Staged partial hepatectomy versus transarterial chemoembolization for the treatment of spontaneous hepatocellular carcinoma rupture: a multicenter analysis in Korea

PURPOSE: The aim of this study was to identify the prognostic factors and compare the long-term outcomes of staged hepatectomy and transarterial chemoembolization (TACE) for patients with spontaneous rupture of hepatocellular carcinoma (HCC). METHODS: This study is a multicenter, retrospective analysis of patients with newly diagnosed ruptured HCC. To compare overall survival between staged hepatectomy group and TACE alone group, we performed propensity score-matching to adjust for significant differences in patient characteristics. To identify prognostic factors, the clinical characteristics at the time of diagnosis of tumor rupture were investigated using Cox-regression analysis. RESULTS: From 2000 to 2014, 172 consecutive patients with newly diagnosed ruptured HCC were treated in 6 Korean centers. One hundred seventeen patients with Child-Pugh class A disease were identified; of which 112 were initially treated with transcatheter arterial embolization (TAE) for hemostasis and five underwent emergency surgery for bleeder ligation. Of the 112 patients treated with TAE, 44 underwent staged hepatectomy, 61 received TACE alone, and 7 received conservative treatment after TAE. Those that underwent staged hepatectomy had significantly higher overall survival than those that underwent TACE alone before matching (P 1,200 mL, and tumor size >5 cm were associated with poor overall survival. CONCLUSION: Staged hepatectomy may offer better long-term survival than TACE alone for spontaneous rupture of HCC. Staged hepatectomy should be considered in spontaneous rupture of HCC with resectable tumor and preserved liver function.

Influencing factors on postoperative hospital stay after laparoscopic cholecystectomy

BACKGROUNDS/AIMS: Laparoscopic cholecystectomy can reduce postoperative pain and recovery time. However, some patients experience prolonged postoperative hospital stay. We aimed to identify factors influencing the postoperative hospital stay after laparoscopic cholecystectomy. METHODS: Patients (n=336) undergoing laparoscopic cholecystectomy for gallbladder pathology at 8 hospitals were enrolled and divided into 2 groups: 2 or less and more than 2 days postoperative stay. Perioperative factors and patient factors were retrospectively analyzed. RESULTS: The patient population median age was 52 years, and consisted of 32 emergency and 304 elective operations. A univariate analysis of perioperative factors revealed significant differences in operation time (p<0.001), perioperative transfusion (p=0.006), emergency operation (p<0.001), acute inflammation (p<0.001), and surgical site infection (p=0.041). A univariate analysis of patient factors revealed significant differences in age (p<0.001), gender (p=0.036), diabetes mellitus (p=0.011), preoperative albumin level (p=0.024), smoking (p=0.010), and American Society of Anesthesiologists score (p=0.003). In a multivariate analysis, operation time (p<0.001), emergency operation (p<0.001), age (p=0.014), and smoking (p=0.022) were identified as independent factors influencing length of postoperative hospital stay. CONCLUSIONS: Operation time, emergency operation, patient age, and smoking influenced the postoperative hospital stay and should be the focus of efforts to reduce hospital stay after laparoscopic cholecystectomy.

A survey of attitudes to clinical practice guidelines in general and adherence of the Korea practical guidelines for management of gallbladder polyp: a survey among private clinicians in Korea

BACKGROUNDS/AIMS: While clinical practice guidelines are effective tools for improving the quality of patient care and provide specific recommendations for daily practice, the usage of them have been often suboptimal. Therefore, evaluation of physician attitude to guidelines is an important initial step in improving guideline adherence levels. The aim of this study was to survey the attitude on general guidelines and adherence with the Korea Practical Guidelines for gallbladder (GB) polyp two year after their publication and distribution among Korean private clinicians. METHODS: To evaluate the survey, questionnaires were sent with a stamp on an addressed envelope to 3,256 private clinicians who were registered at the Seoul Medical Association in April, 2010. From the 3,256 questionnaires, 376 clinicians (11.5%) responded to the survey. RESULTS: A total of 91.0% responders agreed to the statement that general guidelines were useful tools for improving patient care and quality of care. One hundred one responders (26.9%) stated that they were aware of the Korea GB polyp guidelines while 73 physicians (72.3%) founded the guideline had changed their practice and user-friendly. Most of physicians (73.4%) agreed to practical procedures recommended by guidelines. CONCLUSIONS: Korean primary physicians were generally positive to the practical guidelines, as propagation of the guideline among primary physicians may improve adherence to guideline and patients care for GB polyps.

