Cavoatrial Shunt for IVC Obstruction by Organized Thrombosis

Suprarenal IVC obstruction occurs rarely but has various causes. Because this obstruction proceed chronically and usually has collateral circulation, if there is no IVC or hepatic vein obstruction symptom such as Budd-Chiari syndrome, operation is usually needless. However, although symptom is not combined, if malignancy can not be ruled out and there is no proper and radiologically visible collateral, mass resection with IVC wall and bypass graft should be done. 58 year-old female patient visit the hospital for IVC mass that is occasionally discovered by routine abdominal ultrasonography examination. After abdominal CT scanning and IVC venography, IVC obstructive mass between renal vein and hepatic vein was found. Patient didn't show any abnormality in hematological examination such as coagulation and platelet counts. There was no IVC obstruction symptom such as lower limb swelling. Inferior hepatic vein was abnormally dilated and this was regarded as collateral vessel for IVC obstruction. Radiologically, primary leiomyosarcoma was not ruled out and so operation was decided. Suprarenal IVC was dissected and mass was exposed. And with the use of femoral vein and right atrium, temporally veno-veno bypass was performed. Mass including IVC wall was excised and upper end of divided IVC was sutured. Lower end of divided IVC was anastomosed with 16 mm Dacron graft and graft was anastomosed with right atrium by end-to-end methods (Cavoatrial shunt). Postoperative pathologic examination revealed the mass to be organized thrombi. After 2 weeks later, follow-up IVC venography was performed and good patency was found from IVC to right atrium through artificial bypass graft and patient was discharged without complications.

The Outcomes of Curative Surgery for Primary Duodenal Malignancy

Fifteen cases of the primary duodenal malignancies were radically resected from July 1989 to September 1996. These cases were analysed retrospectively with the literature review. The male to female ratio was 8:7. The mean age was 49 years. Histopatholgically, adenocarcinomas were 10 cases, sarcomas were 4 cases and malignant lymphoma was 1 case. The symptoms and signs were abdominal pain and discomfort, weight loss, nausea and vomiting, jaundice, melena and diarrhea in the order of the frequency. We performed Whipple's operations in 11 cases, regional pancretectomy in 1 case, Whipple's operation with Right hemicolectomy in 2 cases and local resection in 3 cases. There was no operative mortality. The perioperative morbidity was 33%. The post operative complications were abscess in abdomen in 3 cases and wound infections in 2 cases. 1 year and 2 years survival rate were 93.3% and 33.3%. Aggressive and radical treatment with curative intention even in the presence of locally advanced disease, could be performed with acceptable mortality and morbidity and expect a better outcome.

Liver Regeneration following Extended Liver Resection combined with Pancreatoduodenectomy / 한국간담췌외과학회지

BACKGROUND/AIMS: In patients with advanced biliary malignancies, a chance of curability is obtained by only performing extended liver resection with concomitant pancreatoduodenectomy. This hepatopancreatoduodenectomy(HPD) is known to carry high risk of hepatic failure. We evaluated the effect of pancreatoduodenectomy on liver regeneration and the risk of hepatic failure in patients having undergone HPD to prevent complications associated with liver function. METHODS: Sixteen cases of HPD with extended liver resection were reviewed in the aspects of liver regeneration and hepatic failure. Twenty cases of extended right hepatectomy were selected as a control group(ERL group) for comparison of liver regeneration. Liver volumes were measured by computed tomogram volumetry. RESULTS: Resection rates of the liver and the pancreas in the HPD group were more than 51% and about 40%, respectively. Right portal vein embolization was performed in 66% of cases and all cases with obstructive jaundice underwent percutaneous biliary drainage. Rate of liver regeneration at postoperative 1 month in HPD group was 162%, and that of the ERL group was 169%, resulting in no statistical difference. There was no occurrence of hepatic failure in the HPD group. CONCLUSIONS: Forty percent resection of pancreatic parenchyme following concomitant pancreatoduodenectomy may not compromise liver regeneration after extended liver resection. Complete external drainage of obstructive jaundice and preoperative portal vein embolization are recommended as preoperative procedures for patients undergoing extended liver resection with pancreatoduodenectomy.

