Two Cases of Plug or Stone in Remnant Intrapancreatic Choledochal Cysts Treated with Endoscopic Retrograde Cholangiopancreatography

Incomplete resection of choledochal cysts (CCs) that extend deep into the pancreas can lead to protein plug or stone formation, pancreatitis, and cholangiocarcinoma. We encountered two cases of choledocholithiasis in remnant intrapancreatic CCs, in which the patients exhibited symptoms after 3 and 21 years of cyst excision. A 21-year-old woman who had undergone excision of a CC, as a neonate, presented with epigastric pain. Abdominal computed tomography (CT) revealed stones inside the remnant pancreatic cyst, which were removed by endoscopic retrograde cholangiopancreatography (ERCP), and her symptoms improved. A 33-year-old woman, who underwent cyst excision 3 years ago, presented with pancreatitis. Abdominal CT showed a radiolucent plug inside the remnant pancreatic cyst. The soft, whitish plug was removed by ERCP, and the pancreatitis improved. These cases indicate that plugs and stones in CCs have the same pathogenetic mechanism, and their form depends on the time since the incomplete excision surgery.

Primary hepatic peripheral T-cell lymphoma mimicking hepatocellular carcinoma: a case report

Peripheral T-cell lymphomas (PTCLs) are aggressive neoplasms which may involve the liver. The imaging manifestations of hepatic lymphoma are highly variable and show overlapping appearances of numerous other hepatic diseases. As the management and prognosis of lymphoma differ markedly from those of other malignant diseases, prompt diagnosis and early effective treatment are very important. Here, we report an atypical case of primary PTCL not otherwise specified involving the liver that exhibited a solitary hepatic mass mimicking hepatocellular carcinoma (HCC) on CT. Liver biopsy is not commonly recommended in highly suspicious cases of HCC. However, in a patient without risk factors for HCC, consideration of other diagnostic possibilities is required and needle biopsy may be a more rational choice. An imaging approach, based on a careful review of clinical and laboratory findings is essential to prevent false-positive diagnosis of HCC and subsequent invasive treatment.

Lymphoepithelial cyst of the pancreas mimicking malignant cystic tumor: report of a case

Lymphoepithelial cysts of the pancreas are a type of true cyst that can mimic pseudocysts and cystic neoplasms. They are very rare, non-malignant lesions that are unilocular or multilocular cystic lesions lined predominantly by mature squamous epithelium and surrounded by non-neoplastic lymphoid elements. We, herein, present a patient with a cystic pancreas tumor mimicking a malignant cystic neoplasm. The patient was admitted with upper abdominal discomfort. Computed tomography showed a 64x39 mm cystic mass in the pancreas tail. She underwent distal pancreatectomy and splenectomy. In the fluid analysis of the pancreas cystic mass, the CEA and CA19-9 were 618 ng/ml and 3.9 U/ml, respectively. The resected pancreas specimen showed a 6.5 cm-sized cyst the pancreas tail. The cyst was well circumscribed and multilocular. The final pathology report of the resected pancreas specimen noted that the cyst was multilocular, and the cyst lining was showing stratified squamous epithelium covering the lymphoid tissue (containing lymphoid follicles), which was consistent with a lymphoepithelial cyst. The patient recovered uneventfully from surgery and has been doing well for the past 3 months. A differential diagnosis of cystic pancreatic lesions is important. We suggest that lymphoepithelial cysts, although very rare, may be included in the differential diagnosis of cystic pancreatic tumors.

