Relationship between the risk of bile duct injury during laparoscopic cholecystectomy and the types of preoperative magnetic resonance cholangiopancreatiocography (MRCP)

BACKGROUNDS/AIMS: Bile duct injury is one of the potential severe complications that can occur during laparoscopic cholecystectomy, which can be cause by anatomic variations in the confluence of the bile duct. Recently magnetic resonance cholangiopancreatiocography (MRCP) has become a helpful tool to detect bile duct variation on a preoperative basis and to prevent bile duct injury during laparoscopic cholecystectomy, as well other hepatic surgeries. This study aimed to clarify the types of bile duct on MRCP and to search for a method of avoiding injury during laparoscopic cholecystectomy. METHODS: Between January 2009 and December 2010, 277 patients underwent laparoscopic cholecystectomy with preoperative MRCP in our institution. On a retrospective basis, the bile ducts were categorized into 5 types according to the Couinaud classification system. RESULTS: The proportion of types was revealed type A (70.4%), type B (8.7%), type C (19.5%), type D (0.7%), type E (0%), and type F (0.7%), respectively. Bile duct injury occurred in 4 cases (1.4%) during laparoscopic cholecystectomy. In particular, the possibility of aberrant extrahepatic confluence (Type C and F) represented the highest risk of duct injury (OR=11.89 [CI: 1.21-116.53]). CONCLUSIONS: Preoperative evaluation of the bile duct anatomy is important to avoid injury of duct during laparoscopic cholecystectomy. Specific types of bile duct variation should be considered as a high risk group for bile duct injury.

Cavo-caval intervention stent insertion after deceased-donor liver transplantation using side-to-side piggyback technique: report of a case

Liver transplantation with preservation of the recipient vena cava (piggyback technique) has been performed as an alternative to the conventional method. Outflow disturbance or obstruction of the vena cava in the early period after liver transplantation is associated with high morbidity and mortality. We used side-to-side cavo-caval anastomosis (modified piggyback technique) in a deceased-donor liver transplantation (DDLT) for venous outflow reconstruction. On postoperative day 9, the patient developed abdominal discomfort, and abnormal liver function showing serum total bilirubin of 6.2 mg/dl and serum AST/ALT of 297/597 IU/L. Doppler ultrasound showed mono-phasic wave forms of the hepatic vein. Computed tomography showed focal narrowing of 9.5 mmx12 mm in diameter at the cavo-caval anastomosis site. Liver biopsy was showed that there was no evidence of acute allograft rejection. Direct venogram showed stenosis of the cavo-caval anastomosis with a pressure gradient of 12 mmHg. An interventional stent was inserted in the stenotic site of the inferior vena cava, and the pressure gradient decreased to 2 mmHg. He was discharged from hospital on postoperative day 23 without any other complications. Herein we report a case of deceased-donor liver transplantation using the modified piggyback technique, who received an inferior vena cava stent due to stricture of the reconstructed orifice of the vena cava.

Xanthogranulomatous Cholecystitis: Clinical review of 14 cases

PURPOSE: Xanthogranulomatous cholecystitis_(XGC) is an unusual and destructive inflammatory process of the gallbladder and it's characterized by severe proliferative fibrosis. XGC usually presents with features of chronic cholecystitis or acute cholecystitis, yet clinically, radiologically and macroscopically, XGC may be difficult to differentiate from gallbladder cancer. The purpose of our study was to evaluate the radiologic features of XGC and their correlation with the clinical, pathologic and surgical findings. METHODS: We performed retrospective analysis on 14 cases of XGCs that were operated on between March 1999 and December 2005. The clinical features, preoperative radiologic findings, operative findings and postoperative courses were reviewed. RESULTS: Fourteen cases of XGC were found among 1451 cases of cholecystectomy (0.96%). Mirizzi's syndrome was observed in 35.7% of the patients. Cholelithiasis and a thickened gallbladder wall were frequent findings. The most characteristic CT finding was hypodense intramural nodule like microabscess, and this was seen in 42.8% of the patients. The most characteristic sonographic finding was the presence of hypoechoic nodule in the gallbladder wall, and this was seen in 55.5% of the patients. 9 patients underwent open cholecystectomy including one case of T-tube choledocholithotomy. Four of five patients who underwent laparoscopic cholecystectomy required conversion to open surgery. A malignant lesion was suspected preoperatively in two cases, and both underwent frozen biopsy during surgery. CONCLUSIONS: Although the preoperative diagnosis of XGC is difficult, the presence of hypodense intramural nodule on CT or hypoechoic nodule in the gallbladder wall on sonography is highly suggestive of XGC. As XGC may resemble malignancy, differentiation is essential, via intraoperative frozen biopsy to deliver the optimal surgical treatment.