Adult-to-Adult Living Donor Liver Transplantation

BACKGROUNDS: Living-donor liver transplantation (LDLT) has been established as an efficacious option to resolve the shortage of cadaveric donor organs for pediatric recipients. This surgical innovation has significantly reduced the pretransplantation mortality for children, but the crisis of increasing scarcity of donor organs in our hospital has led us to extend LDLT to adult recipients. However, the extension of LDLT from pediatric recipients to adult recipients has been made only with limited success largely because of the inability of a relatively small-size left-lobe graft to meet the metabolic demands of an adult recipient. It has been postulated that a left-lobe graft smaller than 40% of the recipient's standard liver volume will not result in a successful adult-to-adult LDLT in chronic parenchymal liver disease. METHODS: From February 1997 to October 1997, 10 LDLTs, using 9 extended left-lobe grafts and 1 right-lobe graft, were performed on patients with end-stage parenchymal liver diseases (9 cases of B-hepatitis-induced cirrhosis with or without an associated hepatocellular carcinoma and 1 case of alcoholic cirrhosis) at the Department of Surgery, Asan Medical Center. The ratios of the graft to the standard liver volume of the recipients were in the range of 30% to 55%. RESULTS: All grafts showed immediate function, but delayed normalization of the serum total bilirubin was demonstrated in all recipients receiving left-lobe grafts. There were no mortalities and serious complications in donors. Two recipients died of sepsis 21 days and 40 days after transplantation, and 8 recipients (80%) are alive with good liver function at a median follow-up of 5.1 months (range 2~10 months). CONCLUSIONS: The aim of this article is to report our experience with adult-to-adult LDLT shows that a graft size greater than 30% of the recipient's standard liver volume is able to meet the metabolic demands of adult recipients with chronic parenchymal liver disease and that LDLT might open a new donor pool for adult recipients when the supply of cadaveric organs is severely restricted.

Splenic Metastasis of Lung Cancer

Splenic metastasis from solid cancer is a rare clinical event. Especially splenic metastasis from the lung is very rare. Most spleen metastases are found at autopsy and are part of a widely spread disease. Solitary splenic metastasis in the abscence of other metastases is extremely rare. The authors report the case of a 54-year-old man in whom the only discover distant metastasis from lung cancer was a splenic mass. The splenic lesion was detected after the resection of the primary lung lesion. The time from diagnosis to the development of splenic metastasis was 25 months. The rarity of a solitary spleen metastasis from lung cancer and the treatment modalities are discussed. When solitary spleen metastasis is suspected in a clinical setting, aggressive treatment is indicated, a splenectomy followed by combined modality treatment to prevent the spread and aggravation of the disease.

Treatment of Ampullary Neoplasm, Diagnosed as Benign on Preoperative Endoscopic Biopsy

Adenoma of the ampulla of Vater is a rare disease, and there is no universal consensus on the management of this entity due to its rarity and unpredictable behavior. Because many of these tumors recur after local excision and because it is difficult to obtain a definitive diagnosis or to exclude malignancy before operation, local excision of ampullary tumors still remains controversial despite being a standard operation for nearly a century. Many surgeons resort to more radical resection, such as pancreatoduodenectomy for treatment of this troublesome disease. The author's report on the evaluation and treatment of 10 patients who underwent pancreatoduodenectomy for ampullatry tumors, diagnosed as benign adenoma on preoperative endoscopic biopsy. Endoscopic retrograde cholangiopancreaticography (ERCP) and computed tomography (CT) was performed in all cases. There were 6 men and 4 women, with a median age of 53 years (22-72 years). Postoperative histopathologic examination revealed that five of the ten patients had had cancerous change within adenoma. Four of the five ampullary adenocarninomas were confined to mucosa, but one had invaded the pancreatic parenchyma. No case was accompanied with lymphatic involvement. Reoperative pancreatoduodenectomy was perfomed in one patient with recurrent villotubular adenoma after local excision of ampulla. All patients are still alive and without any evidence of tumor recurrence after pancreatoduodenectomy (median follow up period 35 months, range 17-77 months). There was no postoperative death. Diagnosis of malignancy could not be ruled out based on a preoperative endoscopic biopsy in ampullary tumors. We conclude that pancreatoduodenectomy with regional lymph node dissection should be the standard treatment in circumstances without any contraindication to extensive surgery.

Major Complications after Orthotopic Liver Transplantations

A retrospective study was conducted to determine the incidence of major complications after liver transplantations which had been performed at Asan Medical Center from August 1992 to October 1996. Among the 43 orthotopic liver transplantations(OLTs), 27 were cadaveric donor liver transplantation(CDLT) including one retransplantation, 16 were living donor liver transplantation(LDLT). The over-all incidence of major complication was 52.4%, and there were no statistical difference between CDLT and LDLT. But the one-year cumulative survival was better in LDLT than CDLT(86.2% vs 63.3% : p < 0.1). To reduce the incidence of major complications after OLT, proper management of donors, early transplantation of recipients and shortening of cold ischemic time are mandatory especially in CDLT.

