Histological Differences between Vascular and Mucosal Hemorrhoids

PURPOSE: The aim of this study is to compare and analyze the histological differences between vascular and mucosal hemorrhoids, two structurally different types of hemorrhoids. METHODS: Internal hemorrhoidal tissue samples were fixed in 10% Formalin solution, and coronal sections included 10-mm proximal and 5-mm distal of the dentate line. Routine Masson-Trichrome and H&E were performed to evaluate the thickness of the mucosa and changes in the structure and the densities of submucosal vessels, connective tissue, and muscle. RESULTS: Compared with the corresponding tissues of mucosal hemorrhoids, the submucosal connective tissue and perivascular connective tissue of vascular hemorrhoids showed a loosened density, severe fragmentation, and an irregular arrangement. The submucosal vascular dilatation was more frequent and more severe in vascular hemorrhoids, but the number of vessels between both types of hemorrhoids did not show much difference. Hypertrophy and regular arrangement of the submucosal muscles were observed more frequently in the mucosal than in the vascular hemorrhoids. CONCLUSION: Compared to mucosal hemorrhoids, vascular hemorrhoids showed augmented damage in submucosal connective tissue and intense dilatation of vessels with a thinner mucosa. On the other hand, compared to vascular hemorrhoids, mucosal hemorrhoids showed hypertrophy of submucosal muscle and relatively minor alterations in vessels with a thicker mucosa. These histological differences may provide the basis for different etiologies between vascular and mucosal hemorrhoids.

Prognostic Factors and Survival Rate of Pancreatic Adenocarcinoma after Curative Surgery

PURPOSE: This retrospective study aimed to identify the outcomes of resected pancreatic cancers and determine the prognostic factors for long term survival based on a single hospital experience. METHODS: Between January 1990 and February 2004, patients with a pancreatic ductal adenocarcinoma who had undergone resection at Severance hospital, Yonsei University, were analyzed retrospectively. RESULTS: Ninety-five patients underwent resection with curative intents for pancreatic adenocarcinoma. Sixty-seven (70.5%) patients had pancreatic head cancer, 27 (28.4%) cancers in the body and tail of the pancreas, and 1 had a diffusely spread type of pancreatic cancer. Procedures employed include Whipple resection (35.8%), pylorus preserving pancreaticoduodenectomy (33.7%), distal pancreatectomy (28.4%), and total pancreatectomy (2.1%). Stage Ia, Ib, IIa, IIb and III were present in 3.2, 4.2, 45.3, 44.2, and 3.2%, respectiely. The overall 5-year survival rate was 20.7%. Only low tumor stage was a significant predictive predictor of survival in univariate analysis (P<0.05). CONCLUSION: Long-term survival in patients with pancreatic adenocarcinoma is determined by the disease stage. This result suggests that early detection would be necessary to improve the survival of patients with pancreatic adenocarcinoma.

Thoracoscopic Splanchnicectomy for Intractable Abdominal Pain

PURPOSE: In patient with intractable abdominal pain due to cancer, with respect to the quality of life, it is often insufficient to relieve pain with the use of analgesics. The development of laparoscopic surgery has made a thoracoscopic splanchnicectomy possible, but the results by using several different methods have varied between different authors. Herein, we introduce a modified method of thoracoscopic splanchnicectomy on the basis of anatomical background from cadaver dissection. METHODS: Sixteen thoracoscopic splanchnicectomies were performed, with the Numerical rating scale (NRS) used for the assessment of pain. The procedure was performed, under general anesthesia, using a double lumen catheter to deflate the lung on the operation side with the patient in the lateral decubitus position. Openings were made in the 7th intercostal space at the postaxillary line for a 12 mm trocar and in the 4th and 5th intercostals spaces for 5 and 2 mm trocars, respectively. The terminal branch of the greater splanchnic nerve ends In 5th intercostal space. Six or seven branches of the splanchnic nerve were cut, dissected downward to just above the diaphragm and then cut. The sympathetic trunk was also cut in this level if the patient suffered from constipation. RESULTS: A splanchicectomy appeared to result in significant reduction of abdominal pain in all cases. The average reduction in the pain score was 78%. There were no postoperative complications. CONCLUSION: A thoracoscopic splanchnicectomy is the treatment of choice for intractable intraabdominal cancer pain, helping with drug cessation or the reduction and recovery of daily activity in most patients.