Fate of Dyspeptic or Colonic Symptoms After Laparoscopic Cholecystectomy

BACKGROUND/AIMS: Gallbladder diseases can give rise to dyspeptic or colonic symptoms in addition to biliary pain. Although most biliary pain shows improvement after cholecystectomy, the fates of dyspeptic or colonic symptoms still remain controversial. This study assessed whether nonspecific gastrointestinal symptoms improved after laparoscopic cholecystectomy (LC) and identified the characteristics of patients who experienced continuing or exacerbated symptoms following surgery. METHODS: Sixty-five patients who underwent LC for uncomplicated gallbladder stones or gallbladder polyps were enrolled. The patients were surveyed on their dyspeptic or colonic symptoms before surgery and again at 3 and 6 months after surgery. Patients' mental sanity was also assessed using a psychological symptom score with the Symptom Checklist-90-Revised questionnaire. RESULTS: Forty-four (67.7%) patients showed one or more dyspeptic or colonic symptoms before surgery. Among these, 31 (47.7%) and 36 (55.4%) patients showed improvement at 3 and 6 months after surgery, respectively. However, 18.5% of patients showed continuing or exacerbated symptoms at 6 months after surgery. These patients did not differ with respect to gallstone or gallbladder polyps, but differed in frequency of gastritis. These patients reported lower postoperative satisfaction. Patients with abdominal symptoms showed higher psychological symptom scores than others. However, poor mental sanity was not related to the symptom exacerbation. CONCLUSIONS: Elective LC improves dyspeptic or colonic symptoms. Approximately 19% of patients reported continuing or exacerbated symptoms following LC. Detailed history-taking regarding gastritis before surgery can be helpful in predicting patients' outcome after LC.

Subepithelial Benign Duodenal Tumors Treated by Surgical Resection: A Case Series at A Single Institution / 대한췌담도학회지

BACKGROUND/AIMS: The incidence of duodenal tumors has increased by health surveillance. However, preoperative diagnosis of subepithelial duodenal tumors remains difficult because of the wide variety of pathologies and the location of the tumors. We analyzed endoscopic, radiological, and pathological features of subepithelial benign duodenal tumors (BDTs), which were treated by surgical resection. METHODS: Five patients with subepithelial BDTs treated by surgical resection were analyzed retrospectively. We compared the preoperative and postoperative diagnosis and evaluated the clinical presentations, endoscopic and radiological findings, surgical treatments, pathological results, and outcomes of these patients. RESULTS: All the patients underwent successful surgical resection. There were two cases of gastrointestinal stromal tumors (GISTs) treated with segmental duodenectomy, one case of carcinoid tumor treated with antrectomy, one case of gangliocytic paraganglioma treated with ampullectomy, and a lipoma removed by mass excision. The two GISTs were in the duodenal third and fourth segment close to the pancreas, and it was difficult to exclude pancreatic tumors by imaging studies. All the patients remained healthy for more than three years. CONCLUSIONS: Subepithelial BDTs are rare and difficult to diagnosis. Awareness and preoperative diagnosis of subepithelial BDTs can lead to minimally invasive treatment, including endoscopic or local surgical resection.

Polyarteritis nodosa presented as a dilatation of the intrahepatic bile duct

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis of small- and medium-sized arteries in multiorgan systems. PAN may affect the gastrointestinal tract in 14%-65% of patients, but rarely involves the biliary tract and liver. We describe a patient without underlying disease who was diagnosed with PAN during resection of the gallbladder and liver.

Differential Expression of E-Cadherin, beta-Catenin, and S100A4 in Intestinal Type and Nonintestinal Type Ampulla of Vater Cancers

BACKGROUND/AIMS: Epithelial-mesenchymal transition (EMT)-related proteins may exhibit differential expression in intestinal type or pancreatobiliary type ampulla of Vater carcinomas (AVCs). We evaluated the expression of E-cadherin, beta-catenin, and S100A4 in intestinal and nonintestinal type AVCs and analyzed their relationships with clinicopathological variables and survival. METHODS: A clinicopathological review of 105 patients with AVCs and immunohistochemical staining for E-cadherin, beta-catenin, and S100A4 were performed. The association between clinicopathological parameters, histological type, and expression of EMT proteins and their effects on survival were analyzed. RESULTS: Sixty-five intestinal type, 35 pancreatobiliary type, and five other types of AVCs were identified. The severity of EMT changes differed between the AVC types; membranous loss of E-cadherin and beta-catenin was observed in nonintestinal type tumors, whereas aberrant nonmembranous beta-catenin expression was observed in intestinal type tumors. EMT-related changes were more pronounced in the invasive tumor margin than in the tumor center, and these EMT-related changes were related to tumor aggressiveness. Among the clinicopathological parameters, a desmoplastic reaction was related to overall survival, and the reaction was more severe in nonintestinal type than in intestinal type AVCs. CONCLUSIONS: Dysregulation of E-cadherin, beta-cadherin, and S100A4 expression may play a role in the carcinogenesis and tumor progression of AVCs.