Significance of Preoperative Portal Vein Emblization of Cirrhotic Liver for Major Hepatectomy

Patients with hepatocellular carcinoma are often combined with liver cirrhosis, which limits the extent of liver resection. We evaluated the effect of preoperative portal vein embolization (PVE) on perioperative course of major hepatectomy of cirrhotic livers. A case-controlled study categorized by PVE and liver cirrhosis was perfomed in 63 cases undergone right lobectomy for hepatocellular carcinoma. The cirrhotic PVE group showed the following changes before and after PVE, respectively; indocyanine green 15 minutes retention rate of 7.5% and 9.1%, left lobe volume of 433.8 ml and 461.5 ml, and portal pressures of 13.0 mmHg and 18.8 mmHg. The non-cirrhotic PVE group showed a smaller increase in the portal pressure after PVE. There were no PVE-related complications. Postoperative changes in the remnant liver volume at 2 weeks and 3 months showed no significant differences between the cirrhotic PVE and the cirrhotic non-PVE groups. Postoperative bleeding and hepatic failure occurred in 5.3% versus 22.7% and additional hepatic decompensation at postoperative 3 months was found in 10.5% versus 18.2% of the cirrhotic PVE and the cirrhotic non-PVE groups, respectively. The mean size of the tumor in mortality cases was 3.8 cm, and there was no mortality in PVE cases with a tumor less than 5 cm. PVE of a functionally preserved cirrhotic liver was a safe procedure and lowered liver function-related complications, which may be at least partially due to atrophy-hypertrophy of the liver parenchyme and to the attenuated portal pressure change following right lobectomy after PVE. Conclusively, preoperative PVE may provide safety after major hepatectomy for the patients with cirrhotic livers or small-sized tumors.

Changing patterna in the Serum Amylase Level and the Serum Lipase Level Following Hepatic Resection with Pringle's Maneuver

Intermittent clamping of the portal pedicle during hepatic resection may reduce the amount of bleeding but it can induce ischemic injury to the liver. Almost all reports about Pringle's maneuver center around the ischemic insult to the liver and the longest duration time. Recently it was reported that prolongation of portal congestion carries a potential risk of serum amylase elevation and pancreatitis after hepatic resection with the intermittent Pringle maneuver. The aim of this prospective study was to analyze the changing patterns of the serum amylase and the lipase levels and to analyze the factors that may be associated with hyperamylasemia and hyperlipasemia after hepatic resection with intermittent Pringle maneuver. The serum amylase and the lipase levels elevated slowly after hepatic resection and reached to the highest level on postoperative day 11. The serum amylase level and the lipase level in the control group was highest on postoperative day 1 and postoperative day 5 respectively. The elevation of the amylase and lipase levels in the major hepatic resection group, the group in which clamping time was more than 30 minutes, and the patient group with normal liver was higher. These results suggest that a prolonged intermittent Pringle's maneuver and the larger amount of resected hepatic parenchyme may cause hyperamylasemia and hyperlipasemia and the underlying mechanism may be the prolonged congestion of the pancreas.

The Effect of Surgical Manipulation on the Bacterial Translocation from the Gut

The bacterial translocation is defined as the passage of viable bacteria or its toxin from the lumen of the gastrointestinal tract through the intestinal mucosa to other site of host. It is believed that bacterial translocation may lead to systemic infection and septicemia. The purpose of this study was to determine what factors in experimental surgical trauma lead to bacterial translocation. Two-nonth-old Wistar albino rats were divided into three groups: A-control; B-anesthesia only and C-anesthesia and surgery. After 24 and 48 hours, caval blood, mesenteric lymph nodes, liver, lung and spleen were harvested aseptically and cultured for aerobic organism. To exclude the possibility of contamination during surgical manipulation and harvesting, swab culture of peritoneal surface was performed. The bacterial translocation seldom occurred 24 hours after surgical manipulation. There was a significant increase in the number of animals with bacterial translocation in group C, 48 hours after manipulation and harvesting, swab culture of peritoneal surface was performed. The bacterial translocation seldom occurred 24 hours after surgical manipulation. There was a significant increase in the number of animals with bacterial translocation in group C, 48 hours after surgical manipulation. The majority of translocating bacteria was E. coli.

