Major Hepatectomy in the HCC Patient with an Indocyanine Green Retention Rate at 15 Minutes of 10% or Higher: Predictive Values of Postoperative Hepatic Failure

PURPOSE: Major hepatic resection is sometimes inevitable in patients with impaired liver function. We evaluated risk factors that cause postoperative liver failure after major hepatic resection in patients with over a 10% Indocyanine Green Retention rate at 15 minutes (ICGR15). METHODS: From Apr. 2002 to Aug. 2009, 32 patients who had over a 10% rate of ICGR15 underwent major hepatic resection (> or =4 Couinaud segments). Among the 32, 9 patients showed postoperative liver failure (less than 50% prothrombine time and/or 5 mg/dl or higher of total bilirubin). This high-risk group was compared to the rest who constituted a low-risk group. RESULTS: Patients with esophageal varix were more common in the high risk group (4 versus 2, p=0.043). Other clinicopathologic features showed no difference between the two groups. We had 2 in-hospital deaths in the high risk group. CONCLUSION: Great care is needed in patients with esophageal varix and limited liver function during major hepatic resection.

The Feasibility of Sentinel Lymph Node Biopsy with a Multidisciplinary Cooperative Team Approach for the Management of Koreans with Cutaneous Malignant Melanoma

BACKGROUND: The regional lymph nodal status is the most powerful independent predictor of survival for patients with clinical N0 primary cutaneous malignant melanoma. OBJECTIVE: We wanted to evaluate the feasibility and morbidity of the sentinel lymph node biopsy (SLNB) staging using a multidisciplinary team approach, in cooperation with other surgical departments, at a university hospital setting. METHODS: Twenty two patients with cutaneous melanoma and who were treated at Kyungpook National University Hospital were included in this study. They all received SLNB, which was done by the Departments of Dermatology and General Surgery. We evaluated the feasibility and side effects of SLNB. RESULTS: Pathologically-positive sentinel nodes were found in 7 of the 22 cases (31.8%) and all 7 patients were consequently upstaged. The whole process involved in SLNB was well tolerated by nearly all the patients, with only mild and transient complications being observed. CONCLUSION: We suggest that in a Korean setting, utilizing SLNB with a multi-disciplinary team approach is a technically feasible procedure that is able to detect occult nodal metastasis with low morbidity rates in patients with cutaneous malignant melanoma.

A Case of Primary Pancreatic Non-Hodgkin's Lymphoma

Primary pancreatic lymphoma is rare, comprising 0.2~4.9% of all pancreatic malignancies and less than 1% of cases of non-Hodgkin's lymphoma. Many patients are diagnosed with lymphoma after radical resection. We report a rare presentation of diffuse large B cell lymphoma, appearing as a primary tumor of the pancreas. A 61-year old female was admitted to the hospital with the complaint of right upper abdominal pain. Computed tomography of the abdomen showed a well defined mass located at the head of the pancreas. A frozen section of pancreas, during laparotomy, revealed lymphoma. The patient received 6 cycles of chemotherapy and is currently in complete remission. This case underscores the importance of differentiating primary lymphoma from the more common adenocarcinoma of the pancreas as treatment and prognosis differ significantly. Primary pancreatic lymphoma should be considered in the differential diagnosis of pancreatic tumors and an attempt to obtain a tissue diagnosis is always necessary before proceeding to radical surgery, especially on young patients.

Comparison of Long-Term Results of Leg Arterial Bypasses between the Patients with Chronic Critical Limb Ischemia and Claudication

Patients with chronic leg arterial occlusion usually present with claudication or chronic critical limb ischemia (CCLI). Infrainguinal bypasses are usually indicated for those patients with CCLI and intermittent claudication that is causing severe disability. PURPOSE: To observe the differences in outcomes of leg arterial bypasses between the patients with CCLI and disabling claudication. METHODS: Three hundreds consecutive patients, with 400 leg bypasses (327 vein grafts and 67 prosthetic grafts, and 6 composite grafts), were enrolled, and stratified into CCLI (n= 245) and disabling claudication (n=155) groups. After a comparison of their demographic features, frequency of coexisting diseases and details of bypass procedures, the early and long-term results of leg arterial bypasses between 2 groups were also compared. The graft patency was determined by periodic measurements of the ankle brachial index and duplex scanning, and the patient survival was determined with the help of a governmental office database. The graft patency, patient survival and amputation-free survival rates were calculated using the Kaplan Meier method, and compared with Log rank tests. RESULTS: The demographic features and frequency of coexisting morbidity were not significantly different between the 2 groups, with the exception of a female preponderance in the CCLI group. Infrapopliteal bypasses were more commonly performed in the CCLI group 40 vs. 20%, P<.0005) and the primary graft patencies were significantly higher in the claudication group (at 3, 5 and 7 years; 90.2, 74.6 and 63.9% vs. 61.9, 58.0 and 50.7%, P<.0005) only after vein bypass. The patient survivals were also significantly longer in the claudication compared to the CCLI group (at 3, 5 and 7 years; 94.7, 74.8 and 68.5% vs. 51.0, 30.8 and 20.5%, P<.0005). CONCLUSION: Despite there being no significant difference in the age or frequencies of coexisting morbidity, a significantly longer patient survival was found in the claudication group. Considering the longer vein graft patency of the claudication group was inconclusive in this retrospective study, an infrainguinal bypass, with an autologous vein, should be considered as a primary treatment for better long-term results in selected claudication patients.