The Oncologic Implications of Tumor Multiplicity in Intrahepatic Cholangiocarcinoma: Its Prognostic Value Might Be Underestimated / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#In the latest staging system of the American Joint Committee on Cancer for intrahepatic cholangiocarcinoma (IHCCC), solitary tumors with vascular invasion and multiple tumors are grouped together as T2. However, recent studies report that multifocal IHCCC has a worse prognosis than a single lesion. This study aimed to investigate the risk factors for IHCCC and explore the prognostic significance of multiplicity after surgical resection. @*Materials and Methods@#A total of 257 patients underwent surgery for IHCCC from 2010 to 2019 and the clinicopathological data were retrospectively reviewed. Risk factor analysis was performed to identify variables associated with survival after resection. Survival outcomes were compared between patients with solitary and multiple tumors. @*Results@#In multivariable analysis, the presence of preoperative symptoms, tumor size, lymph node ratio, multiplicity, and tumor differentiation were identified as risk factors for survival. Among 82 patients with T2, overall survival was significantly longer in patients with solitary tumors (sT2) than in those with multiple tumors (mT2) (p=0.017). Survival was compared among patients with stage II-sT2, stage II-mT2, and stage III. The stage II-sT2 group showed prolonged survival when compared with stage II-mT2 or stage III. Survivals of stage II-mT2 and stage III patients were not statistically different. @*Conclusion@#Tumor multiplicity was an independent risk factor for overall survival of IHCCC after surgical resection. Patients with multiple tumors showed poorer survival than patients with a single tumor. The oncologic significance of multiplicity in IHCCC should be reappraised and reflected in the next staging system update.

Comparison between percutaneous transhepatic gallbladder drainage and upfront laparoscopic cholecystectomy in patients with moderate-to-severe acute cholecystitis: a propensity score-matched analysis

Purpose@#In the Tokyo Guidelines 2018 (TG18), emergency laparoscopic cholecystectomy is recognized as a crucial early treatment option for acute cholecystitis. However, early laparoscopic intervention in patients with moderate-to-severe acute cholecystitis or those with severe comorbidities may increase the risk of complications. Therefore, in the present study, we investigated the association between early laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) in moderate-to-severe acute cholecystitis patients. @*Methods@#We retrospectively analyzed 835 TG18 grade II or III acute cholecystitis patients who underwent laparoscopic cholecystectomy at 4 tertiary medical centers in the Republic of Korea. Patients were classified into 2 groups according to whether PTGBD was performed before surgery, and their short-term postoperative outcomes were analyzed retrospectively. @*Results@#The patients were divided into 2 groups, and 1:1 propensity score matching was conducted to establish the PTGBD group (n = 201) and the early laparoscopic cholecystectomy group (n = 201). The PTGBD group experienced significantly higher rates of preoperative systemic inflammatory response syndrome (24.9% vs. 6.5%, P < 0.001), pneumonia (7.5% vs.3.0%, P = 0.045), and cardiac disease (67.2% vs. 57.7%, P = 0.041) than the early operation group. However, there was no difference in biliary complication (hazard ratio, 1.103; 95% confidence interval, 0.519–2.343; P = 0.799) between the PTGBD group and early laparoscopic cholecystectomy group. @*Conclusion@#In most cases of moderate-to-severe cholecystitis, early laparoscopic cholecystectomy was relatively feasible.However, PTGBD should be considered if patients have the risk factor of underlying disease when experiencing general anesthesia.

