A comparison of the risk factors of intrahepatic recurrence, early recurrencen, and multiple recurrences after resection for single nodular hepatocellular carcinoma

BACKGROUNDS/AIMS: Intrahepatic recurrence is one of the most important causes of compromised prognosis after surgical resection of hepatocellular carcinoma (HCC). This retrospective study was designed to identify and compare the risks of recurrence, early recurrence and multiple recurrences in a single patient population. METHODS: A series of 92 consecutive patients, who received resection for single nodular HCC at our institute from January 2007 to December 2013, were enrolled in this study. The patients were divided into recurrent and non-recurrent groups; the recurrent group was further divided into subgroups by applying two criteria: early and late recurrence (with a cutoff of 18 months), and single and multiple (> or =2) recurrence. The potential risk factors were compared using univariate and multivariate analyses. The subgroup analysis was performed to determine the effects of different cut-off values on the analysis. RESULTS: 41 recurrences (44.6%) occurred during a mean follow-up of 42.4 months. The Child-Pugh score, and the portal vein invasion were found to be independent risk factors of recurrence, but differentiation was the only independent risk factor of early recurrence. The serum alpha-fetoprotein, tumor size, tumor necrosis, and hemorrhage were found to be the risk factors of multiple recurrences according to the univariate analysis, but lacked significance according to the multivariate analysis. When the cutoffs for early and multiple recurrences were changed to 3 nodules, respectively, different risk factors were identified. CONCLUSIONS: Our results implicated that different factors can predict the recurrence, timing, and multiplicity of an HCC recurrence. Further studies should be conducted to prove the complex relationships between tumor burden, invasiveness, and underlying liver cirrhosis for initial tumors, and the timing and multiplicity of recurrent HCC.

Extended distal pancreatectomy for advanced pancreatic neck cancer

BACKGROUNDS/AIMS: We investigated the clinical application of extended distal pancreatectomy in patients with pancreatic neck cancer accompanied by distal pancreatic atrophy. In this study, we have emphasized on the technical aspects of using the linear stapling device for a bulky target organ. METHODS: From March 2010 to September 2013, 46 patients with pancreatic adenocarcinoma, who underwent pancreatic resection with radical intent at our institute, were reviewed retrospectively. Among them, three patients (6.5%) underwent extended distal pancreatectomy. A linear stapling device and vise-grip locking pliers were used for en bloc resection of the distal pancreas, first duodenal portion, and distal common bile duct. The results were compared with those after standard pancreatectomy. RESULTS: All three patients presented with jaundice, and the ratio of pancreatic duct to parenchymal thickness of the pancreatic body was greater than 0.5. Grade A pancreatic fistula developed in all of the cases, but none of these fistulae were lethal. Pathological staging was T3N1M0 in all of the patients. The postoperative daily serum glucose fluctuations and insulin requirements were comparable to those in patients who received pancreaticoduodenectomy or distal pancreatectomy. At the last follow-up, two patients were alive with liver metastasis at 4 and 10 months postoperatively, respectively, and one patient died of liver metastasis at 5 months postoperatively. CONCLUSIONS: While the prognosis of advanced pancreatic neck adenocarcinoma is still dismal, extended distal pancreatectomy is a valid treatment option, especially when there is atrophy of the distal pancreas. Also, the procedure is technically feasible, and further refinement is necessary to improve patient survival.