Does international study group on pancreatic fistula (ISGPF) classification need modification after distal pancreatectomy?

BACKGROUNDS/AIMS: Few reports have validated the clinical postoperative pancreatic fistula (PF) after distal pancreatectomy. The study intended to validate the predictability for clinical PF of drain amylase and lipase and to find out more appropriate postoperative day (POD) for diagnostic criterion of PF. METHODS: A total of 154 patients underwent distal pancreatectomy. We used the clinical database registry system of the Gangnam Severance Hospital and Severance Hospital, Yonsei University Health System for these analyses. The receiver operating characteristic curve of the drain amylase or lipase concentration on each day was used to predict clinical PF (International Study Group on Pancreatic Fistula [ISGPF] grade B or C) and areas under the curves (AUC) were compared. RESULTS: Amylase and lipase AUC values poorly predicted clinical PF before POD 3 and, gradually increased until POD 5 and became well correlated with clinical PF (ISGPF grade B or C). In contrast, the prediction of clinical PF using drain lipase did not differ from that using drain amylase. The drain amylase concentration on POD 6 was most precisely correlated with clinical PF. CONCLUSIONS: Clinical PF prediction was validated by using drain amylase and lipase concentrations, in which drain amylase assessment at POD 6 appeared to be an appropriate diagnostic criterion of PF after distal pancreatectomy. We suggest some modification of ISGPF definition, especially for distal pancreatectomy.

Does Liver Resection Provide Long-Term Survival Benefits for Breast Cancer Patients with Liver Metastasis? A Single Hospital Experience

PURPOSE: Liver resection with colorectal liver metastasis widely accepted and has been considered safe and effective therapeutic option. However, the role of liver resection in breast cancer with liver metastasis is still controversial. Therefore, we reviewed the outcome of liver resection in breast cancer patients with liver metastases in a single hospital experiences. MATERIALS AND METHODS: Between January 1991 and December 2006, 2176 patients underwent breast cancer surgery in Gangnam Severance Hospital. Among these patients, 110 cases of liver metastases were observed during follow-up and 13 of these patients received liver resection with potential feasibility to achieve an R0 resection. RESULTS: The median time interval between initial breast cancer and detection of liver metastasis was 62.5 months (range, 13-121 months). The 1-year and 3-year overall survival rates of the 13 patients with liver resection were 83.1% and 49.2%, respectively. The 1-year and 3-year overall survival rates of patients without extrahepatic metastasis were 83.3% and 66.7% and those of patients with extrahepatic metastasis were 80.0% and 0.0%, respectively (p=0.001). CONCLUSION: Liver resection for metastatic breast cancer results in improved patient survival, particularly in patients with solitary liver metastasis and good general condition.

A model for predicting pancreatic leakage after pancreaticoduodenectomy based on the international study group of pancreatic surgery classification

BACKGROUNDS/AIMS: With recent advances in pancreatic surgery, pancreaticoduodenectomy (PD) has become increasingly safe. However, pancreatic leakage is still one of the leading postoperative complications. An accurate prediction model for pancreatic leakage after PD can be helpful for pancreas surgeons. The aim of this study was to provide a new model that was simple and useful with high accuracy for predicting pancreatic leakage after PD. METHODS: To predict the occurrence of pancreatic leakage, several factors were selected using bivariate analysis and univariate logistic regression analysis. The final model was developed using multivariable logistic regression analysis in the model construction data set. RESULTS: Overall, 41 of 100 patients had pancreatic leakage by the International Study Group on Pancreatic Fistula (ISGPF) criteria. Soft pancreatic parenchyma, small pancreatic duct diameter (< or =3 mm), and combined resection of SMV and portal vein were independently predictive of pancreatic leakage. The risk score (R) for individual patients can be calculated by combining the 3 prognostic values with the regression test: R=0.5986+(0.5533 x pancreatic parenchyma)+(0.5448 x pancreatic duct diameter)+(0.8453 x combined resection). The overall predictive accuracy of the model, as measured by the receiver operating characteristic (ROC) curve, was 0.728. CONCLUSIONS: Although continued refinements and improvements in the model are needed, the present model may assist pancreatic surgeons in the prediction of pancreatic leakage after PD.

