Usefulness of Artificial Jump Graft to Portal Vein Thrombosis in Deceased Donor Liver Transplantation

Severe portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to high associated risks and morbidity. Meanwhile, improvement in operative techniques, resulting in higher success rates has removed PVT from the list of contraindications in deceased donor liver transplantation (DDLT). In this report, we describe a surgical technique for DDLT using polytetrafluoroethylene graft from the inferior mesenteric vein for portal inflow in patient with portomesenteric thrombosis.

Mesoesophagus and other fascial structures of the abdominal and lower thoracic esophagus: a histological study using human embryos and fetuses / 대한해부학회지

A term "mesoesophagus" has been often used by surgeons, but the morphology was not described well. To better understand the structures attaching the human abdominal and lower thoracic esophagus to the body wall, we examined serial or semiserial sections from 10 embryos and 9 fetuses. The esophagus was initially embedded in a large posterior mesenchymal tissue, which included the vertebral column and aorta. Below the tracheal bifurcation at the fifth week, the esophagus formed a mesentery-like structure, which we call the "mesoesophagus," that was sculpted by the enlarging lungs and pleural cavity. The pneumatoenteric recess of the pleuroperitoneal canal was observed in the lowest part of the mesoesophagus. At the seventh week, the mesoesophagus was divided into the upper long and lower short parts by the diaphragm. Near the esophageal hiatus, the pleural cavity provided 1 or 2 recesses in the upper side, while the fetal adrenal gland in the left side was attached to the lower side of the mesoesophagus. At the 10th and 18th week, the mesoesophagus remained along the lower thoracic esophagus, but the abdominal esophagus attached to the diaphragm instead of to the left adrenal. The mesoesophagus did not contain any blood vessels from the aorta and to the azygos vein. The posterior attachment of the abdominal esophagus seemed to develop to the major part of the phrenoesophageal membrane with modification from the increased mass of the left fetal adrenal. After postnatal degeneration of the fetal adrenal, the abdominal esophagus might again obtain a mesentery. Consequently, the mesoesophagus seemed to correspond to a small area containing the pulmonary ligament and aorta in adults.

Breakthrough Urinary Tract Infection: A Clinical Study of Experience of a Single Center

PURPOSE: It has been a common medical practice to use prophylactic antibiotics to prevent recurrent urinary tract infections (UTI) in high risk situations such as urinary tract obstruction, vesicoureteral reflux, neurogenic bladder, or urinary stones. But sometimes, we meet difficult situation of breakthrough infections (BI) which might cause new or progressive renal scarring. The clinical characteristics of children contracting breakthrough UTI experienced in a single center were studied. METHODS: The study was done retrospectively through medical records of 150 pediatric patients who had been cared in pediatric and urologic clinics of Pusan National University Hospital from Jan. 2001 till June 2006 and had prophylactic antibiotics to prevent recurrent UTI. RESULTS: The starting age of prophylactic antibiotics of 150 patient was 1-76 months, and median age was 5 months. The BI developed 61 times in 43 patients (28.7%), 1.5 times per 100 patient-months. The BI occurred more frequently in patients with higher grade of VUR, and in the cases with abnormal DMSA scan. Co-trimoxazole was more effective than 2nd and 3rd generation cephalosporins to prevent UTI. The distribution of causative organisms was more diverse than usual UTI. The causative organisms were sensitive to the antibiotics used for prophylaxis in 29.5%, and resistant in 59.1%. After experience of BI, 40 percents of patients went to the surgical treatment including endoscopic injection of Deflux, 35% to new antibiotics for prophylaxis, 26% remain on the same antibiotics as the previous one. CONCLUSION: Based on our study results, preexisting renal scar might be one of the factors which should be considered in favor of early surgical interventions of VUR. Poor compliance and wrong selection of antibiotics such as cephalosporins are important underlying causes of breakthrough UTIs.

A Study of Factors Related to Recurrent Stones after Surgical Treatment of Hepatolithiasis

PURPOSE: Hepatolithiasis, which is located in proximal sites of the common hepatic bile duct, is a common disease in Korea. Hepatectomy is a more effective treatment for achieving complete removal of stones and biliary strictures. However, the incidence of remnant or recurrent stones is still high. The aim of this study was to evaluate factors related to the recurrence of stones after surgical treatment of hepatolithiasis. METHODS: From February 1999 to February 2009, we conducted a retrospective study of case records of 208 patients who underwent operations for hepatolithiasis at the Department of Surgery, Chonbuk National University Hospital. RESULTS: The male to female ratio was 1:1.97; the mean age was 55 years. Hepatolithiasis was located in the left intrahepatic duct in 69.7% of patients, in the right intrahepatic duct in 14.4%, and in both ducts in 15.9%. Operative procedures were as follows: left lateral sectionectomy in 109 (52.4%), left hemihepatectomy in 26 (12.5%), posterior sectionectomy in 5 (2.4%), a right hemihepatectomy in 8 (3.8%), a choledocholithotomy in 38 (8.6%), a choledocho-enterostomy in 18 (8.6%), a choledochotomy in 1 (0.46%), a choledochal cyst excision in 1 (0.46%), and no primary operation in 2 (0.9%). Complete stone clearance was achieved in 76% after operative treatment. Biliary stricture was significantly associated with remnant stones (p=0.000). In addition, the incidence of recurrent stones was 15.3%. Recurrent stones were associated with biliary stricture (p=0.001), hepatectomy (p=0.003), and bilateral location of stones (p=0.016). During the follow up period, the mortality rate related to operative treatment was 0.96%. CONCLUSION: Biliary stricture, hepatectomy, and bilateral location of stones are associated with recurrent hepatolithiasis after surgery.