Preliminary results of binding pancreaticojejunostomy

BACKGROUNDS/AIMS: The post-operative complications and clinical course of pancreaticoduodenectomy (PD) largely depend on the pancreaticojejunostomy (PJ). Several methods of PJ are in clinical use. We analyzed the early results of binding pancreaticojejunostomy (BPJ), a technique reported by SY Peng. METHODS: We retrospectively reviewed the clinical results of patients who received BPJ in Inha University Hospital from 2006 to 2011. 21 BPJs were performed with Peng's method. The definition of postoperative pancreatic fistula (PF) was a high amylase content (>3 times the upper normal serum value) of the drain fluid (of any measurable volume), at any time on or after the 3rd post-operative day. The pancreatic fistula was graded according to the International Study Group for Pancreatic Fistula (ISGPF) guidelines. RESULTS: Of the 21 patients who received BPJ, 11 were male. The median age was 61.2 years. PD surgery included 4 cases of Whipple's procedures and 17 cases of pylorus-preserving PD. According to the post-operative course, 16 patients recovered well with no evidence of PF. A total of 5 patients (23.8%), including 3 grade A PFs and 2 grade C PFs, suffered from a pancreatic fistula. 3 patients with grade A PF recovered with conservative management. CONCLUSIONS: The BPJ appears to be a relatively safe procedure based on this preliminary study, but further study is needed to validate its safety.

Transition of Treatment Modalities for Peripheral Arterial Occlusive Disease for the Recent 5 Years According to the TASC II Classifications in a Single Institution

PURPOSE: Endovascular treatment for peripheral arterial obstructive disease (PAOD) is replacing traditional arterial bypass in the western world. Yet there are few reports to evaluate the pattern of clinical practice pattern for PAOD in Korea. This study was conducted to evaluate the treatment pattern for PAOD between endovascular treatment and arterial bypass, and to compare their clinical characteristics. METHODS: We conducted a retrospective study on the prospectively maintained database of patients who underwent endovascular treatment and arterial bypass for PAOD from March 2005 to December 2009 in Inha University Hospital. The aortoiliac lesions and femoropopliteal lesions were categorized by the Trans Atlantic Inter-Society Consensus (TASC) II classifications. Their treatments and clinical characteristics were compared between the former period (2005~2007 y) and the latter period (2008~2009 y). RESULTS: Three hundred nine cases (178 patients) were treated for PAOD by either arterial bypass or endovascular treatment. The patients' mean age was 69.1+/-11.3 year old. There was no difference in clinical characteristics between the two periods except for age. Endovascular treatments of both aortoiliac and femoropopliteal arterial lesions were increased in the latter period (P=0.023, P<0.001). Also, the endovascular treatments were increased in the TASC C and D aortoiliac and femoropopliteal lesions in the latter period (P=0.020, P<0.001). CONCLUSION: Endovascular treatment for PAOD is increasing in clinical practice and this shows feasibility in critically ill patient with TASC C and D lesions, although arterial bypass is still important.

The Effect of Duodenojejunal Bypass for T2DM Patients Below BMI 25 kg/m2 in Early Postoperative Period

PURPOSE: Diabetes mellitus refers to one of several risk factors for cardiovascular diseases, renal failure and so on. Medical treatments of T2DM cannot suggest a perfect cure. But gastric bypass resulting in the exclusion of the duodenum and proximal jejunum has been shown to improve or resolve T2DM. The goal of this study is to evaluate the effect of duodenojejunal bypass for T2DM patients below BMI 25 kg/m2 in early postoperative period. METHODS: Duodenojejunal bypass was performed on 25 patients at Inha University Hospital from July 2009 to April 2010. We compared 75 g OGTT, insulin, C peptide to those 7 days postoperative. The definitions for improvement are serum glucose level below 200 mg/dl of 75 g OGTT at 120 min or below 200 mg/dl at every other time in spite of over 200 mg/dl at 120 min. RESULTS: A total of 25 patients (15 men and 10 women) were included. Median value BMI was 23.17 kg/m2 and the mean duration of T2DM was 8.3 years. There was a significant decrease of postoperative 75 g OGTT levels from 176, 268, 345, 373, 371 mg/dl to 125, 170, 200, 225 and 241 mg/dl, respectively (P<0.001). Only patients' age was an independent factor resolution of T2DM based on this study. CONCLUSION: Duodenojejunal bypass could be one viable treatment modality for improving or resolving of T2DM although these are early results. This study has preliminary meanings only and the results of longer follow-up and a larger number of patients are necessary, by which we should be able to determine the effect and indications for surgical treatment of T2DM.

