Spontaneous Rupture of the Hepatic Duct / 한국간담췌외과학회지

Spontaneous rupture of the bile duct is an exceedingly rare and usually recognized fatal cause of peritonitis and intraabdominal sepsis. Several reports of isolated cases have demonstrated its rarity in the absence of operative trauma or severe injury. Perforation of the biliary system occurs most frequently in the gall bladder, which perforation of the hepatic duct is less common, being described mainly in infants, but extremely rarely in adults. The diagnosis of the spontaneous rupture of the bile duct depends on meticulous clinical examination and imaging investigation. The basic principles of treatment are to stop the bile leakage, evacuate the extravasated bile, apply decortication of the encapsulated fluid collection and provide adequate drainage. We report on a patient with spontaneous perforation of the right hepatic duct who presented with abdominal pain, jaundice and fever. Exploratory surgery showed proximal common bile duct obstruction with right hepatic duct perforation.

Subcutaneous Metastasis at the PTBD Catheter Insertion Site in Bile-duct Carcinomas: Report of two cases

Percutaneous transhepatic biliary drainage (PTBD) is the basis for most biliary interventional pro cedures, and the application of preoperative PTBD to patients who have malignant obstructive jaundice has a significant effect on overall morbidity, mortality, and patient survival by allowing selective application of the most appropriate therapeutic modality. There are few case reports on subcutaneous metastasis of bile-duct cancer. We recently observed a subcutaneous metastasis at the catheter insertion site after PTBD in two patients with bile-duct cancer. Although tumor-cell seeding along the catheter tract is a very rare complication, we think that PTBD requires more attention when a curative resection is planned.

Perioperative Management without Blood Transfusion in a Patient with Massive Hemoperitoneum Who Refused a Transfusion

Although there are many controversies about clear-cut guidelines for blood transfusion, blood transfusions are critically important and essential in many emergency cases involving trauma to abdominal organs. However, occasionally there are certain situations in which blood transfusions cannot be made, despite clear indications for urgent blood transfusion based on clinical and laboratory findings. One is the case in which the patient refuses to receive a blood transfusion for reasons based on religious beliefs. We present a case of successful perioperative management without blood transfusion in a patient, a Jehovah's Witness, with a massive hemoperitoneum due to an injury caused by a motor vehicle accident.

Long-Term Survival Rates and Prognostic Factors for a Hepatocellular Carcinoma after a Curative Hepatic Resection

BACKGROUND: The prognosis for a hepatocellular carcinoma (HCC) is very poor because of delayed diagnosis caused by the absence of specific clinical manifestations in the early stage, the limitation of the extent of resection, the high postoperative complication rate due to associated liver cirrhosis, and the high recurrence rate due to multifocal tumorigenesis. Among the various kinds of treatment modalities for HCC, surgical resection is still recognized as the first treatment method. However, it is true that surgical resection has many problems, such as a high operative risk and a high postoperative recurrence rate. Therefore, an evaluation of the factors associated with the overall survival rate and with the recurrence rate is very important for improving the results of operative therapy for HCC. METHODS: We retrospectively analyzed the clinical and the pathological results of 44 curative hepatic resections for HCC performed at Chonnam University Hospital from 1991 to 1997. We evaluated 19 clinical and pathological factors by univariate and multivariate analysis, and we calculated the survival rate by using the Kaplan-Meier method. RESULTS: The cumulative 1-, 3-, and 5-year survival rates were 81%, 66%, and 28%, respectively. In 25 of the 44 cases, recurrences developed, and the 1-, 3-, and 5-year recurrence rates were 38%, 60%, and 65%, respectively. Factors with an independent effect on the overall survival rates were multiplicity of tumors, HBs Ag status, and Child classification. However, liver cirrhosis, ascites, prothrombin time, AFP level, and portal vein invasion were not statistically significant. CONCLUSIONS: The significant prognostic factors detected by multivariate analysis were multiplicity of tumors, HBs Ag status and Child classification. A preoperative evaluation for these factors should be done. If early diagnosis and multidisciplinary therapies are done through frequent postoperative follow-up surveys in these high risk groups, we can anticipate better long-term survival rates after a hepatectomy.

The Agenesis of the Right Lobe of a Liver with Multiple Intrahepatic Bile Duct Stones: A case report

Agenesis of the right lobe of the liver is such a rare congenital anomaly that only about 40 cases have been reported in the literature. This anomaly is considered to be caused by a developmental failure of the right portal vein or by an error of mutual induction between the primitive diaphragm and the endodermal diverticulum representing the primitive liver. When the absence or hypoplasia of the right lobe is found by radiological examinations, several condition, such as liver cirrhosis, a cholangiocarcinoma, and a previous hepatic resection, must be taken into a consideration for a differential diagnosis besides agenesis. Agenesis of the right lobe could be complicated by various biliary tract diseases, including cholelithiasis, a carcinoma of the gallbladder and Mirizzi syndrome, portal hypertension, and rarely volvulus of the stomach, and these complications usually draw clinical attention. We experienced a 58-year-old female who complained of intermittent fever, chills, and jaundice and who was diagnosed with agenesis of the right lobe of the liver with multiple intrahepatic stones by using abdominal CT and MRI. Percutaneous transhepatic biliary drainage was done to relieve the obstructive jaundice, and a percutaneous transhepatic cholangiogram revealed agenesis of the right lobe and abnormal course of the biliary tract. In operative findings, there was no right lobe, and the left lateral segment was markedly enlarged with compensatory hypertrophy. However, the medial segment of the left lobe and caudate lobe was relatively normal in size. The gallbladder was located on the right side of the liver retrohepatically. A cholecystectomy and a choledocholithotomy through a choledochotomy and a retrograde approach after a subsegmentectomy of segments II and III were done.

Xanthogranulomatous Cholecystitis in a Patient with Hemophilia A: A case report

Xanthogranulomatous cholecystitis (XGC) is an uncommon, focal or diffuse destructive inflammatory process of the gallbladder that is assumed to be a variant of chronic cholecystitis. XGC is characterized grossly by irregular thickening of the gallbladder wall with the formation of a yellow mass (xanthogranuloma). Histologically the xanthogranuloma appears as yellow nodules or streaks in a thickened gallbladder wall and is composed of predominantly lipid-laden macrophages, inflammatory cells, and fibroblasts. These xanthogranulomatous foci may extend into adjacent structures, adhesions or ulcerations are often present, and fistula formation may occur. Although the pathogenesis of XGC is unclear, recurrent inflammation in the presence of calculi and biliary stasis are thought to be the main etiological factors because of the histologic evidence of chronic inflammation and the presence of gallstones in a majority of cases. XGC may lead to associated complications such as perforation, abscess, and fistula, and sometimes closely mimics a gallbladder carcinoma. During an operation for XGC, careful surgical technique is required to dissect the gallbladder and to excise the adjacent xanthogranulomatous tissue. Also a careful investigation to find the coincident gallbladder carcinoma is necessary. We report a case with XGC in a hemophilia A patient and a review of the clinical literatures.