External validation of risk prediction platforms for pancreatic fistula after pancreatoduodenectomy using nomograms and artificial intelligence

Purpose@#Postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD).We previously developed nomogram- and artificial intelligence (AI)-based risk prediction platforms for POPF after PD. This study aims to externally validate these platforms. @*Methods@#Between January 2007 and December 2016, a total of 1,576 patients who underwent PD in Seoul National University Hospital, Ilsan Paik Hospital, and Boramae Medical Center were retrospectively reviewed. The individual risk scores for POPF were calculated using each platform by Samsung Medical Center. The predictive ability was evaluated using a receiver operating characteristic curve and the area under the curve (AUC). The optimal predictive value was obtained via backward elimination in accordance with the results from the AI development process. @*Results@#The AUC of the nomogram after external validation was 0.679 (P < 0.001). The values of AUC after backward elimination in the AI model varied from 0.585 to 0.672. A total of 13 risk factors represented the maximal AUC of 0.672 (P < 0.001). @*Conclusion@#We performed external validation of previously developed platforms for predicting POPF. Further research is needed to investigate other potential risk factors and thereby improve the predictability of the platform.

Development and External Validation of Survival Prediction Model for Pancreatic Cancer Using Two Nationwide Databases: Surveillance, Epidemiology and End Results (SEER) and Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP)

Background/Aims@#Several prediction models for evaluating the prognosis of nonmetastatic resected pancreatic ductal adenocarcinoma (PDAC) have been developed, and their performances were reported to be superior to that of the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. We developed a prediction model to evaluate the prognosis of resected PDAC and externally validated it with data from a nationwide Korean database. @*Methods@#Data from the Surveillance, Epidemiology and End Results (SEER) database were utilized for model development, and data from the Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP) database were used for external validation. Potential candidate variables for model development were age, sex, histologic differentiation, tumor location, adjuvant chemotherapy, and the AJCC 8th staging system T and N stages. For external validation, the concordance index (C-index) and time-dependent area under the receiver operating characteristic curve (AUC) were evaluated. @*Results@#Between 2004 and 2016, data from 9,624 patients were utilized for model development, and data from 3,282 patients were used for external validation. In the multivariate Cox proportional hazard model, age, sex, tumor location, T and N stages, histologic differentiation, and adjuvant chemotherapy were independent prognostic factors for resected PDAC. After an exhaustive search and 10-fold cross validation, the best model was finally developed, which included all prognostic variables. The C-index, 1-year, 2-year, 3-year, and 5-year time-dependent AUCs were 0.628, 0.650, 0.665, 0.675, and 0.686, respectively. @*Conclusions@#The survival prediction model for resected PDAC could provide quantitative survival probabilities with reliable performance. External validation studies with other nationwide databases are needed to evaluate the performance of this model.

Prognostic factors predicting survival rate over 10 years of patients with intrahepatic cholangiocarcinoma after hepatic resection

PURPOSE: Hepatic resection is considered as the optimal treatment for intrahepatic cholangiocarcinoma (IHCC); however, the survival rate after resection is low and the analysis of long-term (≥10 years) survivors is rare. This study aims to analyze the clinicopathological factors affecting the long-term survival of patients with IHCC.METHODS: Between January 2003 and December 2012, a single-institution cohort of 429 patients who underwent hepatic resection for IHCC were reviewed retrospectively. Surgical results, recurrence, and survival rates were investigated, and multivariate analyses were performed to identify prognostic factors.RESULTS: The overall 1- , 3- , 5- and 10-year survival rates of patients were 76.5%, 44.1%, 33.3%, and 25.1%, respectively. Multivariate analysis showed that the serum CA 19-9 level (≥38 U/mL) (P < 0.001), lymph node (LN) metastasis (P = 0.001), and lymphovascular invasion (LVI) (P = 0.012) were independent factors associated with overall survival. In particular, CA 19-9 level and histologic type were determined to be independent factors affecting survival for more than 10 years.CONCLUSION: CA 19-9 (≥38 U/mL), LN metastasis, and LVI were identified as independent risk factors for survival after resection of IHCC. CA 19-9 (<38 U/mL) and histologic type were independent factors predicting survival for more than 10 years.