Prognostic Significance of Angiogenesis by Chalkley Counting in Node Negative Cancer of the Ampulla of Vater

Angiogenesis is essential for tumor growth and metastasis. Currently, the Chalkley assay with CD34 immunostaining is the proposed standard method for angiogenesis quantification in solid tumor sections. The purpose of this study was to evaluate the expression of CD34 and its prognostic significance using the Chalkley method in node negative carcinoma of the ampulla of Vater. Between January 1997 and December 2006, 56 node negative patients who had curative resection for carcinoma of the ampulla of Vater were retrospectively reviewed. The Chalkley count was expressed as the mean value of the three counts for each tumor and further divided into two groups according to the mean value of the Chalkley count: low or = 4. The mean Chalkley count value was 4.0 (+/- 3.1). In the low Chalkley group, the 1- and 3-yr recurrence rates were 18.3%, 47.6% respectively; in the high Chalkley group, the 1- and 3-yr recurrence rates were 26.5% and 60.6% respectively. Only high Chalkley count had statistical significance as a factor in recurrence of node negative ampulla of Vater carcinoma. Assessment of angiogenesis may have an important role in the prognostic evaluation of node negative cancer of the ampulla of Vater.

Comparison of Efficacy of Enucleation and Pancreaticoduodenectomy for Small (<3 cm) Branch Duct Type Intraductal Papillary Mucinous Neoplasm Located at the Head of Pancreas and the Uncinate Process

PURPOSE: Accurate indications and the extent of surgery for branch duct intraductal papillary mucinous neoplasm (IPMN) of the pancreas are still debatable. In particular, small tumor is located at the head portion of pancreas presents a dilemma. The purpose of this study is to compare the efficacy of enucleation (EN) with that of pancreaticoduodenectomy (PD) in patients with small (2 cm

Postoperative Nutritional Effects of Early Enteral Feeding Compared with Total Parental Nutrition in Pancreaticoduodectomy Patients: A Prosepective, Randomized Study

The benefits of early enteral feeding (EEN) have been demonstrated in gastrointestinal surgery. But, the impact of EEN has not been elucidated yet. We assessed the postoperative nutritional status of patients who had undergone pancreaticoduodenectomy (PD) according to the postoperative nutritional method and compared the clinical outcomes of two methods. A prospective randomized trial was undertaken following PD. Patients were randomly divided into two groups; the EEN group received the postoperative enteral feed and the control group received the postoperative total parenteral nutrition (TPN) management. Thirty-eight patients were included in our analyses. The first day of bowel movement and time to take a normal soft diet was significantly shorter in EEN group than in TPN group. Prealbumin and transferrin were significantly reduced on post-operative day (POD) 7 and were slowly recovered until POD 90 in the TPN group than in the EEN group. EEN group rapidly recovered weight after POD 21 whereas it was gradually decreased in TPN group until POD 90. EEN after PD is associated with preservation of weight compared with TPN and impact on recovery of digestive function after PD.

S-plasty for pilonidal disease: modified primary closure reducing tension / 대한외과학회지

PURPOSE: S-plasty for pilonidal disease reduces the tension on the midline by distributing it diagonally and flattening the natal cleft. The aim of this study was to evaluate the outcomes of S-plasty on simple midline primary closure and the clinical features of pilonidal patients in a low incidence country. METHODS: S-plasty was applied on 17 patients from July 2008 to October 2010. Data of these patients were collected with computerized prospective database forms during a perioperative period and via telephone interview for follow-up. Surgical site infection (SSI) was defined according to the Center for Disease Control guidelines. The severity of surgical site infection was graded. RESULTS: All patients were treated with primary S-plasty. Two patients (11.7%) developed low grade SSI. The average healing time after S-plasty was 18.1 days. No recurrences were observed. The mean follow-up period was 13.5 months (range, 6 to 33 months). CONCLUSION: We have shown that primary S-plasty for pilonidal disease is simple, and its surgical outcomes are compatible to the results of other surgical treatments. We present primary S-plasty as a feasible treatment option in a low incidence country.