The experience of transumbilical endoscopic appendectomies

Minimally invasive surgery is being widely accepted in various fields of surgery. Although several appendectomy techniques have been reported but, there is no standardization. We report here the experiences of transumbilical endoscopic appendectomy in humans. Between July 2008 and September 2010, ten patients with appendicitis successfully underwent transumbilical endoscopic appendectomies. There were 7 cases of suppurative, 2 cases of gangrenous and 1 case of perforated in operative findings. The ages of the patients were 13-56 years (mean age, 32.7 +/- 15.4 years). Under general anesthesia, a 15-mm port was inserted through the umbilicus and then a two-channel endoscope was inserted in the peritoneal cavity. After appendix identification, counter-traction of the appendix with a direct abdominal wall puncture using a straight round needle prolene was performed to achieve good visualization of the operative field. Tissue dissection was performed using an endoscopic needle knife. Tissue grasping and resected appendix retrieval were done with endoscopic forceps. The average operation time was 79.5 +/- 23.6 minutes (range, 45 to 110 minutes). No procedures were converted to laparoscopic or open appendectomy. Hospital stay was 4-6 days. All patients completely recovered without complications. As it is highly maneuverable, we believe transumbilical endoscopic appendectomy can be a feasible method. And, as surgeons want to proceed from laparoscopic surgery to natural orifice transluminal endoscopic surgery, this procedure could be a triable method.

Clinical, Pathological, and Immunohistochemical Features of Adenomyoma in the Ampulla of Vater / 대한소화기학회지

BACKGROUND/AIMS: Ampullary adenomyoma is a benign lesion whose malignant potential has yet to be confirmed. Despite its benign nature, adenomyoma is frequently misdiagnosed as a carcinoma or adenoma and is overtreated by extensive surgery. This study was performed to analyze the clinical, pathological, and immunohistochemical features of adenomyomas in the ampulla of Vater. METHODS: Nine cases of adenomyoma in the ampulla of Vater, diagnosed in Chungbuk National University Hospital between 2008 and 2011, were enrolled in this study. We reviewed the clinical data on the symptoms, laboratory data, and radiologic findings of the abdominal computed tomography and endoscopic retrograde cholangiopancreatography. For pathological analysis, all the slides were reviewed by one pathologist, and immunohistochemical stainings with antibodies against cytokeratin 7 (CK7), cytokeratin 20 (CK20), alpha-smooth muscle actin (alpha-SMA), and Ki-67 antigen were performed. RESULTS: All the cases were CK7 positive and CK20 negative. A strong cytoplasmic expression of alpha-SMA was confirmed in all cases. The Ki-67 index was less than 1% in eight cases and 5% in one case. Four cases underwent endoscopic papillectomy, and one case received surgical ampullectomy during colorectal cancer surgery. Five cases that underwent endoscopic or surgical treatment remained symptom-free for three years. Four cases that were closely observed with repeated endoscopic examinations exhibited no interval changes in the papillary lesions. CONCLUSIONS: Endoscopic biopsy and immunohistochemistry can aid in the diagnosis of ampullary adenomyomas. Endoscopic papillectomy or surgical ampullectomy is adequate for the treatment of symptomatic ampullary adenomyomas.

Metastatic Clear Cell Renal Cell Carcinoma to the Thyroid Gland / 대한내분비외과학회지

Clear cell renal cell carcinoma (RCC) is the most common histological subtype of malignant renal tumors. Although RCC frequently metastasizes to many organs, it rarely metastasizes to the thyroid gland without evidence of other organ involvement. We report a case of a metastatic renal cell carcinoma to the thyroid gland, which was misdiagnosed preoperatively as a follicular neoplasm from the fine needle aspiration cytology.