Anomalous Vessels Encountered during Hepatoduodenal and / or Aortocaval Lymph Node Dissection

We analyzed the type and the incidence of anomalous vessels encountered during hepatoduodenal and/or aortocaval lymph node dissection. There were 4 cases of an aberrant right hepatic artery from the superior mesenteric artery. There were 4 cases of an aberrant right hepatic artery from the gastroduodenal artery, and there were 2 types of course in aberrant right hepatic artery from the gastroduodenal artery. All hepatic artery branches should be identified before the gastroduodenal artery is ligated and divided, especially when right hepatic artery pulsation is palpated posterolaterally to common bile duct. The inferior polar renal artery from the aorta and double renal vein should be kept in mind during aortocaval lymph node dissection.

Calculation of Standard Liver Volume of Korean Adults / 한국간담췌외과학회지

BACKGROUND/AIMS: Liver size disparity is a common problem in liver transplantation and safe range of remnant liver volume after massive liver resection still remains arguable. CT volumetry is a valuable tool for measurement of total and segmental liver volume. We measured liver volume with CT volumetry to establish a formula for calculating the standard liver volume of Korean adults to provide baseline information for hepatobiliary surgery. METHODS: We devised a video-digitizing volumetry using printed CT film and its limit of error was 3% compared with results from commercial CT volumetry. The volume of 40 normal livers was measured by commercial CT volumetry and by our method. RESULTS: Body index of 40 cases was distributed from -9% to 20%. The whole liver volume correlated well with body surface area and there was no difference between male and female. However, segmental liver volume did not correlate with body surface area. CONCLUSIONS: The Predicting equation was determined to be, whole liver volume(ml) = 691 x body surface area(m2) + 95, with a theoretical range of error of about 10%. This equation can be utilized in liver transplantation as well as massive liver resection for prediction of standard liver volume in Koreans.

Experience of an En Bloc Resection of Right Lobe of Liver, Adrenal, Kidney and Infrahepatic Vena Cava with the Aid of Veno-venous Bypass / 한국간담췌외과학회지

Resection of hepatic tumors located near the confluence of hepatic vein or invading retrohepatic vena cava has become technically feasible and relatively safe with the introduction of veno-venous bypass. Hepatic vascular exclusion(HVE) with the aid of veno-venous bypass using centrifugal pump enables safe resection and reconstruction of vena cava without hemodynamic instability, compared to conventional HVE. The authors report a case of a successful en bloc resection of right lobe and caudate process of liver, right adrenal, right kidney, and retrohepatic vena cava, in order to extirpate huge retroperitoneal tumor, with the aid of veno-venous bypass using centrifugal pump. Pathologic diagnosis revealed B cell type non Hodgkin's lymphoma arising from adrenal gland. After resection, caval defect was reconstructed with Dacron graft. Patency of reconstructed cava could be observed at five months postoperatively.

Clinical Experience with Hepatic Resection for a Ruptured Hepatocellular Carcinoma

Spontaneous rupture of a hepatocellular carcinoma (HCC) is an uncommon but fatal complication of this disease. Hepatic resection provides the only hope of cure for patients with a ruptured HCC. However, reports on hepatectomies for ruptured HCCs are sparse in Korea, so we reviewed our clinical experience with hepatic resection for this potentially fatal complication. Nine cases of ruptured HCCs were treated by hepatectomies at our department between April 1990 and January 1997. The results of the clinical review are as follows: 1) The incidence of spontaneous rupture to all HCCs was 4.4%. Ages ranged from 36 to 75 years with a mean age of 50.6 years, and sex ratio was 3.5 : 1 with a male predominance. 2) Most patients (7 cases, 78%) had right upper quadrant abdominal pain and/or epigastralgia with a duration of 3 hours to 1 month. Two cases were presented in a state of hemorrhagic shock. 3) HBsAg was positive in all cases, and the level of the alpha-fetoprotein was more than 10,000mg/ml in 5 cases. 4) Liver cirrhosis was presented in 7 cases (78%) 5) The site of the rupture was the right lobe in 4 cases (44%) and the left lobe in 5 cases (56%) 7) The types of hepatectomies included a right lobectomy in 2 cases, a left lobectomy in 2 cases, a left lateral segmentectomy in 2 cases and a partial hepatectomy in 3 cases. 8) Complete removal of the tumor was carried out in 6 cases, and palliative resection was performed in 3 cases. 9) Overall 1-year and 2-year cumulative survival rates were 64% and 43%, respectively. In conclusion, Hepatic resection is considered to be the treatment of choice for a ruptured HCC, and long-term survival can be observed in a few patients with ruptured HCCs who underwent curative resections.

An experimental study on the enhanced cytolytic effects of natural killer cells by interleukin 2

No abstract available.