Repair of Large Spinal Soft Tissue Defect Resulting from Spinal Tuberculosis Using Bilateral Latissimus Dorsi Musculocutaneous Advancement Flap: A Case Report

PURPOSE: Since spinal tuberculosis is increasing in prevalence, it appears that a repair of spinal soft tissue defect as a complication of spinal tuberculosis can be a meaningful work. We report this convenient and practical reconstructive surgery which use bilateral latissimus dorsi musculocutaneous advancement flap. METHODS: Before the operation, 13x9.5cm sized skin and soft tissue defect was located on the dorsal part of a patient from T11 to L3. And dura was exposed on L2. Under the general endotrachel anesthesia, the patient was placed in prone position. After massive saline irrigation, dissection of the bilateral latissimus dorsi musculocutaneous flaps was begun just upper to the paraspinous muscles (at T11 level) by seperating the paraspinous muscles from overlying latissimus dorsi muscles. The plane between the paraspinous muscles fascia and the posterior edge of the latissimus dorsi muscle was ill-defined in the area of deformity, but it could be identified to find attachment of thoracolumbar fascia. The seperation between latissimus dorsi and external oblique muscle was identified, and submuscular plane of dissection was developed between the two muscles. The detachment from thoracolumbar fascia was done. These dissections was facilitated to advance the flap. The posterior perforating vasculature of the latissimus dorsi muscle was divided when encountered approximately 6cm lateral to midline. Seperating the origin of the latissimus dorsi muscle from rib was done. The dissection was continued on the deep surface of the latissimus dorsi muscle until bilateral latissimus dorsi musculocutaneous flaps were enough to advance for closure. Once this dissection was completely bilateraly, the bipedicled erector spinae muscle was advanced to the midline and was repaired 3-0 nylon to cover the exposed vertebrae. And two musculocutaneous units were advanced to the midline for closure. Three 400cc hemovacs were inserted beneath bilateral latissimus dorsi musculocutaneous flaps and above exposed vertebra. The flap was sutured with 3-0 & 4-0 nylon & 4-0 vicryl. RESULTS: The patient was kept in prone and lateral position. Suture site was stitched out on POD14 without wound dehiscence. According to observative findings, suture site was stable on POD55 without wound problem. CONCLUSION: Bilateral latissimus dorsi musculocutaneous advancement flap was one of the useful methods in repairing of large spinal soft tissue defect resulting from spinal tuberculosis.

Renal Carcinoma Cell Metastasis into Pancreas : A Single Center Experience

INTRODUCTION: Renal cell carcinoma (RCC) is a relative rare tumor, accounting for approximately 3% of adult malignancies. Renal cell carcinoma has a high metastatic potential and is renowned for its ability to spread to almost any organ of the body. Pancreas is a rare site for metastasis from other primary cancers. Moreover, pancreatic metastasis is difficult to differentiate and may be misdiagnosed as a primary pancreatic cancer. The aim of this study was to review our cases of renal cell carcinoma that had metastasized to the pancreas after radical nephrectomy. METHODS: We did a retrospective review of the records of 4 patients with pathologically confirmed RCC that had metastasized to the pancreas after radical nephrectomy. RESULTS: Our group of 4 patients consisted of 2 men and 2 women. Their average age was 58.7 years (+/- 10.51 years). The locations within the pancreas were the head, in 2 (50.0%) and the body/tail in 2 (50.0%) patients. The pancreatic metastases were treated by pancreaticoduodenectomy in 2 patients, and by distal pancreatectomy in 2 patients. Median survival duration was 109.0 (+/- 67.3 months) "Median" is associated with an interquartile range (25% to 75%). The number 67.3 appears to be a standard deviation which is associated with the "mean". CONCLUSIONS: RCC is an unpredictable tumor that may result in a late metastasis even from an early stage. Aggressive surgical management of pancreatic lesions offers a chance of long-term survival.

Orbital Wall Reconstruction by Copying a Template(defect model) from the Facial CT in Blow-out Fracture

PURPOSE: Recently, orbital wall fracture is common injuries in the face. Facial CT is essential for the accurate diagnosis and appropriate treatment to reconstruct of the orbital wall. The objective of this study was to report the method for accurate measurement of area and shape of the bony defect in the blow-out fractures using facial CT in prior to surgery. METHODS: The authors experienced 46 cases of orbital wall fractures and examined for diplopia, sensory disturbance in the area of distribution of the infraorbital nerve, and enophthalmos in the preoperation and followed 1 months after surgery, from August 2007 to May 2008. Bony defect was predicted by measuring continuous defect size from 3mm interval facial CT. Copying from the defect model(template), we reconstructed orbital wall with resorbable sheet(Inion CPS(R), Inion Oy, Tampere, Finland). RESULTS: One months after surgery using this method, 26(100%) of the 26 patients improved in the diplopia and sensory disturbance in the area of distribution of the infraorbital nerve. Also 8(72.7%) of the 11 patients had enophthalmos took favorable turn. CONCLUSION: This accurate and time-saving method is practicable for determining the location, shape and size of the bony defect. Using this method, we can reconstruc

