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.

The Feasibility of Fundal Retraction of the Gallbladder in the Single Port Laparoscopic Cholecystectomy: Comparison between a 4-instrument Fundal Retraction Group and a 3-instrument Group

PURPOSE: Owing to the accumulation of surgical experience, the indications of single port laparoscopic cholecystectomy (SLC) have increased. To overcome the difficulties and limitations of SLC, we included an additional instrument for use in retracting the gallbladder fundus. The aim of this study was to investigate the feasibility of 4-instrument fundal retraction SLC. METHODS: We retrospectively analyzed 134 patients who had undergone SLC for benign gallbladder disease. We compared the clinical outcome between patients who had undergone SLC without fundal retraction (3-instrument SLC, n=102) and those who had undergone SLC with fundal retraction (4-instrument fundal retraction SLC, n=32). RESULTS: Of 134 patients, 47 were male and 87 were female. A significantly higher proportion of patients in the 4-instrument fundal retraction group had gallbladder distention and wall thickening than patients in the 3-instrument SLC group. No statistically significant difference in the incidence of pericholecystic inflammation, adhesion, and gallbladder perforation; duration of operation, the incidence of complications, and duration of postoperative hospital stay was observed between the two groups. In univariate analysis to perform 4-instrument fundal retraction SLC, higher BMI, the presence of gallbladder distension, and wall thickening were significant factors. In multivariate analysis, gallbladder distention and the presence of concurrent operation during SLC were independently significant factors for performing 4-instrument fundal retraction SLC. CONCLUSION: Four-instrument fundal retraction SLC is a feasible and safe surgical procedure, particularly in patients with a high BMI, gallbladder distention, wall thickening, inflammation, or adhesions. If difficulties are encountered during 3-instrument SLC, simple fundal retraction using an additional instrument may be the preferred option prior to converting the operation to conventional laparoscopic cholecystectomy.

Surgical experience and clinical outcome of traumatic pancreatic injury

BACKGROUNDS/AIMS: Traumatic pancreatic injury is rare and various surgical procedures can be applied according to the severity of injury. We reviewed our experience of pancreatic injury and investigated the clinical outcome. METHODS: Fifty-six patients were treated conservatively or with surgery for pancreatic injury at the Department of Surgery, Korea University Medical Center of Korea University College of Medicine from January 2001 to February 2012. RESULTS: Forty-one men and 15 women were included (mean age, 32 years; range, 5-66 years). Twelve patients were hypotensive at admission. According to the American Association for the Surgery of Trauma grade, 15 patients were grade I, 16 were grade II, 10 were grade III, 13 were grade IV, and one patient was grade V. A total of 41 patients underwent exploratory surgery. Complications developed in 35 patients, and 19 patients demonstrated intra-abdominal abscesses associated with pancreatic leakage. Four mortalities occurred. More adult patients (n=42) required intensive care than that of pediatric patients (n=14) (p=0.03). However, more pediatric patients had hyperamylasemia at admission (p=0.023). A significantly higher proportion of patients in the hypotensive group had blunt abdominal injuries, associated extra-abdominal injuries, combined intra-abdominal injuries, longer ICU stays, and a higher mortality rate. CONCLUSIONS: Associated intra-abdominal and extra-abdominal injuries are frequent in patients with traumatic pancreatic injury. Despite the complication rate, most patients recovered. Mortalities were associated with combined injuries being placed into bleeding, hypovolemic shock, and multiorgan failure.