Transduodenal ampullectomy for ampullary tumors - single center experience of consecutive 26 patients

PURPOSE: Transduodenal ampullectomy (TDA) has been reported in a limited number of cases and in a small number of case series. The aim of this study was to analyze perioperative and long-term oncological outcomes of patients with ampullary tumors who underwent TDA in a single large-volume center. METHODS: Through a retrospective review of data from 2004 to 2016, we identified 26 patients who underwent TDA at Asan Medical Center. RESULTS: Eleven of 26 patients underwent TDA for T1 and carcinoma in situ (high-grade dysplasia) cancer; these patients are still alive without recurrence. A major in-hospital complication (3.8%) occurred in 1 case, but there was no case of 90-day mortality. In addition, none of the patients was diagnosed as having newly developed diabetes mellitus after TDA. No significant differences were found between open and laparoscopic-TDA in terms of operation time, painkiller use, and hospital stay. CONCLUSION: TDA is a feasible and effective surgical procedure for the treatment of selected patients with ampullary tumors. It is an alternative treatment option in cases of ampullary tumors not amenable to endoscopic papillectomy or pancreaticoduodenectomy.

Branch duct intraductal papillary mucinous neoplasm of the pancreas: single-center experience with 324 patients who underwent surgical resection

BACKGROUNDS/AIMS: International treatment guidelines for branch duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas have been proposed, for features associated with malignancy and invasiveness. We investigated the clinicopathological characteristics that are predictive of malignancy or invasiveness and disease recurrence. METHODS: A review of 324 patients with resected and pathologically confirmed BD-IPMN, between March 1997 and December 2013, was conducted. RESULTS: There were 144 (44.4%) low grade dysplasia (LGD), 138 (42.6%) intermediate grade dysplasia (IMGD), 17 (5.3%) high grade dysplasia (HGD), and 25 (7.7%) invasive carcinoma (invIPMC) cases. The 5-year survival rates were 98.1% for LGD, 95.3% for IMGD, 100% for HGD, and 71.8% for invIPMC. Through a univariate analysis, the male sex was associated with malignancy, and CA19-9 was related to both malignant and invasive IPMN. The high risk or worrisome features of the international guidelines were associated with both malignant and invasive IPMN: the total bilirubin of the head/uncinate lesion, tumor size, mural nodule, and the size of the main pancreatic duct (MPD). Through a multivariate analysis, the male sex, elevated CA19-9, mural nodule, and dilated MPD diameter were independently correlated with the malignant IPMN. The elevated CA19-9 and dilated MPD diameter were also correlated with invasive carcinoma. The patient age and the initial pathological diagnosis were strongly associated with disease recurrence following surgical resection. CONCLUSIONS: The high risk or worrisome features in the current treatment guidelines for BD-IPMN are confined to the morphological characteristics of the disease. Patient factors and biological features should also be considered in order to develop optimal therapeutic or surveillance strategies.

Surgical Treatment of Adult Degenerative Scoliosis

The rapid increase of elderly population has resulted in increased prevalence of adult scoliosis. Adult scoliosis is divided into adult idiopathic scoliosis and adult degenerative scoliosis. These two types of scoliosis vary in patient age, curve pattern and clinical symptoms, which necessitate different surgical indications and options. Back pain and deformity are major indications for surgery in adult idiopathic scoliosis, whereas radiating pain to the legs due to foraminal stenosis is what often requires surgery in adult degenerative scoliosis. When selecting a surgical method, major symptoms and underlying medical diseases should be carefully evaluated, not only to relieve symptoms but also to minimize postoperative complications. Surgical options for adult degenerative scoliosis include: decompression alone; decompression and limited short fusion; and decompression coupled with long fusion and correction of deformity. Decompression and limited short fusion can be applied to patients with a small Cobb's angle and normal sagittal imbalance. For those with a large Cobb's angle and positive sagittal imbalance, long fusion with correction of deformity is required. When long fusion is applied, a careful decision regarding the extent of fusion level should be made when selecting L5 or S1 as the distal fusion level and T10 or the thoracolumbar junction as the proximal fusion level. For the fusion extending to the sacrum, restoration of sagittal balance and rigid fixation with additional iliac screws should be considered. Any surgical procedures for adult degenerative scoliosis are known to have relatively high occurrences of complications; therefore, risks and benefits should be meticulously considered before selecting a surgical procedure.