Orbital Wall Reconstruction by Copying a Template(defect model) from the Facial CT in Blow-out Fracture

PURPOSE: Recently, orbital wall fracture is common injuries in the face. Facial CT is essential for the accurate diagnosis and appropriate treatment to reconstruct of the orbital wall. The objective of this study was to report the method for accurate measurement of area and shape of the bony defect in the blow-out fractures using facial CT in prior to surgery. METHODS: The authors experienced 46 cases of orbital wall fractures and examined for diplopia, sensory disturbance in the area of distribution of the infraorbital nerve, and enophthalmos in the preoperation and followed 1 months after surgery, from August 2007 to May 2008. Bony defect was predicted by measuring continuous defect size from 3mm interval facial CT. Copying from the defect model(template), we reconstructed orbital wall with resorbable sheet(Inion CPS(R), Inion Oy, Tampere, Finland). RESULTS: One months after surgery using this method, 26(100%) of the 26 patients improved in the diplopia and sensory disturbance in the area of distribution of the infraorbital nerve. Also 8(72.7%) of the 11 patients had enophthalmos took favorable turn. CONCLUSION: This accurate and time-saving method is practicable for determining the location, shape and size of the bony defect. Using this method, we can reconstruc

Early Experiences of Robotic-assisted Laparoscopic Liver Resection

PURPOSE: The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentations. Robotic surgery for hepatic resection has not yet been extensively reported. PATIENTS and METHODS: Between March and May 2007, we performed 3 robot-assisted left lateral sectionectomies of the liver. Case 1 had a hepatocellular carcinoma (HCC), case 2 had colon cancer with liver metastasis, and case 3 had intrahepatic duct stones. RESULTS: All patients had successful operation and recovered without complications. Shorter length of hospital stays, earlier start of oral feeding and less amount of ascites were found. However, case 1 had recurrent HCC at 3 months after operation. CONCLUSION: Robotic-assisted liver surgery is still a new field in its developing stage. In patients with small malignant tumors and benign liver diseases, robotic-assisted laparoscopic resection is feasible and safe. Through experience, the use of robotics is expected to increase in the treatment of benign diseases and malignant neoplsms. However, careful patient selection is important and long-term outcomes need to be evaluated.

Initial Experience with Laparoscopic and DaVinci Robotic-assisted Liver Resection

PURPOSE: Although laparoscopic surgery has become more popular, its technical difficulties have limited the applications of this technique to liver surgery. We report here on our experience with liver resection with perfoming laparoscopic assisted and DaVinci robot assisted hepatectomy. METHODS: We retrospectively evaluated 40 patients who underwent laparoscopic assisted and DaVinci robotic assisted hepatectomy at the Yonsei University Health System from January 2002 to January 2008. RESULTS: Thirty patients (75%) had malignancy and ten patients (15%) had benign disease. We performed Lt. hepatectomy (7.5%), wedge resection (17.5%), segmentectomy (30%) and Lt. lateral segmentectomy (45%). The rate of conversion to laparotomy was due to intraoperative bleeding was 10%. The complication and mortality rates were 7.5% and 0%, respectively CONCLUSION: Laparoscopic and DaVinci robot hepatectomy showed a reduced time to oral intake, a shortened hospital stay and a smaller incisional scar compared to open surgery. So, laparoscopic and DaVinci robot hepatectomy should be performed in selected patients as the postoperative status of the patients is better than that with performing open hepatectomy.

Ki-67 and VEGF as Possible Prognostic Factors in Radically-resected Ampulla of Vater Cancer

PURPOSE: Ampulla of Vater cancer has a more favorable prognosis and survival than other malignant periampullary tumors. The pathologic staging of ampulla of Vater carcinoma is a key determinant of the patient's prognosis. However, we have often encountered patients in whom the course of their disease differed substantially from what would be predicted based on their clinical staging, which highlights the need to consider additional predictive factors. We applied an immunohistochemical technique to examine the expression of Ki-67 and VEGF in radicallyresected ampulla of Vater carcinomas, and then compared the status of expression with several clinicopathologic factors. METHODS: Sixty-four patients who underwent curative resection for ampulla of Vater cancer between January 1992 and December 2006 at the Yonsei University College of Medicine were reviewed. The relationships between the expression of molecular markers and clinicopathologic factors were determined. RESULTS: There was no relationship between the clinicopathologic characteristics and the expression of molecular markers in patients with ampulla of Vater cancer. Among the clinicopathologic characteristics, lymph node metastasis was identified as an independent factor of survival after curative resection for ampulla of Vater carcinoma. CONCLUSION: Measurement of Ki-67 and VEGF in patients with ampulla of Vater carcinoma may have an important role in identifying the poor prognostic group.