Management of Duodenal Perforations after Endoscopic Retrograde Cholangiopancreatography / 대한소화기내시경학회지

BACKGROUND/AIMS: Surgery has been the mainstay of treatment for duodenal perforations after the introduction of endoscopic retrograde cholangiopancreatography (ERCP). Yet there have recently been arguments that conservative management with or without endoscopic intervention may be possible and safe. METHODS: For the patients who received ERCP at Inha University Hospital from Jan. 2001 to Dec. 2007, we retrospectively analyzed the clinical manifestations, the treatment and the clinical outcomes of the cases with duodenal perforation. RESULTS: Among the 1708 ERCP cases, duodenal perforation occurred in eleven (0.6%) patients. There were two cases of duodenal perforations (type I), four cases of peri-Vaterian injury (type II), two cases of bile duct perforations (type III) and three cases of retroperitoneal perforations (type IV). Six patients (55%) were treated surgically while the others were managed conservatively. Except for one death (9.1%), ten patients fully recovered. Either residual diseases or fluid collections, as seen on CT, were present in the surgically managed patients. The median time interval between ERCP and surgery was 19 hours (range: 8~30 hours). CONCLUSIONS: To decide on the management of duodenal perforation after ERCP, the presence of residual disease or the leakage of intraluminal contents should be considered along with the type of the perforation.

Efficacy and feasibility of laparoscopic subtotal cholecystectomy for acute cholecystitis

BACKGROUNDS/AIMS: For patients with acute cholecystitis, conversion from laparoscopic cholecystectomy to open surgery is not uncommon due to possibilities of serious hemorrhage at the liver bed and bile duct injury. Recent studies reported successful laparoscopic subtotal cholecystectomy for acute cholecystitis. The purpose of this study was to determine the efficacy and feasibility of such an operation based on the experience of surgeons at our facility. METHODS: In this study, we enrolled 144 patients who had received either laparoscopic subtotal cholecystectomy (LSC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC) for acute cholecystitis from January 2004 to December 2009 at the Department of Surgery of our hospital. Their symptoms, signs, operative findings, pathologic results and postoperative results were compared and analyzed. RESULTS: There were 26 patients in the LSC group 80 in the LC group and 38 in the OC group. There were no differences in mean age, sex, and symptoms of acute cholecystitis. The LSC group showed higher CRP levels (p<0.001) and a higher grade according to the Tokyo criteria (p=0.001). The mean operative time was 115.6 minutes and mean blood loss was 158.9 ml without intra-operative or postoperative transfusion. There weren't any bile duct injuries during the operation. No group suffered bile leakage. Drains were removed 3.3 days after the operation in the LC group, the shortest time compared to the other groups (p<0.001). LC and LSC groups demonstrated shorter postoperative hospital days and time to diet resumption than the OC group (p<0.001). CONCLUSIONS: LSC appears to be a safe and effective treatment in cases of severe acute cholecystitis that require consideration of conversion to open surgery.

Inferior Vena Cava (IVC) Filter Retrieval Rates after Catheter Directed Thrombolysis or Pharmacomechanical Thrombectomy in Deep Vein Thrombosis (DVT) and Its Characteristics

PURPOSE: Inferior vena cava (IVC) filter is commonly practiced to prevent pulmonary embolism during endovascular therapy of deep vein thrombosis (EndoDVT). When the thrombus is trapped inside the filter during intervention, its removal is quite challenging. The purpose of this study is to determine retrieval rates of IVC filter after EndoDVT and its characteristics. METHODS: Patients who underwent EndoDVT in Inha Unversity Hospital from June 2004 to May 2009 were reviewed retrospectively. Retrievable IVC filter was inserted before EndoDVT. EndoDVT was done by catheter directed thrombolysis or pharmacomechanical thrombectomy using urokinase. IVC filter retrieval was decided according to computed tomography after 2 weeks. RESULTS: 126 patients were treated with EndoDVT. Optease (n=101) and Tulip (n=25) IVC filters were inserted. IVC filters were retrieved in 42.9% (54/126). There was no IVC filter related complication during its insertion and removal. IVC filter was not retrieved in 72 patients. Reasons for its failure include residual thrombosis in IVC filter (n=28), high risk for recurrent DVT (n=34), massive pulmonary embolism (n=8), and death (n=2). Residual thrombus inside IVC filter disappeared in 5 patients during 6-month follow up. CONCLUSION: IVC filters retrieval rate after EndoDVT was 42.9%. This can be improved by thorough patient follow up and extended retrievability.

