of propofol TCI with 1 ng/ml (group R1) or 3 ng/ml (group R3) of remifentanil. The heart rate (HR), systolic (SAP), mean (MAP) and diastolic arterial pressure (DAP) were measured at pre-induction, before and after endotracheal intubation. RESULTS: After intubation, the HR, SAP, MAP and DAP increased significantly in the two groups compared with the pre-intubation values. However, the HR, SAP, MAP and DAP for group R3 were lower than group R1 for 5 min after intubation. CONCLUSIONS: In elderly patients administered 4 microg/ml of propofol TCI, we suggest that the optimal effect-site concentration of remifentanil to minimize the cardiovascular changes to endotracheal intubation is 3 ng/ml rather than 1 ng/ml.

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BACKGROUND: This study was designed to compare the hemodynamic changes in response to direct laryngoscopy with using the McCoy or Macintosh blade. METHODS: Seventy seven patients were randomly allocated into two groups. The induction of anesthesia was done with target controlled infusion of propofol (5 microgram/ml) and remifentanil (3 ng/ml) and vecuronium 0.1 mg/kg was also given. The vocal cords were visualized with either the McCoy or the Macintosh laryngoscope blade, and then tracheal intubation was performed. The heart rate and blood pressure were measured just before induction, at intubation and at 1, 3 and 5 minutes after intubation. RESULTS: There were no significant differences in the blood pressure and heart rate responses to tracheal intubation with using the McCoy or Macintosh blade. But, in the Macintosh groups, the blood pressure at 1 and 3 minutes and the heart rate at 1 minute after intubation were increased significantly compared with the preintubation values. Also, in the McCoy groups, the blood pressure and heart rate at 1 minute after intubation were significantly higher than the preintubation values. CONCLUSIONS: The McCoy and the Macintosh blade show similar changes in heart rate and blood pressure after tracheal intuba tion.

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