Clinicopathological Characteristics in Combined Hepatocellular-Cholangiocarcinoma: A Single Center Study in Korea

PURPOSE: Combined hepatocellular-cholangiocarcinoma (CHCC) is an uncommon form of cancer, and its clinicopathological features have rarely been reported in detail. This study was undertaken to evaluate the clinicopathological characteristics and prognostic factors of CHCC. MATERIALS AND METHODS: The clinicopathological features of patients diagnosed with CHCC at Severance Hospital between January 1996 and December 2007 were retrospectively studied by comparing them with the features of patients with hepatocellular carcinoma (HCC) or cholangiocarcinoma (CC) who had undergone a hepatic resection during the same period. RESULTS: Forty-three patients diagnosed with CHCC were included in this study (M : F=35 : 8, median age, 55 years). According to the parameters of the American Joint Committee on Cancer staging, there were 6 (14.0%), 9 (20.9%), 25 (58.1%), and 3 (7.0%) patients with stages I, II, III, and IV cancer, respectively. Thirty-two of the 43 patients underwent resection with curative intent. After resection, 27 patients (84.4%) had tumor recurrence during the follow-up period of 18 months (range: 6-106 months), and the median time to recurrence was 13 months. Overall median survival periods after hepatic resection of CHCC, HCC and CC were 34, 103 and 38.9 months, respectively (p<0.001). The median overall survival for all patients with CHCC was 21 months, and the 5-year survival rate was 18.1%. The presence of portal vein thrombosis and distant metastasis were independent prognostic factors of poor survival. CONCLUSION: Even after curative hepatic resection, the presence of a cholangiocellular component appeared to be a poor prognostic indicator in patients with primary liver cancer.

Solitary Extrahepatic Intraabdominal Metastasis from Hepatocellular Carcinoma after Liver Transplantation

A liver transplantation is a treatment option in selected patients with hepatocellular carcinoma (HCC). Despite the adequate selection of candidates, recurrences of HCC may still develop. Solitary extrahepatic metastasis from HCC after a liver transplantation is rare. Here we report two cases of HCC demonstrated extrahepatic recurrence to the adrenal gland and spleen, respectively, within one year after a liver transplantation. Since the treatment of solitary extrahepatic metastasis from HCC after a liver transplantation is not standardized, surgical resection was performed. In the case of HCC adrenal metastasis, innumerable intrahepatic metastases were found two months after the adrenalectomy. And 16 months after adrenalectomy, the patient expired due to tumor progression and hepatic failure. In the case of HCC splenic metastasis, postoperative radiation therapy was performed. However, two recurrent HCC nodules were found 15 months after the splenectomy and received transarterial chemoembolization (TACE). And 29 month after the splenectomy, the patient also expired as same causes of former patient.

Solitary Extrahepatic Intraabdominal Metastasis from Hepatocellular Carcinoma after Liver Transplantation

A liver transplantation is a treatment option in selected patients with hepatocellular carcinoma (HCC). Despite the adequate selection of candidates, recurrences of HCC may still develop. Solitary extrahepatic metastasis from HCC after a liver transplantation is rare. Here we report two cases of HCC demonstrated extrahepatic recurrence to the adrenal gland and spleen, respectively, within one year after a liver transplantation. Since the treatment of solitary extrahepatic metastasis from HCC after a liver transplantation is not standardized, surgical resection was performed. In the case of HCC adrenal metastasis, innumerable intrahepatic metastases were found two months after the adrenalectomy. And 16 months after adrenalectomy, the patient expired due to tumor progression and hepatic failure. In the case of HCC splenic metastasis, postoperative radiation therapy was performed. However, two recurrent HCC nodules were found 15 months after the splenectomy and received transarterial chemoembolization (TACE). And 29 month after the splenectomy, the patient also expired as same causes of former patient.