Performance of chromID Clostridium difficile Agar Compared with BBL C. difficile Selective Agar for Detection of C. difficile in Stool Specimens

We evaluated the performance of a new chromogenic medium for detection of Clostridium difficile, chromID C. difficile agar (CDIF; bioMerieux, France), by comparison with BBL C. difficile Selective Agar (CDSA; Becton Dickinson and Company, USA). After heat pre-treatment (80degrees C, 5 min), 185 diarrheal stool samples were inoculated onto the two media types and incubated anaerobically for 24 hr and 48 hr for CDIF and for 48 hr and 72 hr for CDSA. All typical colonies on each medium were examined by Gram staining, and the gram-positive rods confirmed to contain the tpi gene by PCR were identified as C. difficile. C. difficile was recovered from 36 samples by using a combination of the two media. The sensitivity with CDIF 48 hr was highest (100%) and was significantly higher than that with CDIF 24 hr (58.3%; P<0.001), because samples with a low burden of C. difficile tended to require prolonged incubation up to 48 hr (P<0.001). The specificity of CDIF 24 hr and CDIF 48 hr (99.3% and 90.6%, respectively) was significantly higher than that of CDSA 48 hr and CDSA 72 hr (72.5% and 67.1%, respectively; P<0.001). CDIF was effective for detecting C. difficile in heat-pretreated stool specimens, thus reducing unnecessary testing for toxin production in non-C. difficile isolates and turnaround time.

Clinical Results of Auto-Iliac Cancellous Bone Grafts Combined with Implantation of Autologous Bone Marrow Cells for Osteonecrosis of the Femoral Head: A Minimum 5-Year Follow-Up

PURPOSE: There are no reports about bone graft and cell therapy for the osteonecrosis of femoral head (ONFH). We prospectively evaluated the clinical results of auto-iliac cancellous bone grafts combined with implantation of autologous bone marrow cells for ONFH. MATERIALS AND METHODS: Sixty-one hips in 52 patients with ONFH treated with bone graft and cell therapy were enrolled, and the average follow-up of the patients was 68 (60-88) months. Necrotic lesions were classified according to their size by the Steinberg method and location of necrosis. RESULTS: At the last follow-up, the percentage of excellent or good results was 80% (12/15 hips) in the small lesion group, 65% (17/26 hips) in the medium size group, and 28% (6/20 hips) in the large size group. The procedures were a clinical success in 4 of 5 hips (80%) of stage I, 23 of 35 hips (65.7%) of stage II, 7 of 18 hips (38.9%) of stage III, and 1 of 3 hips (33.3%) of stage IV grade, according to the Association Research Circulation Osseous grading system. Among the 20 cases with large sized necrotic lesions, 17 cases were laterally located and this group showed the worst outcomes, with 13 hips (76.5%) having bad or failed clinical results. CONCLUSION: The results of the present study suggested that patients who have a large sized lesion or medium sized laterally located lesion would not be good candidates for the head preserving procedure. However, for medium sized lesions, this procedure generated clinical results comparable to those of other head preserving procedures.