Clinical Experience with Hirschsprung's Disease

The aim of this study is to review our clinical experience with patients with Hirschsprung's disease (HD) Medical records of 39 children who underwent definitive surgery for HD at Inha University Hospital from September 1996 to June 2008 were analyzed by age at presentation, sex, gestational age, birth weight, clinical presentation, diagnostic tools, level of aganglionosis, surgical procedures, postoperative complications, and postoperative bowel function. Twenty-five patients (64.1%) were males and 14 (35.9%) were females. Thirty patients (76.9%) were diagnosed and treated in the neonatal period. The transitional zone was at the rectosigmoid region in 89.7%. Twenty-seven patients (69%) were treated by preliminary colostomy or ileostomy. Twenty-four patients had the Duhamel operation, 6 patients anorectal myectomy, and 9 patients had transanal endorectal pull-through (TEP). Five of 9 patients who had the TEP procedure did laparoscopic assistance. Postoperatively, seventeen patients (83%) passed stool once or more times per day and 3 patients had stool soiling. This study demonstrated that the majority of the patients had good results. To determine which treatment is most effective comparative review by operation method would be required.

Prevalence and Characteristics of Major Vascular Diseases of Elderly Men in the Incheon Area

PURPOSE: As Korea is an aging society (WHO classification) and projected to be an aged society in 10 years, peripheral vascular diseases (PVD) in the elderly population has emerged as an important social and medical issue. But their prevalence was rarely reported in Korea. The purpose of this study is to define the prevalence of carotid artery stenosis (CAS), abdominal aortic aneurysm (AAA), and peripheral arterial occlusive disease (PAOD) of lower limb in the Incheon area. METHODS: Elderly men (> or =65 years) were referred randomly from the Incheon Federation of Korean Senior Citizens' Association (from Nov 2008 to Sep 2009) to Inha Univeristy Hospital, Incheon, Korea for a PVD screening program. The subjects were screened for CAS and AAA by duplex. CAS was defined as > or =50% internal CAS and AAA as > or =3 cm aortic diameter in minor axis. PAOD of lower limb was screened by measurement of ankle brachial index (ABI); ABI of < or =0.9 was considered abnormal. RESULTS: 1150 subjects were screened including 103 octogenarians (9.0%). Mean age was 72.3+/-0.2 years. Combined conditions were hypertension (54.3%), diabetes mellitus (25.2%), coronary artery disease (15.6%), dyslipidemia (18.9%), obesity (31.1%) and smoking history (71.7%). CAS was detected in 7.7% (89/1,150) subjects. Thirty-three (2.9%) were diagnosed with AAA. PAOD was detected in 50 subjects (4.4%). CONCLUSION: Prevalence of PVD in Korea is not lower compared to that of western countries, especially the USA and the UK. A nationwide program for timely detection and treatment for PVD should be developed.

Predicting Factors of Nonsentinel Lymph Node Metastasis in Breast Cancer Patients with Sentinel Lymph Node Metastasis

