The 10 Years of Experiences with GISTs

PURPOSE: Gastrointestinal stromal tumors (GISTs) possess highly variable clinical behaviors and the study thereof is insufficient. There are no standard guidelines for diagnosis and treatment of GISTs, so it is difficult to predict recurrences and conduct appropriate treatments. Throughout the last 10 years of experiences with GIST patients, we have identified the variables predicting recurrences and classified the risk groups by NIH classification, Fletcher risk stratification and UICC TNM stage. METHODS: From January 1998 to December 2007, 88 patients with pathologic confirm and surgical resection were diagnosed with GISTs. GISTs were diagnosed when the tumor had characteristic histologic features and confirmed positive by KIT, CD34, or PDGFRA. RESULTS: The size, mitotic index, existence of symptoms, and origins of tumor correlate statistically with recurrence (0.002, <0.001, 0.027, 0.011). The NIH classification, Fletcher risk stratification and UICC TNM stage are correlated with recurrence (0.001, <0.001, <0.001) and 5 year disease free survival, statistically (0.009, <0.001, <0.001). Fifteen patients experienced recurrences. 14 patients were treated with imatinib, and 6 of them showed a response to the treatment. All 4 patients who had R1 resection did not survived due to the progression of the disease. CONCLUSION: The patients with large, high mitotic index, symptomatic, or extra-gastric tumor require strict surveillance. Also, patients with low risk must be under surveillance due to the possibility of recurrence. It is important to perform R0, en bloc resection. Although the imatinib is the treatment of choice with recurred or metastatic GISTs, the disease is likely to develop resistance, further studies on newly targeted therapy is in need.

Comparative Analysis of Vascular Endothelial Growth Factor-A, C, D Expression in Colorectal Cancer with Liver Metastasis

PURPOSE: We aimed to investigate the correlations between expressions of angiogenic cytokines VEGF-A, C, D of primary colorectal cancer and liver metastasis. METHODS: We examined paraffin-embedded primary colorectal cancer tissue from 45 patients who had liver resection due to colorectal liver metastasis (metastasis group) and 37 patients who had surgical resection due to colorectal cancer only (control group). In the control group, local recurrence and distant metastasis had not occurred. Immunohistochemical staining for VEGF-A, C and D was performed. We analysed the correlations between expression of VEGF-A, C and D in primary colorectal cancer tissues and clinicopathologic parameters. RESULTS: VEGF-A expressions of primary colorectal carcinoma were not different between the two groups. VEGF-C was more frequently expressed in the metastasis group (P=0.008) but VEGF-D was more expressed in the control group (P=0.003). Patients with VEGF-C negative and VEGF-D positive expression were predominant in the control group (P=0.020). Tumor location, T stage, lymph node metastasis and tumor differentiation were not related with the expressions of VEGF-A, C, D but only preoperative CEA was positively correlated with VEGF-A and C expression. CONCLUSION: Expressions of VEGF-C in primary tumor were more frequent in metastatic colorectal cancer and expressions of VEGF-D were more frequent in nonmetastatic colorectal cancer. More large-scale prospective studies for VEGF-C and D expression in colorectal cancer are necessary.

Pancreaticopleural Fistula with Hemothorax

Pancreaticopleural fistula is an uncommon complication of chronic pancreatitis. We report a case of pancreaticopleural fistula that was presented with right-sided hemothorax. A 49-year-old male with a history of chronic alcoholism was presented with a month of dyspnea. A chest radiography showed a right-sided massive pleural effusion with old-blood-colored fluids and amylase levels of 1,020 IU/L. On the chest computerized tomography (CT), there was pleural effusion and a well-defined tract from the posterior mediastinum to the pseudocyst in the tail of the pancreas. Even with conservative treatment with closed thoracostomy, octreotide and gabexate mesilate, he developed hemothorax. Abdominal CT revealed an increase of the hemorrhagic pancreatic pseudocyst. Distal pancreatectomy with splenectomy and external drainage of the pancreaticopleural fistula on the posterior mediasternum were performed. The patient had an uneventful course and was discharged on the 27th postoperative day. Management of pancreaticopleural fistula is multimodal included medication, endoscopic stenting and surgery. Surgery in pancreaticopleural fistula might be beneficial in selective cases.

Pancreatico-pleural Fistula: A Rare Cause of Hemorrhagic Pleural: A case report / 대한흉부외과학회지

A pancreatico-pleural fistula (PPF), caused by rupture of a pancreatic pseudocyststectomy or obstruction of the pancreatic duct, is a rare condition. A 48-year-old man with chronic alcoholism was admitted with a massive pleural effusion. Pleural fluid studies revealed elevated amylase and lipase. A PPF complicated by a ruptured pancreatic pseudocyststectomy was diagnosed by computerized tomography scan. Although the symptoms improved with conservative management, (chest tube drainage, NPO, total parenteral nutrition, and a pancreatic secretion inhibitor), a distal pancreatectomy, including a pseudocystectomy and thoracotomy, were performed for an increasing size of the hemorrhagic pancreatic pseudocyststectomy and a recurrent hemorrhagic pleural effusion. There were no post-operative complications and the patient was discharged on post-operative day 27.