Synchronous double primary cancers associated with a choledochal cyst and anomalous pancreaticobiliary ductal union / 대한외과학회지

A 60-year-old female was admitted with epigastric pain lasting a month. Preoperative diagnosis was choledochal cyst with anomalous pancreaticobiliaryductal union (APBDU), C-P type. A papillary mass measuring 2.5 x 1.9 cm was found adjacent to the pancreaticocholedochal junction. Gallbladder (GB) cancer was also observed. Pyloric-preserving pancreaticoduodenectomy (PPPD) was performed. The patient received adjuvant chemotherapy/radiation therapy on the tumor bed. The gallbladder cancer showed serosal invasion, while the bile duct cancer extended into the pancreas. Although common bile duct (CBD) cancer lesion showed focally positive for p53 and the gallbladder cancer lesion showed negative for p53, the Ki-67 labeling index of the CBD cancer and GB cancer were about 10% and 30%, respectively. Nine months after curative resection, a stricture on the subhepatic colon developed due to adjuvant radiation therapy. Localized peritoneal seedings were incidentally found during a right hemicolectomy. The patient underwent chemotherapy and had no evidence of tumor recurrence for two years after PPPD.

The Standization of Clinical Information for the Korean Hepatocellular Carcinoma Registry

Obtaining the basic statistical data on cancer diseases is essential to plan cancer research and to determine the proper tools to use for diagnosing and treating cancer. By using the national wide cancer registry, more accurate data has been collected and more informative cancerrelated statistical data can be calculated such as the occurrence rate, the death rate, the survival rate and so on. In Korea, the primary liver cancer registry has been active since 2003, and the clinical data from 10,886 patients has been collected. Unfortunately there are time and security limitations for recording and sharing this data and so a more convenient system is required. Therefore, we have revised the original primary hepatoma cancer registry to give a summary of research itself and an analysis of patients' data for the government's national wide evaluation and management of primary hepatoma.

The Clinical Characteristics of Acinar Cell Carcinoma in the Pancreas

Acinar cell carcinoma (ACC) is a very rare type of pancreatic cancer that makes up less than 1% of all pancreatic cancers. The prognosis of ACC is very poor and the mean survival interval is only 18-19 months. The only effective treatment is currently early radical resection. MATERIALS AND METHODS: To determine ACC`s clinical characteristics and the treatment efficacy, we conducted a retrospective chart review to study the clinical characteristics, laboratory findings, pathology and treatment responses of 10 ACC patients among 3042 pancreatic cancer patients who were diagnosed in Severance Hospital and Kangnam Severance Hospital of Yonsei University, College of Medicine from 1988.01.01 to 2008.12.31. RESULTS: The 10 ACC patients were 6 males and 4 females. The mean age of the 10 ACC patients was 53.2 years. The most of the patients (7/10) complained the pain on the epigastric area and there was no jaundice in 8 patients (80%). Unfortunately, regional or distant metastases were founded in 8 patients (80%) at the time of the first diagnosis. The initial mean CA19-9 level was increased to 73.5 U/ml (range: 0.1~350.0 U/ml). Six of 10 patients underwent radical surgery and 4 of 10, including 1 with open and closure, were treated with conservative treatment. The median survival interval was 22.4 months with operative treatment and 1.5 months with conservative treatment. The median overall survival interval was 19.4 months. The median disease free survival was 17 months. The liver was the most common recurrent site (3 cases). CONCLUSIONS: An early radical resection is currently the best and only treatment for ACC, but in rare cases, post-operative adjuvant chemotherapy shows hopeful results and so this requires more study.

The Factors Affecting Transplanted Hepatocytes Repopulation in Rats with Liver Fibrosis

PURPOSE: Cell therapy for various diseases has gained wide acceptance. Because most patients with chronic liver failure have mild-to-severe liver cirrhosis, there are many limitations to clinical applications. We analyzed how to increase cell engraftment in rats with liver fibrosis. METHODS: We used analbuminemic SD rats (NARs) as recipients of syngeneic CAG-EGFP SD hepatocytes obtained by the 2 perfusion method. Hepatic fibrosis was induced with thioacetamide in drinking water for 6 weeks in the recipient NARs. NARs were pre-treated with gadolinium, doxorubicin, and gliotoxin before hepatocyte transplantation. We evaluated the degree of cell engraftment by RT-PCR and immunofluorescent staining for GFP and albumin. The transplanted cells were detected by immunostaining for albumin, and serum albumin was also measured. RESULTS: Although detection of GFP by RT-PCR was variable, albumin was detected in all groups 4 wks after hepatocyte transplantation. GFP and albumin were also detected by immunofluorescent staining 1 and 4 wks after cell transplantation. In control rats, albumin production was maximal at 3 wks, and after that it rapidly decreased. In the gadolinium and doxorubicin-treated group, albumin production was increased up to 4 wks. Albumin production in the gadolinium-treated group was superior to that of the doxorubicin-treated group. CONCLUSION: Kupffer cells play the most important role in cell engraftment in hepatic fibrosis. Therefore, perturbation of kupffer cells in hepatic fibrosis is needed to increase cell engraftment.