PURPOSE: The purpose of this study was to investigate the predictors of nonsentinel lymph node (NSLN) metastasis in breast cancer and to evaluate the usefulness of the scoring systems and nomograms. METHODS: In this analysis, we reviewed the clinicopathologic features of 70 patients who had undergone sentinel lymph node (SLN) biopsy and axillary lymph node dissection. The clinical features of patients, histologic parameters and hormonal receptor status of primary tumor and histopathologic features of SLN metastasis were noted retrospectively. Furthermore, the receiver operating characteristic (ROC) curve was drawn and the area under the ROC curve (AUC) was calculated to assess the discriminative power of the scoring systems and nomograms. RESULTS: The metastatic tumor size in SLN (P<0.001), extracapsular invasion (P=0.002), percentage of positive SLNs among the removed SLNs (P=0.011), primary tumor size (P=0.038) were associated significantly with NSLN metastasis, statistically, in univariate analysis. Based on multivariate logistic regression, the metastatic tumor size was the only prognostic factor of NSLN metastasis (P=0.012). The AUC of Memorial Sloan-Kettering Cancer Center scoring system was greater than other systems, significantly (P=0.004). CONCLUSION: We have shown in this study that it would be possible to predict NSLN status based on the metastatic tumor size in SLN. Although the significance was not achieved in multivariate analysis, the size of primary tumor, extracapsular invasion of metastasis in SLN, percentage of positive SLNs among the removed SLNs had the potential to be a predictive factor of NSLN metastasis. MSKCC scoring system appears to be more effective and accurate than other scoring systems for selecting patients for whom axillary lymph node dissection can be avoided.

Clinical Experience of Endoleak after Endovascular Aortic Aneurysm Repair

PURPOSE: Endoleak is a common complication following endovascular aortic aneurysm repairs (EVAR). The aim of this study was to discover the frequency and characteristics after EVAR with on-label use. METHODS: A retrospective review was performed on 25 patients who underwent EVAR in Inha University Hospital between December 2005 and February 2009. The data included in this study accounted for patient characteristics, anatomic features, operative technical details, and types of devices used. The results of EVAR were analyzed for clinical success, technical success and endoleak. RESULTS: Endoleaks were observed during 11 (47.8%) procedures. Type I endoleaks were observed in 2 (18.2%) cases. A total of 6 type II intraoperative endoleaks (54.5%) were observed. 3 type III endoleaks (27.3%) occurred. But all endoleaks were resolved without additional intervention CT scan after 6 months. CONCLUSION: Although the endovascular management of AAAs is less invasive than open surgery, many complications including endoleak were still the most common adverse event during the first postoperative month. However, observation may be a good treatment for minor endoleak after EVAR.

Clinicopathological Characteristics of Apocrine Carcinoma of the Breast

PURPOSE: Apocrine carcinoma of the breast is rare and there is confusion about the criteria of its histopathologic diagnosis. The purpose of this study is to investigate the clinical and pathologic characteristics of the disease. METHODS: 9 patients diagnosed with apocrine carcinoma or apocrine carcinoma in situ and 1,009 patients diagnosed with non-apocrine carcinoma of the breast from April 1999 to March 2008 were retrospectively analyzed. RESULTS: The mean age of the patients with apocrine carcinoma was 52.3 year. 5 patients (55.6%) among 9 patients with apocrine carcinoma were postmenopausal. There were 2,1 and 6 patients with stage 0, I and II disease, respectively according the TNM stage. These demographic and clinical differences between the patients with apocrine carcinoma and non-apocrine carcinoma were not significant. Only four patients (44.4%) were preoperatively diagnosed with apocrine carcinoma or apocrine carcinoma in situ. By surgical biopsy, additional 5 patients were diagnosed as apocrine carcinoma. In the immunohistochemical study, Bcl-2 was positive in one (12.5%) of 8 patients. p53 was positive in 4 (44.4%) of 9 patients. Expressions of estrogen and progesterone receptor were positive only in two patients (22.2%) with weakly positive staining. Androgen receptor was positively expressed in all cases (100%) of apocrine carcinoma. Overexpression of c-erb-B2 was detected in four patients. CONCLUSION: Treatment modality and prognosis of apocrine carcinoma are similar as non-apocrine carcinoma. But its preoperative diagnosis is more difficult than that of non-apocrine carcinoma and it shows different expression of hormone receptor. Further study is needed for the development of new hormonal therapy using androgen.