Laparoscopic Common Bile Duct Exploration in Patients with Failed Endoscopic Stone Extraction

PURPOSE: Laparoscopic common bile duct exploration (LCBDE) has more advantages than conventional common bile duct surgery, but the use of this route for stone removal and biliary drainage remains controversial. The goal of this study was to investigate the usefulness of LCBDE in patients who had been failed in the endoscopic stone extraction. METHODS: From November 2005 to August 2008, 52 patients underwent LCBDE due to failure of endoscopic stone extraction in Chungnam National University Hospital. Clinical data were collected and analyzed retrospectively. RESULTS: Duodenal diverticulum (23 cases, 44.2%) was the most common cause in failure of endoscopic stone extraction and large common bile duct stone 12 cases (23.1%), previous upper gastrointestinal operation 10 cases (19.2%) were followed. Twenty four patients did not have preoperative biliary drainage, such as PTBD, ENBD, PTGBD. Forty-five patients (86.5%) of the 52 participating patients underwent LCBDE successfully, but 7 cases resulted in open surgery for the following reasons: 3 cases of severe intraabdominal adhesions, 3 cases of stone impaction in ampulla portion, and 1 case of a remnant stone. External biliary drainage was performed in 41 cases with T-tube (31 cases, 68.9%), PTBD (7 cases, 15.6%), ENBD (3 cases, 6.7%). The stone clearance of LCBDE was 95.6%. Remnant stone weredetected in 2 cases (4.4%) and removed with choledochoscope via external biliary drain. Postoperative complications happened in 5 cases (9.5%). Procedure related complications happened in 2 cases (3.8%). CONCLUSION: LCBDE is useful technique in patients with failed endoscopic stone extraction, and biliary drainage may be necessary for detection and removal of latent remnant CBD stones.

Anaplastic Carcinoma of the Pancreas

Local invasion or distant metastasis is frequently seen in patients with anaplastic carcinoma at the time of presentation, and this is unlike the usual cases of pancreatic carcinoma. So most cases of anaplastic carcinoma are confirmed by autopsy. We report here on our experiences of two cases of the anaplastic pancreatic carcinoma that were confirmed by the postoperative pathology. From January 2006 to December 2006, two patients at Chung-Nam National University Hospital were postoperatively diagnosed as having anaplastic carcinoma of the pancreas. The clinicopathologic data of these patients was reviewed. Case 1) A seventy-years-old male was admitted to our hospital due to his left abdominal pain. On physical examination, there was ill-defined palpable mass on the left upper abdomen. The CA 19-9 level was 4.8 (U/ml). On the abdominal CT scans, a 14.8 cm sized cystic mass with a mild enhancing internal solid portion was detected. He underwent distal pancreatectomy, total gastrectomy and segmental resection of the transverse colon due to direct invasion. The mass was pathologically confirmed as anaplastic pancreatic carcinoma. Postoperatively 3 months later, multiple liver and lymph node metastases were detected on the follow-up CT scan. Case 2) A sixty-five years-old female was referred to our department for a splenic hilar mass that involved the distal pancreas. The CA19-9 level was 3.18 (U/ml). On the preoperative CT scan, an 8.0 cm sized irregular mass with heterogenous contrast enhancement was detected on the tail of the pancreas. She underwent distal pancreatectomy with splenectomy and segmental resection of the transverse colon due to direct invasion. On the pathology report, the pancreatic mass was revealed to be anaplastic carcinoma of the pancreas. One month later, a recurred pancreatic mass and multiple liver and peritoneal metastases were detected on the follow-up CT scan. Anaplastic pancreatic carcinomas show distinctive aggressive behavior and a dismal prognosis.

Clinical Predictive Factors for Acute Gangrenous Cholecystitis

PURPOSE: The postoperative morbidity and mortality for acute gangrenous cholecystitis (AGC) are higher than for acute nongangrenous cholecystitis (ANGC). However, preoperative predictive factors for the outcome of gangrenous cholecystitis have not been identified. The goal of this study was to determine the preoperative clinical predictive factors for the outcome of surgical treatment for acute gangrenous cholecystitis. METHODS: From January 2005 to December 2006, the medical records of 173 patients who underwent laparoscopic cholecystectomy for acute cholecystitis were reviewed and analyzed retrospectively. RESULTS: Among 173 patients with acute cholecystits, 57 (32.9%) had pathologically confirmed gangrenous cholecystits. Six variables were found to be associated with gangrenous cholecystits by univariate analysis: an age > or = 55 years, the presence of associated diseases, hypertension, fever (> or =37 degrees), an increased white blood cell count (> or = 15,450/mm3) and glucose. Four variables were identified that were associated with gangrenous cholecystits by multivariate analysis: an age > or = 55 years, the presence of associated diseases, hypertension, and an increased white blood cell count (> or =15450/mm3). CONCLUSION: The results of this study suggest that patients with an age > or = 55 years, the presence of associated diseases, hypertension, and an increased white blood cell count (> or =15450/mm3) have an increased risk of gangrenous cholecystitis and require immediate surgery.