Apolipoprotein A-1 as a Factor to Assess Recovery of the Liver Function after Hepatectomy and Liver Transplantation

PURPOSE: The aim of this study is to determine whether the serum apolipoprotein A1(apoA1) level, as measured at different time points after hepatectomy and liver transplantation, can predict the synthesis ability of the liver and the nutritional status. We also investigated the usefulness of regions of interest(ROIs) as an indicator of the recovery status of the liver after liver transplantation. METHODS: 93 patients (21: laparoscopic cholecystectomy, 53: partial hepatectomy, 19: liver transplantation) were operated on under general anesthesia. The serum levels of apoA1, prealbumin, albumin, aspartate aminotransferase and alanine aminotransferase and the prothrombin time were measured at pre- and post-operation. The liver conditions were a normal liver (50 cases), hepatitis (16 cases) and liver cirrhosis (28 cases). The mean hepatic attenuation was calculated by averaging the ROI values that were obtained at different hepatic segments. RESULTS: The serum apoA1 level was minimally changed during the perioperative period in the laparoscopic cholecystectomy group. Yet in most cases, the serum apoA1 level after partial hepatectomy and liver transplantation was decreased on postoperative days (PODs) 1 and 7, but it nearly recovered to the preoperative level on POD 30. There were significant differences in the values of apoA1 between the normal liver and co-existent liver disease at the various time points. The ROI value after transplantation gradually increased and it reached a normal level by POD 30. CONCLUSION: The serum apoA1 level can be an indicator of liver's ability to synthesize protein and the nutritional status after partial hepatectomy. In addition, ROIs of the unenhanced CT image can reflect the recovery status of the liver after transplantation.

Analysis of 1,000 Cases of Abdominal UltrasonographyPerformed by a Pediatrician / 대한소아소화기영양학회지

PURPOSE: The aim of this study was to evaluate the clinical usefulness of ultrasound examination of children performed by a pediatrician. METHODS: One thousand children who presented with symptoms of a gastrointestinal disorder and underwent abdominal ultrasound evaluation in the Department of Pediatrics, between January 2003 and June 2006, were included in this study. We analyzed the patient's medical records and ultrasound results retrospectively. RESULTS: Among the 1,000 patients, 58.4% were male and 41.6% were female. The mean age of the patients was 4.7+/-4.0 years. The main reasons for ultrasound were abdominal pain (43.9%), vomiting (17.3%), elevated liver enzymes (11.8%), and jaundice (9.8%). Abnormal ultrasound findings were present in 57.9% of cases. The major abnormal findings were mesenteric lymphadenitis (29.2%), fatty liver (12.1%), hepatitis (6.4%), hepatosplenomegaly (6.2%), and acute appendicitis (4.8%). The time interval between the initial medical evaluation and the ultrasound evaluation was within 24 hours in most cases (78.5%). The main findings in children with abdominal pain were mesenteric lymphadenitis (32.6%), fatty liver (5.9%), intussusception (2.7%), and acute appendicitis (2.7%). The main findings in children with vomiting were mesenteric lymphadenitis (12.7%), hypertrophic pyloric stenosis (10.4%), and acute appendicitis (3.5%). The major ultrasound findings in children with urinary tract diseases were hydronephrosis (45.4%), urolithiasis (21.5%) and cystic renal disease (18.1%). CONCLUSION: Ultrasound examination played an important role as a non-invasive and prompt screening examination for detection of abdominal diseases. Ultrasound was an important tool for pediatricians to determine timely information for patient management.

The Long Term Follow up Study of Newborns with TSH Elevation without Low T4 / 대한소아내분비학회지

PURPOSE: In this study, we aimed to find useful methods for diagnosis and treatment of hyperthyrotropinemia in neonates showing normal T4 and elevated TSH levels in neonatal screening test. METHODS: We retrospectively reviewed the medical records of 16 male and 26 female neonates whose T4 were normal and TSH were elevated in the neonatal screening test from 1994 to 2006. The clinical data, including perinatal history, thyroid function test and radionuclide scannig was analysed. RESULTS: Of the forty-two patients, male was 38.1% and female was 61.9%. Mean T4 and TSH level were 8.61+/-1.55 ug/dL, 49.66+/-36.56 uU/mL respectively. At the recheck, when recalled, TSH were normalized in 8 patients (19.1%), still elevated in 34 patients (80.9%). (99m)TC thyroid scan was performed in 36 cases. The results were normal in 18 cases (50.0%), diffuse enlargement in 11 cases (30.5%), ectopic thyroid, poor visualization, hypoplasia respectly in 11.2%, 5.5%, 2.8%. Fourteen patients (33.3%) had histories of povidone use for umbilical care. Of the 42 patients, 27 (64.0%) cases were treated by thyroid hormone, 15 cases (36.0%) were followed up without treatment. Among 15 cases without treatment, 8 patients showed TSH normalization at 1.5 months, 5 patients at 3 months, one patient at 6 months and one patient at 9 months. Among 27 cases with treatment, 18 cases (66.7%) are being treated, 5 cases (18.6%) are being treated more than 3 years, the 3-years treatment was ended in 6 cases (22.2%), follow up loss was 3 cases (11.1%). CONCLUSION: At long term follow up, TSH was normalized in many patients who showed normal T4 and elevated TSH levels in neonatal screening test. Imaging study such as (99m)TC thyroid scanning was helpful to decide whether to treat with thyroid hormone replacement. To predict longer term prognosis of cases without thyroid hormone replacement, long term follow up of large number of patients is needed.