Clinical Considerations of Intestinal Atresia

PURPOSE: The mortality of intestinal atresia has decreased remarkably owing to prenatal diagnosis, development of diagnosis method, neonatal intensive care, surgical technique, total parenteral nutrition and performing of early surgery. The clinical consideration of our experience about intestinal atresia would be helpful in the understanding of disease. METHODS: We reviewed the clinical presentation, hospital days, diagnosis method, surgical method, postoperative early complication and mortality based on medical records, retrospectively, in 32 cases of intestinal atresia encountered at Inha University Hospital between March 1997 and May 2009. RESULTS: The involved sites were; duodenum (n=11; 34.4%), jejunoileum (n=20; 62.5%), and colon (n=1; 3.1%). The mean postoperative fasting time was 6.38 days. The postoperative morbidity was 9.4% and mortality was 3.1%. CONCLUSION: Complete recovery from intestinal atresia can be insured by prompt diagnosis, early surgery and careful neonatal intensive care.

Comparison of Laparoscopic Adrenalectomy with Open Adrenalectomy for Adrenal Tumor / 대한내시경복강경외과학회지

PURPOSE: The definite indications of laparoscopic adrenalectomy (LA) and the limitations of minimally invasive surgery have yet to be determined. To verify the benefit and safety of LA, we compared the results of LA with those of open adrenalectomy (OA) and we further analyzed the clinical results of LA in accordance with the time period of performing this surgery. METHODS: We retrospectively reviewed 69 patients who received adrenalectomy between 1997 and 2008. We compared LA with OA. The LA was divided into subsets of the early and late groups, and the transperitoneal approach and retroperitoneal approach groups, and we compared and analyzed the results of each group, along with the results of the OA and LA groups. For each of the groups, we analyzed the following factors; age, gender, tumor size, tumor location, the operative time, the time under anesthesia, the amounts of blood loss and transfusion, the time to first oral intake, the length of the postoperative hospital stay and the complications. RESULTS: LA (25 cases), as compared to OA (20 cases), showed better results for the amount of transfusion, the time to first oral intake, the length of the postoperative hospital stay and the complication rates (p=0.032; p=0.017; p=0.02). As for CA (4 cases), the time to first oral intake and the length of the postoperative hospital stay were significantly longer than that of LA (p=0.001; p=0.021). LA done in the late period demonstrated less blood loss and a shorter time to first oral intake as compared to the LA of the early period (p=0.032; p=0.019). There were no significant statistical differences between the results of the peritoneal or retroperitoneal approaches. CONCLUSION: LA has the merits of a shortening hospital stay and decreased complication. Furthermore, as the experience with this type of surgery accumulates, these merits are likely to become stronger. Thus, surgeons are expected to carefully decide on choosing the surgical methods by fully understanding the benefits and indications of LA.

Laparoscopic Versus Open Appendectomy for Perforated Appendicitis in Children

PURPOSE: Appendectomy is the most common emergent surgical operation in children. Laparoscopic appendectomy is currently a popular procedure in children, but pediatric laparoscopic appendectomy is controversial for its efficacy and safety, especially for perforated appendicitis. We compared the efficacy and safety between laparoscopic appendectomy (LA) and open appendectomy (OA) for treating perforated appendicitis of children. METHODS: This study involved a total of 69 patients who underwent appendectomy for perforated appendicitis at our institution between March 2005 and September 2007, and these patients were less than 15 years old. There were 41 patients in the LA group and 28 patients in the OA group. The demographic data, operative time, length of the hospital stay, bowel movement, pain control and complications were assessed. RESULTS: There was no significant difference between the LA and OA groups with respect to gender, age, the operation time, the length of the hospital stay, bowel movement and pain control. There was one complication (2.4%) in the LA group and four complications (16.6%) in the OA group, but there was no significant difference (P=0.062). There was no wound infection. CONCLUSION: Laparoscopic appendectomy for the children with perforated appendicitis is a safe procedure. Yet we need further high quality randomized trials to compare the 2 techniques.