Liver Abscess Caused by Edwardsiella tarda: A Case Report

Edwardsiella tarda is a member of the family Enterobacteriaceae, commonly found in tropical and subtropical aquatic environments. Most E. tarda infections are linked to exposure to water or animals that inhabit water. However, it is still an uncommon pathogen in humans and causes mainly watery diarrhea. We describe a case of liver abscess caused by E. tarda. A 60-yr-old Korean man, with underlying diabetes mellitus, had a 10-day stay in Egypt 15 days before presentation. Ultrasound-guided percutaneous transhepatic abscess aspiration was performed. Pus culture revealed E. tarda, which was susceptible to all the antibiotics commonly used against Gram-negative organisms. The patient was treated with cefobactam for 10 days and piperacillin/tazobactam for another 5 days combined with an additional abscess aspiration due to recurrent fever. This therapy led to clinical improvement. The possible source of infection in this case may have been the drinking water supplied during travel in Egypt, but we cannot completely rule out a domestic source, because a liver abscess caused by E. tarda has been reported in a Japanese patient without travel history. Considering the Korean custom of eating raw fish or shrimp, climate changes, and increasing international travel, infections due to E. tarda may increase in Korea. Clinical microbiologists should be aware of this potential pathogen, and prompt investigation of the infection source and site is needed.

Subsequent Hip Fracture in Osteoporotic Hip Fracture Patients

PURPOSE: A significant number of patients who have experienced previous surgical treatment for an osteoporotic hip fracture experience a subsequent hip fracture (SHF) on the opposite side. This study aims to analyze the risk factors and the correlation between osteoporosis and SHF on the opposite side in order to assess the usefulness of bisphosphonate treatment for the prevention of SHFs. MATERIALS AND METHODS: We included 517 patients treated from March 1997 to April 2009 in this study. The inclusion criteria included previous unilateral hip fracture, without osteoporotic treatment, and a T-score less than -3.0 at the time of the fracture. We studied these patients in terms of death, SHF, alcoholism, living alone, dementia, dizziness, health status, osteoporotic treatment after fracture and bone mineral density (BMD). In total, 34 patients experienced a SHF. We selected another 34 patients without a SHF who had similar age, sex, body mass index, BMD, diagnosis, treatment and a follow up period for a matched pair study. We compared these two groups. The average follow up was 8.3 years and 8.1 years, respectively. RESULTS: The mortality rate of the 517 patients was 138 (27%). The BMD at the time of fracture demonstrated no statistical difference between the two groups (p>0.05). Nine patients (26%) within the SHF group were prescribed Risedronate and 18 patients (53%) received the same treatment in the non-SHF group. There was a statistical relationship with the treatment of osteoporosis (p=0.026). The average BMD of patients with SHF was -5.13 and -5.02 in patients without SHF was (p>0.05). CONCLUSION: Although primary surgical treatments are important for an excellent outcome in osteoporotic hip fractures, treatment of osteoporosis itself is just as important for preventing SHFs.

Total Hip Arthroplasty Using S-ROM Prosthesis for Dysplastic Hip

PURPOSE: The purpose of this study was to evaluate the clinical and radiological results of total hip arthroplasty using a proximal modular femoral stem in patients who had secondary coxarthrosis associated with a dysplastic hip. MATERIALS AND METHODS: Forty-two patients (45 hips) with secondary coxarthrosis were evaluated after undergoing primary total hip arthroplasty using an S-ROM proximal modular femoral stem. The average follow-up was 80 months (range: 60 to 96 months). Clinical and radiological assessments were performed based on the Harris hip score and the radiological changes around the prosthesis. RESULTS: The average Harris hip score improved from 52.2 points to 88.5 points. All femoral stems showed stable fixation; there were 37 cases by bony ingrowth and 8 cases by stable fibrous ingrowth. Neither osteolysis nor progressive radiolucent lines around the femoral stem were found at the last follow-up. Forty-one hips (91.9%) revealed excellent or good clinical results at the most recent follow-up. CONCLUSION: For advanced secondary coxarthrosis, total hip arthroplasty with the use of the proximal modular femoral stem yielded good mid-term results with respect to the clinical and radiological criteria.