Paraduodenal Hernia

Internal abdominal hernias are an unusual cause of intestinal occlusion. They are responsible for 2% of all the intestinal obstructions. Various types of hernia have been described. Paraduodenal hernias are relatively rare congenital malformations and result from incomplete rotation of the midgut with entrapment of the small intestine beneath the developing colon. We report a case of paraduodenal hernia of the small intestine in a 32-year-old man with presentation of intestinal obstruction. The patient suffered from nausea, vomiting and acute abdominal pain for 9 hours. Abdominal CT showed sac-like mass of clustered, dilatated small bowel in the right upper quadrant. At operation, herniation of small intestine into a retroperitoneal space through a defect on right mesocolon was noted. A right paraduodenal (mesocolic) hernia was diagnosed. The patient made an uneventful recovery except some diarrhea after extensive segmental resectio of strangulated small bowel. Paraduodenal hernia is important as it usually presents as intestinal obstruction, and is often misdiagnosed before laparotomy. Mortality is increased significantly with delays in surgical treatment. Though rare, paraduodenal hernia should be taken into account in a differential diagnosis of intestinal obstruction. Early surgical intervention allows uneventful recovery and also prevents the possible complication of gangrenous bowels.

A Clinical Analysis of Thyroglossal Duct Cyst and Sinus

PURPOSE: Anomalies in the thyroglossal duct are the most common midline, or paramedian cervical lesions of congenital origin. Presenting as a thyroglossal duct cyst (TGDC) or a thyroglossal duct sinus (TGDS), they are found in all age groups. This clinical study was intended to elucidate the clinical characteristics, and the outcomes, of surgical treatment of these anomalies. METHODS: Between January 1992 and May 2002, 91 patients underwent surgery for a TGDC or a TGDS at 4 hospitals affiliated to Hallym University. The demographics of the patients, the clinical characteristics of the lesions, and the outcomes of the treatments were retrospectively evaluated. These characteristics were evaluated according to age groups; younger than 15 (38 patients) and older than 15 (53 patients) years. RESULTS: The male to female ratio was 1.67: 1 (It is better to give the actual figures.), with the first decade showing the highest incidence in the age distribution (33%). Painless masses (83.6%) were the most common presenting symptom, with most symptoms having been manifest for less than 1 year (67%). TGDCs were 90% and TGDSs were 10%. There were 62 cases of infrahyoid and 18 of suprahyoid lesions, with 80 cases on the midline and 11 on the paramedian within 2 cm from the midline. Of the paramedian lesions, 2 cases were in the younger group and 9 were in the older group. This tendency of laterality in the location by age group showed no statistical significance (p=0.172). All the patients underwent a Sistrunk operation, and one experienced a recurrence. CONCLUSION: This study justified the Sistrunk operation as the treatment of choice for anomalies of the thyroglossal duct. The lateral lesions occurred in the old age groups more frequently. A careful approach is needed with paramedian cervial lesions in adults to avoid the loss of the proper treatment of possible hidden congenital lesions.

Pancreatic Islet Cell Autotransplantation in the Canine Model / 대한이식학회지

INTRODUCTION: Islet cell transplantation is an attractive alternative to whole organ pancreas transplantation, because it is clearly the safer and simpler surgical procedure for recipients. PURPOSE: The authors intended to examine the functional outcome of islet autografting and the factors related to islet graft survival in mongrel dogs. METHODS: Eighteen adult mongrel dogs were used for the study of total pancreatectomy and islet autotransplantation. The harvested total pancreas was preserved in iced Hank's balanced salt solution (HBSS). The islets were properly isolated by a modified Recordi method. RESULTS: The median volume of the transplanted pancreatic islet tissue was 2.1 mL (range 0.7 to 5.0) and purity was 63% (range 10 to 95). Twelve dogs from the experimental group having undergone successful autografting of islets were followed for a minimum of 6 weeks. Three of the 12 dogs maintained insulin secretory function for 6 weeks and the other 7 dogs showed normal Kg values for 6 months following islet transplantation. In the remaining 2 cases, islet graft function was sustained for 1 year. The median required insulin dosage for maintenance of normal FPG was 0.7 U/kg per day (range 0 to 1.6). The insulin requirement correlated well with the IEq/ kg level (r=.90, P6,000 IEq/kg had a better chance of being insulin-independent. CONCLUSION: In this study, we confirmed that autotransplantation of islet cells on pancreatectomized dogs can render nearly normoglycemia, and islet transplantation dogs can be used as a model for the assessment of insulin secretory function.