The Factors Affecting Transplanted Hepatocytes Repopulation in Rats with Liver Fibrosis

PURPOSE: Cell therapy for various diseases has gained wide acceptance. Because most patients with chronic liver failure have mild-to-severe liver cirrhosis, there are many limitations to clinical applications. We analyzed how to increase cell engraftment in rats with liver fibrosis. METHODS: We used analbuminemic SD rats (NARs) as recipients of syngeneic CAG-EGFP SD hepatocytes obtained by the 2 perfusion method. Hepatic fibrosis was induced with thioacetamide in drinking water for 6 weeks in the recipient NARs. NARs were pre-treated with gadolinium, doxorubicin, and gliotoxin before hepatocyte transplantation. We evaluated the degree of cell engraftment by RT-PCR and immunofluorescent staining for GFP and albumin. The transplanted cells were detected by immunostaining for albumin, and serum albumin was also measured. RESULTS: Although detection of GFP by RT-PCR was variable, albumin was detected in all groups 4 wks after hepatocyte transplantation. GFP and albumin were also detected by immunofluorescent staining 1 and 4 wks after cell transplantation. In control rats, albumin production was maximal at 3 wks, and after that it rapidly decreased. In the gadolinium and doxorubicin-treated group, albumin production was increased up to 4 wks. Albumin production in the gadolinium-treated group was superior to that of the doxorubicin-treated group. CONCLUSION: Kupffer cells play the most important role in cell engraftment in hepatic fibrosis. Therefore, perturbation of kupffer cells in hepatic fibrosis is needed to increase cell engraftment.

The Extracellular Matrix Affected Proliferation and Cell Adhesion of Human Adipose Tissue Derived Mesenchymal Stem Cells in vitro

PURPOSE: Human mesenchymal stem cells (hMSCs) have the potency for self-renewal and differentiation into various kinds of cells. The hMSCs are obtained from the various tissues, including adipose tissue, bone marrow and cord blood. The extracellular matrix (ECM) is an important factor that affects cell adherence, growth, migration, apoptosis and differentiation both in vitro and vivo. The adipose-derived mesenchymal stem cells (AD-MSCs) have CD29 (integrin) on the cell surface, which is the receptor for fibronectin. The aim of this study is to validate the efficacy of ECM, and especially fibronectin, for cell expansion. METHODS: The AD-MSCs were obtained from the abdominal fat of humans. These cells were seeded onto culture plates coated with fibronectin-Human (FN) and plates without ECM (control). The cells were incubated for 3 passages and the cellular morphology was simultaneously observed with microscopy. CCK-8 assay was performed to compare the proliferation ability in each condition at the same passage. Immunocytochemistry staining for integrin-beta1 was performed to observe the cell to cell interaction. RESULTS: The hAD-MSCs in the FN-coated and non-coated plates exhibited cytoplasm staining for integrin-beta1. In all the cultures, extended fibroblastic-shaped cells that turned into rhomboid cells were most frequently observed. The cell growth rates for the non coated culture plate were lower than those for the FN coated plates. After 72 hour culture under the different coated concentrations of FN and the non coated condition (control), the control group had a lower growth rate. In the culture with a FN coated plate, a significant change was observed as compared with that of the control group. We observed an increase in cell proliferation, with a maximum of 140%, on the FN coated plate by performing CCK-8 assay. In comparison, integrin beta1 on the cells was more expressed in the FN-coated plates than that in the non-coated plates. CONCLUSION: The cell morphology can be changed faster in the FN coated culture plates than that in the non coated culture plates. Because proliferation and adhesion with FN can enhance the expansion, the culture within a FN coated plate is needed to encourage hAD-MSCs to proliferate in vitro.