Experience of Total Laparoscopic Hepatectomy

PURPOSE: The aim of this study is to assess the feasibility and clinical outcomes of laparoscopic liver resection by reviewing our experience of laparoscopic liver resection performed in a single institution. METHODS: We retrospectively analyzed the clinical outcome of 64 patients that had undergone laparoscopic liver resection for various liver diseases between May 2003 and June 2006. RESULTS: The patients were composed of 36 men and 28 women, with a mean age of 56.9 years. Indications for laparoscopic liver resection included 37 cases of a tumor (20 hepatocellular carcinomas, 8 metastatic cancers and 9 benign tumors) and 25 cases of IHD stones. The surgical procedures were 19 tumorectomy cases, 24 left lateral sectionectomy cases, 15 left hepatectomy cases, 4 right posterior sectionectomy cases and 2 right hepatectomy cases. The mean surgical time was 280.3 minutes. Intraoperative transfusion was required for 18 patients (28.1%). There was one postoperative death (1.6%) due to biliary sepsis after a left lateral sectionectomy for an IHD stone. Postoperative complications developed in 9 cases (14.0%) (2 intraabdominal abscesses, 1 hematoma, 1 bile leakage, 1 ascites, 1 gastric variceal bleeding, 1 ulcer bleeding and 1 anastomosis leakage), all of which were improved by conservative management. The mean postoperative hospital stay was 11.0 days. CONCLUSION: Our experience shows that laparoscopic liver resection is a feasible operation and is comparable to surgery with the open method. However, a prospective comparative study with long term follow-up is needed to confirm the equivalence of the procedures.

Total Laparoscopic Right Hepatectomy

Until now, reports on laparoscopic liver resections have mainly involved the antero-lateral segments (Couinaud segments II~VI), but those on laparoscopic major liver resection including a right hepatectomy are rare. Herein, we report on two total laparoscopic right hepatectomy cases. One patient was a 69-year-old female, with a hepatocellular carcinoma, and the other a 59-year-old female, with right intrahepatic duct stones. A total laparoscopic right hepatectomy was performed using four or five trocars. After cholecystectomy, the right liver was dissected from the IVC and surrounding ligaments until the right hepatic vein was visualized. After full mobilization of the right liver, the right portal vein, hepatic artery and bile duct were dissected and individually divided. The hepatic parenchyma was dissected along the ischemic line, using a Harmonic scalpel, into the superficial parenchyma and CUSA into the deep parenchyma. The large branches of the hepatic veins were controlled with endoclips. The right hepatic vein was transected with endo-GIA. The epigastric trocar site was extensionally incised for removal of the specimen. The operative times were 385 and 480 minutes the first and second case, respectively. Intraoperative transfusion was needed in the second patient due to biliary cirrhosis and distorted anatomy associated with an IHD stone. The two patients were discharged on postoperative days 15 and 6, respectively, without postoperative complications. These cases confirm that a total laparoscopic right hepatectomy is a feasible and safe operation. However, the technical problems, such as long operation time and bleeding during liver parenchymal resection, should be resolved in order that this procedure can be accomplished more safely.

The Causes and Clinical Significance of Hyperamylasemia Following Colorectal Surgery

PURPOSE: Postoperative hyperamylasemia and pancreatitis may sometimes follow abdominal surgery but the significance and cause of hyperamylasemia after colorectal surgery were not studied enoughly. Our study was designed to identify the incidence of hyperamylasemia after colorectal surgery, to investigate the effect of hyperamylasemia on postoperative hospital course, and to clarify the causes such as extent of colorectal resection or intraoperative events. METHODS: The serum amylase was determined in post operative first day in random sampled 72 patient among whom underwent elective colorectal resection from March 2000 to July 2001. If a hyperamylasemia was evident, repeated check the level till it returned to within normal range. Other factors that seemed to affect serum amylase such as traction of pancreas during operative manupulation, intraoperative hypotensive episode or infused drug and volume expanders etc. were reviewed and analysed. RESULTS: Hyperamylasemia occurred in 25 patients (34.7%) after colorectal surgery. Serum amylse level returned to normal in all but nine patients (12.4%) by third postoperative day, two patients (2.8%) by the fifth postoperative day. Pancreas manupulation and intraoperative use of volume expander, amylopectin were found to be significantly associated with postoperative hyperamylasemia by 2-test and pearson correlation analysis. The developement of hyperamylasemia did not adversely influence the postoperative hospital course. CONCLUSIONS: Twenty-five (34.7%) in seventy-two patients who underwent colorectal surgery developed hyperamylasemia after operation. The incidence was significantly high in a group who underwent surgical procedure with more pancreas manupulation and infused hydroxyethyl starch (amylopectin) containing volume expander. The development of postoperative hyperamylasemia did not seem to influence adversely the postoperative hospital course in this study.