Bowel infarction due to intestinal mucormycosis in an immunocompetent patient / 대한외과학회지

Mucormycosis is a fatal opportunistic fungal infection that typically occurs in immunocompromised patients. The classical manifestation of mucormycosis is a rhinocerebral infection, and although primary gastrointestinal infection is uncommon, it has an extremely high mortality rate in immunocompromised patients. Furthermore, cases of gastrointestinal mucormycosis in an immunocompetent host are rarely reported. Here, we describe our experience of a male patient, with no underlying disease, who succumbed to a bowel infarction caused by intestinal mucormycosis during mechanical ventilatory care for severe pneumonia and septic shock.

Retroperitoneal Tumors Mimicking Adrenal Tumor / 대한내분비외과학회지

Periadrenal retroperitoneal tumors are frequently misdiagnosed as adrenal tumors because of its rarity and anatomical vicinity. Thus, there are only very few cases reported and little information available in the literature. Preoperative diagnoses of theses tumors are challenging. The definitive diagnosis is based on postoperative pathological findings. We report two cases of periadrenal retroperitoneal tumors that mimicked adrenal neoplasms. Final diagnoses were mature cystic teratoma and papillary renal carcinoma, respectively. Although periadrenal retroperitoneal tumors are rare, it should be considered in the differential diagnosis of adrenal incidentalomas.

Common bile duct dilatation after cholecystectomy: a one-year prospective study / 대한외과학회지

PURPOSE: Bile duct dilatation after cholecystectomy continues to be a matter of controversy. We aimed determine the magnitude of common bile duct (CBD) dilatation after cholecystectomy followed up to 1 year. METHODS: Sixty-four cases (age, 47.3 +/- 11.7 years; men, 28; women, 36) enrolled in this study. They received laparoscopic cholecystectomy in Chungbuk National University Hospital for symptomatic cholelithiasis or gallbladder polyps with normal bile duct, less than 7 mm. The CBD diameter was measured by one radiologist using ultrasonography at the maximum point after full length evaluation of extrahepatic bile duct. Forty-five and thirty-one cases were followed at 6 months and 1 year, respectively. RESULTS: The CBD was dilated slightly from 4.1 mm at baseline to 5.1 mm at 6 months and 6.1 mm at 12 months after cholecystectomy. The number of cases of CBD dilatation of more than 7 mm at 6 months and at 12 months after cholecystectomy were 11 (24.4%) and 9 (29.0%), respectively. Seven cases at 6 months and 5 cases at 12 months showed bile duct dilation of more than 3 mm compared to baseline. There were no cases having bile duct dilation of more than 10 mm. CONCLUSION: Postcholecystectomy dilatation of the bile duct occured slightly in most cases. But some cases showed more than 3 mm dilatation over baseline. Asymptomatic bile duct dilatation of up to 10 mm can be considered as normal range in patients after cholecystectomy.

Extended Spectrum-beta-Lactamase or Carbapenemase Producing Bacteria Isolated from Patients with Acute Cholangitis

BACKGROUND/AIMS: This study assessed the antibiotic resistance organisms isolated from the blood and bile of acute cholangitis and evaluated risk factors associated with them and their impact on clinical outcomes. METHODS: The identities and antibiotic resistance profiles of bacteria isolated from 433 cases of acute cholangitis from 346 patients were analyzed. Risk factors and the outcomes of patients infected with them were assessed. RESULTS: Microorganisms were isolated from 266 of 419 blood cultures and 256 of 260 bile cultures. Isolates from bile and blood were identical in 71% of the cases. A total of 20 extended spectrum-beta-lactamase (ESBL)-producers and 4 carbapenemase-producing organisms were isolated from blood, and 34 ESBL-producers and 13 carbapenemase-producers were isolated from bile. Sixty-four (14.8%) cases were infected with any one of these bacteria isolated from blood or bile. Risk factors associated with them in blood were nosocomial infection and prior biliary intervention. In bile, indwelling biliary device was a risk factor associated with them. Antibiotic-resistant bacteria were associated with mortality, independent of other prognostic factors. CONCLUSIONS: ESBL or carbapenemase-producing bacteria were frequently isolated in acute cholangitis patients especially with prior biliary intervention and nosocomial infection. Isolation of antibiotic-resistant bacteria was an independent risk factor of mortality.