The Results of Renal Transplantation after Lymphocyte Cross-match Negative Conversion by Combination Therapy with Plasmapheresis, Intravenous Gamma Globulin and Potent Immunosuppresants in Patients with Positive LCM / 대한이식학회지

PURPOSE: It is well-known that kidney transplantation cannot be done if recipient has circulating antibodies showing positive lymphocyte cross-match (LCX) to organ donor. In the United States and European countries, the incidence of positive LCX to cadaveric donors in patients who are on the waiting list is up to 20~40%. Unfortunately, these patients also show high rate of positive LCX to live donors when they have donor candidates in their family members and have to be on dialysis until compatible donor comes up. Recently, Eugene J Schweitzer and his associates at the University of Maryland used the combination therapy with plasmapheresis, intravenous gamma globulin and potent immunosuppression to induce negative conversion of LCX in patients who were LCX positive to their living donors and reported the good results after the trial. We did the combination therapy in patients who had positive LCX to their living donors and reported the results. METHODS: Seven patients, four women and three men who showed positive LCX to their living donors, underwent the conversion trials between January 1 and July 31, 2002. The mean age of patients was 43.86 (35~60) and the duration of dialyses varies from 9 to 120 months. We used combination therapy with plasmapheresis, intravenous gamma globulin injection, tacrolimus, mycophenolate mofetil (MMF) and steroids. Plasmapheresis had been done on every other day up to 6 times to induce negative conversion of LCX. If patient continue to show positive LCX to donor after 6 times of plasmapheresis, we stopped the therapy. The numbers of plasmapheresis varies from two to six times. Kidney transplantations were preformed immediately after negative conversion of LCX as a semi-elective procedures. Five to ten day courses of ATG (or OKT3) were used as an induction immunosuppression after transplantation and tacrolimus, MMF, and steroids were used as a maintenance immunosuppression. RESULTS: We could achieve negative conversion of LCX in six out of seven patients, and kidney transplantations were performed in these 6 patients successfully. There was no hyperacute rejection during the operations, but three patients developed acute rejection episodes during their early postoperative periods. Steroid pulse therapies were used as a primary therapy to treat acute rejection and all three patients showed complete recovery of their graft function after the treatments. Baseline serum creatinine level varies from 1.0 mg/dl to 1.9 mg/dl with 3 to 6 months follow-up periods after transplantations. We could not induce negative conversion in one patient and he remained on hemodialysis. CONCLUSION: We did successful kidney transplantations in six patients who achieved negative conversion of LCX to their donors after the combination therapy with plasmapheresis and potent immunosuppression. All patients showed excellent graft function since their operations and did not have any significant complications except three reversible acute rejection episodes. According to the results, although it is preliminary, we recommend the use of the combination therapy in patient who has LCX positive living donor. Further long-term study with more numbers of patients is needed for the evaluation of the efficacy of this trial.

BK Virus Induced Interstitial Nephritis in Renal Transplants: Diagnosis, Treatment and Prognosis / 대한이식학회지

PURPOSE: It is difficult to differentiate BKV nephritis (BKVN) from acute rejection. We diagnosed 8 cases of BKVN in renal transplantation recipients. Herein, we report the clinical nature of BKVN in terms of diagnosis, treatment and prognosis. METHODS: Between June 1998 and September 2002, 8 cases of BKVN were confirmed by H and E stain, immunohistochemical study against SV40, and electron microscopy in renal allograft biopsy samples. Additionally, between April and September 2002, we obtained urine sample for urine cytology from 49 potential donors, 40 end-stage renal failure patients awaiting renal transplantation, and 140 renal transplant recipients who were hospitalized with variable causes and 32 renal transplants as a routine follow-up. RESULTS: In 7 male and 1 female patients, BKVN was diagnosed mean of 20.4 months after transplantation. The kind of immunosuppression they had been on were mycophenolate mofetil (6/8), azathioprine (1/8), cyclosporin (4/8), tacrolimus (4/8). Range of whole blood levels of cyclosporine and tacrolimus at the time of diagnosis of BKVN were 187.5~252.5 ng/ml and 11~16.5 ng/ml, respectively. Four patients had treated acute rejection episode, and in 6 patients, pathologically proven acute rejection was found concomitantly with BKVN. After reduction of net immunosuppression (discontinuation of MMF and AZA, dose reduction of cyclosporine or tacrolimus, and switch from tacrolimus to cyclosporine), renal function of 3 patients was fully recovered. However, 4 patients with delayed diagnosis lost grafts. In urine cytologic examination, 15 patients (one in end-stage renal failure patient, 10 in renal transplant recipients with elevated serum creatinine, 2 in patients with other infection, and 2 in other situation) were found to secrete decoy cell through urine. CONCLUSION: BKVN should be considered in the differential diagnosis of renal allograft dysfunction. Early diagnosis of BKVN and reduction of net immunosuppression can rescue the grafts. Monitoring of decoy cell in the urine cytology is a simple diagnostic tool both for screening of graft with dysfunction and follow-up of grafts after diagnosis and treatment of BKVN.