The Extracellular Matrix Affected Proliferation and Cell Adhesion of Human Adipose Tissue Derived Mesenchymal Stem Cells in vitro

PURPOSE: Human mesenchymal stem cells (hMSCs) have the potency for self-renewal and differentiation into various kinds of cells. The hMSCs are obtained from the various tissues, including adipose tissue, bone marrow and cord blood. The extracellular matrix (ECM) is an important factor that affects cell adherence, growth, migration, apoptosis and differentiation both in vitro and vivo. The adipose-derived mesenchymal stem cells (AD-MSCs) have CD29 (integrin) on the cell surface, which is the receptor for fibronectin. The aim of this study is to validate the efficacy of ECM, and especially fibronectin, for cell expansion. METHODS: The AD-MSCs were obtained from the abdominal fat of humans. These cells were seeded onto culture plates coated with fibronectin-Human (FN) and plates without ECM (control). The cells were incubated for 3 passages and the cellular morphology was simultaneously observed with microscopy. CCK-8 assay was performed to compare the proliferation ability in each condition at the same passage. Immunocytochemistry staining for integrin-beta1 was performed to observe the cell to cell interaction. RESULTS: The hAD-MSCs in the FN-coated and non-coated plates exhibited cytoplasm staining for integrin-beta1. In all the cultures, extended fibroblastic-shaped cells that turned into rhomboid cells were most frequently observed. The cell growth rates for the non coated culture plate were lower than those for the FN coated plates. After 72 hour culture under the different coated concentrations of FN and the non coated condition (control), the control group had a lower growth rate. In the culture with a FN coated plate, a significant change was observed as compared with that of the control group. We observed an increase in cell proliferation, with a maximum of 140%, on the FN coated plate by performing CCK-8 assay. In comparison, integrin beta1 on the cells was more expressed in the FN-coated plates than that in the non-coated plates. CONCLUSION: The cell morphology can be changed faster in the FN coated culture plates than that in the non coated culture plates. Because proliferation and adhesion with FN can enhance the expansion, the culture within a FN coated plate is needed to encourage hAD-MSCs to proliferate in vitro.

Mesenchymal Stem Cells: The Promotion of Endodermal-Induction Using Activin A

PURPOSE: The most important consideration for therapy using MSCs is the differentiation of the target organ's cell type. For in-vitro hepatogenic differentiation of MSCs, the main focus is efficient induction of the MSCs into the endoderm stage. Activin A, which is a signaling molecule that is similar to Nodal, promotes the induction of definitive endoderm from both ESs and MSCs. The protocols for induction into definitive endoderm have shown different efficiency and reproducibility depending on the researchers or the sources of the MSCs. Thus, a study on the various conditions of Activin A is needed to efficiently differentiate MSCs into the definitive endoderm lineage of MSCs. METHODS: MSCs were isolated from human adipose tissues and these were cultured in MCM (MSCs Culture Medium) on a human fibronectin coated plate. At 70~80% confluence, the MSCs were harvested and cultured in MCM supplemented with Activin A, at a 50 ng/mL concentration, and FGF4. The expression of the genes related with MSCs or primitive endoderm were analyzed by RT-PCR. The changes of cell morphology for differentiation were also observed by a light microscope & a SEM. RESULTS: The expression of genes related with primitive foregut endoderm was seen in the groups that were treated with a higher concentration of Activin A. The morphology of the cells that differentiated into definitive endoderm were not different from those of the undifferentiated MSCs. The expression of genes related with functional primitive hepatocytes was seen in the early phase during hepatic differentiation. The cell morphology was changed to a similar cuboidal form in a time-dependent manner. CONCLUSION: Activin A promotes a more rapid induction of definitive endoderm. It also makes an efficient condition for the differentiation into primitive foregut endoderm at a higher concentration.