Erratum: Extended Spectrum-beta-Lactamase or Carbapenemase Producing Bacteria Isolated from Patients with Acute Cholangitis

The publisher wishes to apologize for incorrectly displaying the author (Jung-Ho Han) name. We correct his name from Jung-Ho Han to Joung-Ho Han.

Relationship between Tortuosity and Atherosclerotic Changes of the Abdominal Aorta / 대한혈관외과학회지

PURPOSE: Tortuosity and atherosclerosis of the abdominal aorta are commonly observed in the elderly. Few studies about aortic tortuous changes have been performed. This study was carried out to investigate the relationship between aortic tortuous and atherosclerotic changes. METHODS: We included 2,920 patients by reviewing computerized tomography scans in Chungbuk National University Hospital during 2007. We classified the abdominal aorta into straight (I form) and tortuous forms (T form), defined as a deviation involving more than half the aortic diameter. The T form was further subdivided into 2 types (C type, 1 curve; T type, >2 curves). The calcification index (CI) was also measured. The tortuosity index (TI) was measured in 60 patients each with the I form and the C and S types. We analyzed relationships between tortuosity and clinical variables. RESULTS: The incidence of tortuosity was 56.2%, and in the 7th, 8th, 9th decades of life it was 61.7%, 77.3%, and 91.0%, respectively. In univariate analysis, age, female sex, hypertension, and CI were statistically significant. In multivariate analysis, CI was not statistically significant between the I and T forms but significant between the I form and the S type. TI in the T form was lower than in the I form. However, no difference was seen between the I form and C type. CONCLUSION: A tortuous change of the abdominal aorta was seen earlier and more frequently than an atherosclerotic change and were associated with aging, calcification, and hypertension. Aortic calcification was associated with more complex tortuous changes.

Sonic Hedgehog Protein Expression in Various Thyroid Tissues and Its Clinical Implication / 대한내분비외과학회지

PURPOSE: The Hedgehog (Hh) signaling pathway is important in embryonic development including cell differentiation and proliferation. Recently, activation of this pathway has been implicated in several forms of solid cancers. We investigated sonic hedgehog (Shh) protein expression and its relation to differentiation and clinicopathologic characteristics in thyroid cancer cell lines and tissues. METHODS: FTC-236, FTC-238, and XTC-1. We made tissue microarray slides using 80 thyroid surgical specimen: 40 benign and 40 malignant lesions. Immunohistochemical staining was performed using anti-Shh antibody. mRNA expression of NIS, thyroglobulin, and CD97 were evaluated by RT-PCR. Cyclopamine was used as a Shh signal inhibitor. RESULTS: Shh expression was more prominent in TPC-1, FTC-133, and XTC-1 cell lines than the others. Cyclopamine downregulated CD97 and upregulated thyroglobulin mRNA expression, but did not induce mRNA expression of NIS. Thyroid tissues showed varied expression of Shh in both benign and malignant diseases. Shh expression was detected in 38 of 50 (76%) normal, in 18 of 25 (72%) non-neoplastic benign, in nine of 15 (60%) benign tumors, and in 31 of 40 (77%) malignant tumors. Shh over-expression was significantly less frequent in papillary thyroid carcinomas than in normal or benign thyroid tissues. In addition, Shh protein expression did not relate to clinicopathologic characteristics in papillary thyroid carcinomas. CONCLUSION: Thyroid tissues and cell lines vary in expression of Shh. Cyclopamine can induce redifferentiation in thyroid cancer cell lines. Shh protein expression, however, is unrelated to clinicopathologic characteristics in papillary thyroid carcinomas.