Wedge Resection of the Stomach for Gastric Submucosal Tumors: Laparoscopic vs. Open

PURPOSE: Laparoscopic wedge resection (LWR) is replacing open wedge resection (OWR) as the standard surgical treatment for gastric submucosal tumors. However, few scientific comparisons exist as to whether LWR or OWR is better in terms of postoperative outcomes. This study was performed to compare these two treatment modalities for the treatment of gastric submucosal tumors by evaluating the postoperative outcomes. METHODS: Between 1993 and 2004, 112 patients with a gastric submucosal tumor had undergone either LWR (n=42) or OWR (n=70). Their medical records were retrospectively reviewed with regard to tumor size, operative time, time to first flatus, postoperative hospital stay and analgesics use. RESULTS: The demographics and tumor characteristics of the patients were similar in both groups. Four (9 %) cases in the LWR group were converted to an open procedure. The mean operation time was longer in the LWR than the OWR group (100.6 vs. 84.3 min)(P = 0.015). The time to first flatus (1.8 +/- 0.1 vs. 3.3 +/- 0.1 days, respectively, P < 0.0001) and soft diet intake (3.5 +/- 0.3 vs. 6.0 +/- 0.2 days, respectively, P < 0.0001) were shorter in the LWR compared to the OWR group. The postoperative hospital stay was significantly shorter in the LWR than in the OWR group (5.3 +/- 0.6 vs. 8.5 +/- 0.2 days) (P < 0.0001). The number of analgesics uses (2.7 +/- 0.4 times) in the LWR was less than that in the OWR group (2.7 +/- 0.4 vs. 4.1 +/- 0.5 times)(P=0.0056). CONCLUSION: Laparoscopic wedge resection of a gastric submucosal tumor was superior to open wedge resection in terms of the postoperative outcomes. Laparoscopic wedge resection could be considered the first-line treatment for gastric submucosal tumors.

A Study for Mechanism of Biliary Ductal Injury in Patients with Anomalous Pancreaticobiliary Ductal Union: A Study for Mechanism of Biliary Injury in APBDU / 한국간담췌외과학회지

PURPOSE: It has been known that clinical features of anomalous pancreaticobiliary ductal union (APBDU) are thought to result from cholestasis and regurgitation of pancreatic juice. The purpose of our study is to clarify the relationship of clinicopathological factors and to get information on mechanism of biliary ductal injury in APBDU. METHODS: A total of 23 patients who underwent operation for APBDU from March 1995 to March 2003 were examined. The results of patients were analyzed for their relevance to the clinicopathological factors such as age, sex, age at onset, size of cyst, grade of inflammation, type of APBDU, level of pancreatic enzymes sampled from biliary ductal system, and Ki67 labeling index. RESULTS: Level of amylase in biliary ductal system was decreased with age, especially after 20 years. The grade of hyperplasia in gallbladder was increased with level of amylase in gallbladder. The grade of inflammation in gallbladder was increased with age, but inflammation of gallbladder decreased with the level of amylase in gallbladder, and the size of cyst was increased with grade of inflammation and age. CONCLUSION: Level of amylase in the bile of biliary ductal system was decreased with age, especially after 20 years, which suggests that reflux of pancreatic amylase is closely related with onset of symptom in adult with APBDU. As far as mechanism of biliary ductal injury in APBDU is concerned, inflammation of biliary ductal system is increased with age and size of cyst. And hyperplasia of gallbladder is increased with the degree of regurgitation of pancreatic juice.

Aneurysmal Subarachnoid Hemorrhage in Geriatric Patients / 대한뇌혈관학회지

Intracranial aneurysms are the most common source of nontraumatic subarachnoid hemorrhage (SAH) in elderly patients. Despite the fact that more patients who present with SAH are middle-aged, the age-specific incidence for SAH increases with increasing age. The elderly patients with aneurysmal SAH have a trend toward poor outcome. Furthermore there are age-associated factors that increase perioperative and postoperative risks. In this paper, authors will review and discuss the reason why older patients have a poorer outcome and management for aneurysmal SAH in geriatric patients.