Mesenchymal Stem Cells: The Promotion of Endodermal-Induction Using Activin A

PURPOSE: The most important consideration for therapy using MSCs is the differentiation of the target organ's cell type. For in-vitro hepatogenic differentiation of MSCs, the main focus is efficient induction of the MSCs into the endoderm stage. Activin A, which is a signaling molecule that is similar to Nodal, promotes the induction of definitive endoderm from both ESs and MSCs. The protocols for induction into definitive endoderm have shown different efficiency and reproducibility depending on the researchers or the sources of the MSCs. Thus, a study on the various conditions of Activin A is needed to efficiently differentiate MSCs into the definitive endoderm lineage of MSCs. METHODS: MSCs were isolated from human adipose tissues and these were cultured in MCM (MSCs Culture Medium) on a human fibronectin coated plate. At 70~80% confluence, the MSCs were harvested and cultured in MCM supplemented with Activin A, at a 50 ng/mL concentration, and FGF4. The expression of the genes related with MSCs or primitive endoderm were analyzed by RT-PCR. The changes of cell morphology for differentiation were also observed by a light microscope & a SEM. RESULTS: The expression of genes related with primitive foregut endoderm was seen in the groups that were treated with a higher concentration of Activin A. The morphology of the cells that differentiated into definitive endoderm were not different from those of the undifferentiated MSCs. The expression of genes related with functional primitive hepatocytes was seen in the early phase during hepatic differentiation. The cell morphology was changed to a similar cuboidal form in a time-dependent manner. CONCLUSION: Activin A promotes a more rapid induction of definitive endoderm. It also makes an efficient condition for the differentiation into primitive foregut endoderm at a higher concentration.

The Efficacy of Hepatic Resection after Neoadjuvant Transarterial Chemoembolization (TACE) and Radiation Therapy in Hepatocellular Carcinoma Greater Than 5 cm in Size

In cases of large hepatocellular carcinoma (HCC), neoadjuvant treatment such as transarterial chemoembolization (TACE) and radiation therapy can be performed. The aim of this study was to evaluate the outcome of these treatments prior to hepatic resection. Between January 1994 and May 2007, 16 patients with HCC greater than 5 cm in size were treated with TACE and radiation therapy prior to hepatic resection. The clinicopathologic factors were reviewed retrospectively. Of the 16 patients, there were 14 men and two women, and the median age was 52.5 yr. TACE was performed three times in average, and the median radiation dosage was 45 Gy. The median diameter of tumor on specimen was 9.0 cm. The degree of tumor necrosis was more than 90% in 14 patients. The median survival time was 13.3 months. Five patients had survived more than 2 yr and there were two patients who had survived more than 5 yr. Although the prognosis of large HCC treated with neoadjuvant therapy is not satisfactory, some showed long-term survival loger than 5 yr. Further research will be required to examine the survival and disease control effect in a prospective randomized study.

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.

The Surgical Treatments for the Hepatolithiasis

Hepatolithiasis is characterized by its intractable nature and frequent recurrences that require multiple operative interventions. Intrahepatic stones consist of calcium bilirubinate in most cases, but these stones contain more cholesterol than the stones in the common bile duct. The pathogenesis of primary bile duct stones is based upon bile stasis and infection. Bile duct stricture and dilatation of the duct are usually present in cases with brown pigmented stones. In addition to cholangitis, liver abscess and longstanding sepsis, intrahepatic stones and strictures can cause secondary biliary cirrhosis and intrahepatic cholangiocarcinomas. Pyogenic cholangitis that's due to strictures and hepatolithiasis tends to recur; therefore, operations such as stricturoplasty, hepaticojejunostomy and liver resection are inevitable. The primary goals of surgery are to eliminate stones and the atrophic liver tissue, and to correct the bile stasis. Recent advances have been made in noninvasive treatments, such as percutaneous transhepatic cholangioscopic lithotripsy (PTCSL). Because postoperative residual stones and recurrent stones occur frequently, PTCSL and dilatation therapy will improve the outcomes of patients suffering with hepatolithiasis combined with bile duct stricture.