Tuberculous Abscess of the Graft in a Renal Transplant Recipient after Chronic Rejection: Case Report / 대한이식학회지

Tuberculosis is a significant opportunistic infection often found in transplant recipients. Although not common, tuberculosis has been known to develop in higher incidence among transplant recipients than in the general population. The diagnosis and treatment of the tuberculosis in transplant recipients are more complicated because of the side effects of antituberculous agents, their interaction with immunosuppressive drugs, and the higher incidence of atypical presentations with extrapulmonary disease. The patient in this report had no evidence of tuberculous infection anywhere through the body before the transplant. The course of disease was continuously devastating despite active antituberculosis therapy. Only after the transplant nephrectomy, patient's general condition improved. The authors report a patient with tuberculous abscess, developed in a renal allograft after chronic rejection.

Candida Polyarthritis in a Renal Transplant Patient / 대한이식학회지

Candidal infection has been known to cause significant morbidity and mortality in renal transplant patients. Type of immunosuppressive regimens, prolonged antibiotics therapy, metabolic derangement such as diabetes and corticosteroid use, the long-term use of indwelling urinary and intravenous catheters are important predisposing factors in the development of candidal infection. Septic arthritis caused by Candida species is relatively uncommon, occurring most frequently as a complication of disseminated candidiasis. Although several drugs are available for the treatment of Candida arthritis, intravenous amphotericin B therapy has been shown to most consistently result in successful treatment. We report herein successful outcome of treatment with amphotericin B for septic arthritis due to C. albicans after a successful second renal transplant.

A Clinical study of the Coexistion Thyroid Carcinoma in Hashimoto's Thyroiditis ( HT )

Being described first 1912 by Hashimoto, Chronic lymphocytic thyroiditis has been most commonly diagnosed as inflammatory thyroid disease. Despite of worldwide reports about the concomitant malignancy with Hashimoto's thyroiditis, the definite incidence of coexsiting malignancy and the etiologic relationship between these different pathologic conditions remains to be brought out. Analyzing 18 cases of coexisting thyroid carcinoma among 80 cases of Hashimoto's thyroiditis, confirmed by pathologic study at Presbyterian medical center in Chonju between 1991 and 1995, the authors intended to make guideline of management for them. The results are as follows: 1. The incidence of coexisting carcinoma with HT was 18/80(22.5%). 2. The average age of patients with coexisting carcinoma was 44.1 years and all of them were female.3. Cold nodules on thyroid scan were noticed in 23 cases(22.7%) of HT and 7 cases(33.8%) of coexisting carcinoma with HT. 4. Calcified lesions on thyroid sonography were detected in 0 cases of HT and 4 cases(50%) of coexisting carcinoma. 5. The pathologic types of carcinoma were papillary(17/18, 94.4%) and follicular(1/18, 5.6%). 6. 3 cases of coexisting carcinoma had metastatic lesions on peritracheal lymph nodes and another 3 cases had on ipsilateral jugular nodes. 7. The carcinoma of smaller than 0.5cm were 7 cases, of 0.6-1.0cm were 3 cases, of 1.1-1.5cm were 5 cases, and so 15 cases(83.3%) were occult carcinoma. Only 3 cases were larger than 1.6cm. 8. Coexisting carcinoma patients with HT underwent subtotal thyroidectomy (4 cases), subtotal thyroidectomy & anterior compartment dissection (ACD, 6 cases), subtotal thyroidectomy & modified RND (2 cases), thyroid lobectomy & ACD (4 cases), thyroid lobectomy & modified RND (1 cases), or near total thyroidectomy & ACD (1 case).

Treatment of Budd-Chiari Syndrome by Portacaval & Cavo-Atrial Bypass

The Budd-Chiari syndrome is no longer a rare disease in the world, but there has been small cases reported until now in Korea. There are three forms of Budd-Chiari syndrome, among them membranous web in the inferior vena cava is the most common form in the oriental area. Authors have expereinced the Budd-Chiari syndrome, 49 year old female patient, caused by membranous web associated with the long thrombus in the inferior vena cava. She underwent side-to-side portacaval shunt and cavoatrial shunt using 19 mm diameter, 25 cm length polytetrafluoroetylene graft. Postoperative major morbidities were ARF and pneumonia. She has improved clinically and pathologically after operation. It is concluded that combined portacaval shunt and cavoatrial shunt has been effective to relieve the symptoms of Budd-Chiari syndrome caused by membranous web and inferior vena cava thrombotic occlusion.