Microglandular Adenosis / 한국유방암학회지

Microglandular adenosis (MGA) of the breast is a very rare and benign proliferative lesion. Most patients complain of a palpable breast mass that may arouse a clinical suspicion of breast cancer. Histopathologically, it is hard to distinguish MGA from breast cancer because of the lack of a myoepithelial layer and infiltrative proliferation. Several studies have reported a strong relationship between MGA and carcinoma arising in MGA, so the mass should be excised completely in cases of MGA determined from a core needle biopsy rather than observation. A 72-years-old woman presented with a palpable breast mass. On physical examination, a mass was palpable in the right upper outer quadrant area and somewhat fixed to the surrounding tissues and pectoralis major muscle. We could not detect any mass or dense lesion on mammography because of a grade 4 dense breast. Ultrasonographic findings revealed a low echoic lesion with indistinct margins. The result of a core needle biopsy was MGA, which was confirmed by excision. We report one case of MGA, which was believed to breast cancer clinically.

Can Review of Sonographic Findings Spare Diagnostic Thyroidectomy in Patients with Thyroid Nodules Suspicious of Follicular Neoplasm Cytologically?

PURPOSE: Follicular neoplasms (FNs) such as follicular adenoma and carcinoma (FTC), nodular hyperplasia (NH) and follicular variant of papillary carcinoma (FVPC) share cytological features. In the present study, we investigate whether review of sonographic findings in patients with thyroid nodules suspicious of FN spares diagnostic thyroidectomies (DTs) by excluding benign diseases such as NH or not. METHODS: From June 1999 to May 2007, DTs were performed on 98 patients who had nodules suspicious of FN. High resolution sonographic findings are available for 53 patients. According to the final histologic diagnosis: Group I (23 patients) consisted of 20 FNs (11 FTCs), 1 Hurthle cell adenoma, 2 FVPC; Group II (30 patients) consisted of all others (23 NHs, 4 Hashimoto's thyroiditis, 3 papillary carcinomas (PTCs). Sonographic features were compared between the two groups. RESULTS: Three differential sonographic findings (DSF) i.e. irregular margin, absence of peripheral halo or marked inhomogeniety were identified more often in Group II than Group I (P<0.05). If we spared DTs for patients who have at least one DSF, 18 patients (34.0%) would have been selected for clinical follow-up whose final diagnoses were 14 NHs and 4 PTCs (including 1 FVPC). Sparing DTs by DSFs shows sensitivity, 56.7%; specificity, 95.7%; positive predictive value, 94.4%; negative predictive value, 62.9%; and accuracy, 73.6%, respectively. CONCLUSION: In patients with thyroid nodules suspicious of FN, sonographic findings such as irregular margin, absence of peripheral halo or marked inhomogeneity might spare DTs with the help of other diagnostic modalities such as cytogenetic or immunohistochemical studies.

Effect of Patient Safety Education in Surgical Clerkship to Develop Competencies for Managing and Preventing Medical Errors / 한국의학교육

PURPOSE: The aims of this study were to define the necessity and effectiveness of patient safety education during surgical clerkship to develop competency for managing and preventing medical errors. METHODS: Fifty 3rd-year students participated in the patient safety education program during a 4-week surgical clerkship. The students were divided into 4 groups: control group, pretest-only group, education-only group, and pretest and education group. Students were assessed using short essays and an oral exam for reasoning skills, clinical performance exams for patient education and communication skills, and multisource feedback and direct observation of error reporting for real-world problem-solving skills. The results were analyzed with SPSS 14.0K. The reliability (Cronbach alpha) of the entire assessment was 0.893. RESULTS: There was no difference in scores between early and late clerkship groups. Reasoning skills were improved by the pretest. Reasoning, patient education, and error reporting skills were much more developed by patient safety education. Real-world error identification, reporting, and communication did not change after the 4-week course. CONCLUSIONS: Patient safety education during surgical clerkship is necessary and effective. Error prevention and competency management in the real world should developed.