The Outcome after Curative Resection for a Huge (> or = 10cm) Hepatocellular Carcinoma

PURPOSE: Recent studies have reported improved perioperative and long-term outcomes for the initial postoperative results for patients with a huge HCC. The purpose of this study was to investigate the surgical outcomes of patients with a huge HCC and we wanted to identify any subgroup that would likely benefit from hepatic resection. METHODS: From January 1996 to August 2006, 55 patients were diagnosed with a huge HCC (> or = 10cm in diameter). All the tumors were classified as either the expanding nodular type or the non- expanding nodular type. RESULTS: The mean age of the patients was 50.6 years and 39 patients were male. The most common cause of liver disease was hepatitis B virus. The mean size of tumor was 11.9 cm. Microscopic liver cirrhosis was present in 17 patients. Twenty-three patients had tumors of the expanding nodular type. Curative resection was performed in 50 patients. The 5-year diseasefree and overall survival rates after resection were 35.8% and 41.0%, respectively. Univariate analysis revealed that surgical margins of < or = 1.0, a non-curative resection, the non-expanding nodular type and microscopic vascular invasion were adverse prognostic factors for survival. Multivariate analysis indicated that the gross tumor classification (expanding nodular vs. nonexpanding nodular) was the only independent prognostic factor. CONCLUSIONS: Huge HCC is not a homogenous group and the gross tumor pattern may represent the biologic behavior of huge HCC. Because the outcome of surgical treatment is far better than that of non-surgical treatment, resection should be actively considered for patients with a huge HCC. An expanding nodular type tumor is the best candidate for surgical resection.

Single Center Experience (Ten Years) with Surgical Resection for Treating Hepatocellular Carcinoma: Strategies for improving the long-term survival after resection

PURPOSE: Although surgical resection is the most effective treatment for hepatocellular carcinoma (HCC), high recurrence after resection is a major challenging problem. We attempted to determine the optimal strategies for improving the long-term surgical outcome through the review of our 10 years' experience with surgically treating HCC. METHODS: We retrospectively reviewed 497 patients who received curative resection at the Yonsei University Health System from January 1996 to August 2006. RESULTS: The 5 year disease-free rate and the overall survival rate after curative resection were 45.0% and 63.9%, respectively. Of the 497 patients, 491 (98.8%) were Child-Pugh A and 107 (56.3%) were diagnosed with liver cirrhosis. The postoperative complication and mortality rates were 28.6% and 1.8%, respectively. Of the 243 recurrent patients, 184 (75.7%) were diagnosed with intrahepatic recurrence alone. Of these intrahepatic recurrent patients, 169 (91.9%) received active treatment, including transplantation (n=7), re-resection (n=12), local ablation therapy (n=18) and transarterial chemoembolization (n=132). Multivariate analysis revealed that perioperative transfusion, a satellite nodule, the pathologic TNM stage, the Edmondsons-Steiner grade, the serum alkaline phosphatase (ALP) and aspartate aminotransferase levels and cirrhosis were associated with disease free survival, and perioperative transfusion, a satellite nodule, macroscopic vascular invasion, the Edmondsons-Steiner grade, the ALP and serum albumin levels and the platelet count were related with overall survival after resection. CONCLUSIONS: The long-term surgical outcome of HCC can be further improved by proper patient selection, delicately performed surgery and administering postoperative adjuvant therapy for patients with a high risk of recurrence. Early diagnosis and aggressive treatment are needed to treat the recurrence