Surgical management of adult choledochal cysts.

OBJECTIVES: Results of the surgical management of 17 choledochal cysts in adults at the Department of Surgery, Siriraj Hospital, Mahidol University, are presented MATERIAL AND METHOD: All the patients who underwent diagnosis and were surgically managed during the period between October 1990 and January 1999 were analyzed retrospectively. Cysts were classified anatomically according to the descriptions of Todani et al. The authors assessed the clinical features, operative procedure and outcome of the patients. RESULTS: There were 15 females and 2 males, with ages ranging from 16-45 years. Only 2 patients (11.8%) had the clinical triad: jaundice, abdominal pain and mass. Clinical pancreatitis was presented in 3 patients (17.6%). There were 10 type 1 (58.8%), 6 type IVa (35.3%) and one type V (5.9%) according to Todanis classification. Cholangiocarcinoma was found in one patient (5.9%). Extrahepatic cyst excision with a Roux-en-Y hepatico-jejunostomy was performed on 16 patients with type I or IVa cysts (94.1%). There were no surgical deaths or complications. Ten survivors are well. The authors lost contact with 6 patients during follow-up (35.2%). The median follow up was 3.2 years. The patient with cholangiocarcinoma died 2 years after treatment. CONCLUSION: This experience recommends total extra-hepatic cyst excision with Roux-en-Y hepaticojejunostomy as the treatment of choice for adult choledochal cyst type I and IV to eliminate the risk of recurrent cholangitis and malignancy.

Pancreatic adenocarcinoma: A 10-year-experience in Siriraj Hospital.

Carcinoma of the pancreas is not a common disease in Thailand, and is not included in the list of the 10 leading cancers in the country. One hundred and sixty-eight patients with this cancer were treated at the Siriraj Hospital during January 1987 till December 1996. Ninety-five patients (56.6%) were male and the male to female ratio was 1.3 : 1. The mean age was 61.9 years (range 27-86 years). Back pain and/or abdominal pain was the most common presenting symptom (59.5%), followed by anorexia and weight loss (56.6%). Jaundice was found in 88 patients (52.4%), and the mean serum billirubin among these icteric patients was 18.2 mg/dl. Eighty-two per cent of the patients had tumour at the head of pancreas, and nearly 60% of the patients already had metastatic disease at the time of operation. Histological confirmation was obtained in only 49 patients (29.2%). Majority of the patients underwent some forms of palliative surgery, and the resectability rate was approximately 14%. Because of the low resectability rate and high incidence of metastasis, pancreatic cancer is still a disease with poor prognosis.

Adrenal cortical carcinoma presenting as liver abscess: Report of a case.

A 60 year-old woman presented with clinical signs and symptoms of liver abscess. She had a cystic mass on the right lobe of the liver. Liver needle aspiration was performed and anchovy-paste like material was obtained. She recovered after treatment with oral metronidazole even though investigations for Entamoeba histolytica were negative. Two and a half years later, she returned with the same clinical signs and symptoms. Liver needle aspirations were performed many times and the same anchovy-paste like material was obtained but no definite diagnosis was made. Finally, laparotomy showed an extrahepatic retroperitoneal cystic mass of the right adrenal gland adjacent to the liver. Intravenous pyelography, adrenal CT scan and adrenal angiography were performed. The tumor was removed and the final histopathological diagnosis was adrenal cortical carcinoma.

DNA analysis of hepatocellular carcinoma.

Specimens from 13 cases of resectable hepatocellular carcinoma (HCC) were studied using flow cytometry. The correlation between histological features and ploidy distribution showed those with higher histological grading (HCC grade III or IV) to display an increased tendency towards aneuploidy and polyploidy than those with low grade (HCC grade II and clear cell type of HCC). Along with the tumor’s increased tendency towards aneuploidy and polyploidy, the percent DNA distribution in the S- and G2 – phase was also found increased. The same applied to the DNA index, we also detected a strong correlation between proliferation index and ploidy pattern of HCC.

Aggressive treatment of malignant duodenocolic fistula: A case report.

Malignant duodenocolic fistula is a rare complication of gastrointestinal malignancy for which carcinoma of the ascending colon is the most common cause. A case of 39-year-old female with duodenocolic fistula caused by adenocarcinoma of the hepatic flexure was reported. Successful surgical treatment was achieved by right hemicolectomy en bloc with proximal pancreatoduodenectomy. The patient received a full course of adjuvant chemotherapy and she is now completely free of symptom and without any evidence of recurrent disease, 2 years after the resection.

Immunohistochemical and ultrastructural studies of myofibroblasts in hepatocellular carcinoma.

Sections from 13 hepatocellular carcinomas (HCCs) were examined to determine the myofibroblasts (MFBs) in tumour fibrous stroma and cirrhotic fibrous stroma, using monoclonal antibodies to specific actins HHF-35, 1A4 and sarcomeric actin. Histological grading of tumours with the expression of a labelling index using monoclonal antibodies to proliferative cell nuclear antigen (PC-10) were correlated with the amount of MFBs. The results showed a statistically significant increase in the amount of MFBs in tumour fibrous stroma. However, no significant correlation was found between the amount of MFBs with histological grading or the labelling index. However, a good correlation with statistically significant differences between the histological grading of HCC with the labelling index was shown. In conclusion, MFBs found in the tumour fibrous septa of HCC were a response by the stromal reaction or a desmoplastic reaction intended to limit the tumour size by contraction.