Pelvic actinomycosis associated with bilateral hydronephrosis developed in a nulligravida woman / 대한산부인과학회지

Pelvic actinomycosis is well-known to be associated with the longstanding use of intrauterine devices, sometimes related with a pregnancy history and an obstetric and/or gynecologic surgery. It can extend to the retroperitoneum and may also be associated with ureteral obstruction. In this case, pelvic actinomycosis in the form of bilateral tubo-ovarian abscess extending to the retroperitoneum resulting in bilateral hydronephrosis occurred in a nulligravida woman who had only few prior sexual intercourses. Apparently, pelvic actinomycosis can occur without any specific history. Moreover, such could possibly give rise to hydronephrosis by direct extension to the retroperitoneum.

Laparoscopic Necrosectomy for Treating Infected Necrotizing Pancreatitis

Infected pancreatic necrosis is generally considered as an indication for surgical management, and this condition has traditionally been treated by laparotomy. However, open surgery still has high morbidity and mortality rates. The application of minimally invasive surgery to this disease entity has been recently tried with the possibility of incurring less morbidity. Herein we report on two cases of successful laparoscopic necrosectomy for treating infected pancreatic necrosis. Two patients developed acute necrotizing pancreatitis that involved the neck, body and tail of the pancreas after heavy drinking. Initially, percutanous drainage (PCD) was performed for these lesions. However, surgical debridement was decided on due to the patients' non-responsiveness to medical treatment and infection was documented in the drainage fluid. Laparoscopic necrosectomy was performed using 5 trocars. The transmesocolic approach was adopted for the lesion around the pancreas body and tail, and the transgastrocolic approach was used for the lesion around the pancreas neck. The operation time was 190 and 225 minutes, respectively. There was no mortality. Although a pancreatic fistula occurred in one patient, it was improved by conservative management. Our cases show the technical feasibility and effectiveness of laparoscopic necrosectomy, but more experience is needed for this procedure to become a useful treatment option for infected pancreatic necrosis.

Chylous ascites, following radical hysterectomy with pelvic lymph node dissection in a patient with cervical cancer / 대한산부인과학회지

Chylous ascites is a disorder caused by various diseases and conditions that interfere with the abdominal or retroperitoneal lymphatics. There are several gynecologic reports on chylous ascites with radiation therapy and para-aortic lymph node dissection. However, the report of chylous ascites caused by performing only pelvic lymph node dissection was extremely rare. In most cases after surgical trauma, it is resolved after dietary managements but it may be associated with serious nutritional and immunologic consequences due to the constant loss of protein and lymphocytes. The authors experienced a 42-year-old woman with cervical cancer Ib1 who presented with chylous ascites after a radical hysterectomy and bilateral pelvic lymph node dissection. She was successfully managed by fasting and low fat diet. We report this case of chylous ascites following pelvic lymph node dissection with a brief review of literature.

Comparison of perinatal outcomes with gestational weeks and severity of disease in the preterm delivery associated with preeclampsia / 대한산부인과학회지

OBJECTIVE: The purpose of this study was to comparison of perinatal outcomes with gestational weeks and severity of disease in the preterm delivery associated with preeclampsia. METHODS: Of the 274 cases, we reviewed retrospectively the medical records of 176 preeclampsia mothers and infants delivered before 37 weeks of gestation in the Department of Obstetrics and Gynecology, Inje University Ilsanpaik Hospital from January 2000 to December 2006. RESULTS: In preeclampsia related to premature birth, it was not different the frequency of maternal age and parity in both mild and severe group. Among indications of delivery, nonreassuring fetal heart rate pattern was most frequent in mild preeclampsia, and maternal condition was in severe preeclampsia. In addition, the rate of cesarean section was higher in severe preeclampsia. Only the severity of preeclampsia was related to prognosis in mothers. On the other hands, gestational weeks on delivery and severity of preeclampsia were related to prognosis in neonates who were born 27(+0)~33(+6) gestatonal weeks. In each group of delayed birth, no statistical significance was observed in maternal and neonatal complications according to birth delay. CONCLUSIONS: In case of maternal complications, severity of preeclampsia is related to prognosis. In case of neonatal complications, if the delivery is between 27(+0)~33(+6) gestational weeks, gestational weeks and severity of preeclampsia are importatnt indicators related to the neonate's prognosis. After 34(+0) gestational weeks, severity of preeclampsia and gestational weeks of delivery are not related to the neonate's prognosis.

Expression of Survivin in extrapelvic endometriosis / 대한산부인과학회지

OBJECTIVE: To examine survivin expression in extrapelvic endometriosis. METHODS: The study group consisted of 14 cases with extrapelvic endometriosis which were confirmed histologically. The control group (total, n=47) was divided into 2 groups. Group I included normal endometrium (n=34) obtained from hysterectomy specimens with myoma and without endometriosis. Group II included ovarian endometrioma (n=13) obtained from laparoscopy. Expression of survivin was immunohistochemically confirmed. RESULTS: In extrapelvic endometriosis, the expression of nucleus in glandular epithelium and stromal cells were significantly stronger than normal endometrium. But cytoplasm expression of glandular epithelial cells and stromal cells in extrapelvic endometriosis showed statistically lower in comparison with normal endometrium. In ovarian endometrioma, the expression of nucleus in glandular epithelial cells and stromal cells was significantly stronger than normal endometrium. But the expression of nucleus in glandular epithelial cells with ovarian endometrioma was stronger than during proliferative phase but was not significant. Also cytoplasm expression of ovarian endometrioma was lower than normal endometrium. There was no difference in survivin expression between extrapelvic endometriosis and ovarian endometrioma. CONCLUSIONS: In extrapelvic endometriosis, survivin expression was stronger than normal endometrium except cytoplasm. Our findings suggest that increased survivin expression may contribute to survival of extrapelvic implants.

Total Laparoscopic Liver Resection for a Metastatic Lesion Located in the Caudate Lobe

Isolated resection of the caudate lobe of the liver is a technically demanding operation because of its unique anatomical location. Moreover the laparoscopic approach for this operative procedure has been rarely attempted. We report on a total laparoscopic liver resection of the caudate lobe including Spiegel lobe and most of paracaval portion that was performed in a 63-year-old male with a colorectal liver metastasis. The operative procedure was performed using five trocars with the patient placed in the lithotomy position. The operative time was 170 minutes. Blood loss was 350 ml and no perioperaive transfusion was needed. The patient was discharged on postoperative day 4 without any significant complications. This case shows that total laparoscopic liver resection of the caudate lobe is a feasible operation and that laparoscopic approach may be a useful option for the lesion located in Spiegel lobe in selected cases.

Clinical Analysis on Patients with Traumatic Liver Injury

PURPOSE: The liver is one of the most commonly injured organs in abdominal trauma. Surgery has played a major role in treating traumatic liver injury. Recently, it was reported that conservative treatment could be the first-line management for hemodynamically stable patients without combined intraabdominal surgical problems. The aim of this study was to examine the prognostic factors in traumatic liver injury. METHODS: The medical records of 41 patients who were treated for traumatic liver injury at Seoul National University Bundang Hospital from March 2003 to October 2007 were retrospectively reviewed. RESULTS: Among the 41 patients, 34 cases (82.9%) were managed nonsurgically, and 7 cases (17.1%) were managed surgically. Out of the 5 (12.2%) mortalities, 2 were encountered in those who underwent surgery, and 3 were encountered in those who were treated nonsurgically. Univariate analysis showed that the initial systolic blood pressure, the initial hemoglobin level, and the grade of liver injury were significant prognostic factors for survival. Multivariate analysis indicated that initial low systolic blood pressure was the only independent risk factor. CONCLUSION: Patients with unstable vital signs initially have a poor prognosis. Aggressive management might be helpful for improving the survival rate in these patients.