Risk Factors Affecting Pancreatic Fistula after Pancreaticoduodenectomy

PURPOSE: Pancreacticoduodenectomy is the procedure of choice for managing periampullary malignancy. But pancreatojejunostomy site leakage is a very critical complication because it is hard to prevent leakage. The aim of this study is to analyze the risk factors of pancreatic leakage after pancreaticoduodenectomy. METHODS: We retrospectively reviewed 172 consecutive patients who had received pancreaticoduodenectomy at Inha University Hospital between Apr. 1996 and Mar. 2006. We analyzed the pancreatic leakage rates according to the clinical characteristics, the pathologic and laboratory findings and the anastomosis methods. RESULTS: There were differences in the mean age and pathologic findings between the two groups. There were 115 (66.9%) patients older than 60 years, while the other 57 patients (33.1%) were younger than 60 years. The incidence of developing pancreatic fistula in patients older than 60 years was 21.7% (25/115) while this was 8.8% (5/57) for the younger patients, and the difference was significant (p=0.03). The patients with a dilated pancreatic duct showed a lower rate of esser post-operative pancreatic fistula than the patients with a non-dilated duct (p=0.001). Other factors, including the anastomosis method and the pathologic diagnosis, didn't show any statistical difference. According to the pathologic diagnosis, the patients with pancreatitis and stomach cancer revealed pancreatic fistula to a smaller extent; there were 6 cases (3.5%) of pancreatitis and 22(12.8%) of stomach cancer. Among the case with pancreatic fistula, there were 0 cases of pancreatitis and 2 cases (6,7%) of stomach cancer, but the difference was not statistically significant. CONCLUSION: Our study demonstrated that pancreatic fistula is related to age and a dilated pancreatic duct. Surgeon must take these risk factors into consideration when performing pancreaticoduodenectomy. We recommend surgeons to use skillful technique to prevent pancreatic fistula.

Patterns of First Failure after Management of Hilar Cholangiocarcinoma

PURPOSE: This study was conducted to evaluate the patterns of disease progression following either resection or palliative management of hilar cholangiocarcinoma and to clarify the polarity of the resection margin. METHODS: The medical records of 78 hilar cholangiocarcinoma patients who were admitted to the Inha University Hospital between June of 1996 and May of 2006 were retrospectively reviewed. The patterns of recurrence were compared between the margin positive, margin negative and palliative management groups, and factors influencing recurrence and survival were then analyzed using the Cox proportional hazard model. RESULTS: The hilar cholangiocarcinoma recurred or progressed in 56 patients (71.8%) following the initial treatment, and the median progression free survival (PFS) time was 10.1 months. The 3-yr estimates of overall relapse and the median PFS were 90.7% and 17 months, respectively, in the resection group (n=32) and 100% and 7 months, respectively, in the palliative group (n=46) (p=0.045). There was no significant difference observed in the 3-yr estimates of overall disease progression or the median PFS according to the margin positivity or resection methods. When the disease progression pattern was analyzed, there was no significant difference observed between the groups, however, the survival analysis showed that survival was greater in the group that underwent resection with curative intent than in the palliative management group (p=0.001). Adjuvant chemotherapy or radiotherapy had no effect on recurrence or survival, and poor differentiation was the only significant prognostic factor for survival identified when the Cox proportional hazard model was used. CONCLUSION: Because no difference in the pattern of disease progression existed, aggressive surgical resection should be attempted to prevent recurrence and to increase survival, even in cases in which a suspicious positive resection margin is present.

Gasless Endoscopic Thyroidectomy via an Anterior Chest Wall Approach Using a Flap-Lifting System

PURPOSE: Endoscopic thyroidectomy (ET) requires a proper working space for adequate visualization of anatomical structures and proper instrument manipulation. The purpose of this prospective study was to estimate the feasibility and safety of ET using an anterior chest wall approach without gas insufflation. MATERIALS AND METHODS: The working space was created under a direct and endoscopic view through a 3-cm incision on the anterior chest wall. A retracting device was then inserted to establish the working space, and subsequent procedures were performed endoscopically. All data were reviewed using a prospective database. RESULTS: We performed 30 ETs in patients with benign thyroid tumors from December 2003 to December 2005. The procedures were completed successfully in 29 patients (mean operative time: 160.6 min; range: 90-345 min). One patient with ET was converted to open thyroidectomy secondary to substernal extension of the tumor. None of the patients developed permanent postoperative hypocalcemia or recurrent laryngeal nerve paralysis. Three patients exhibited some degree of transient recurrent laryngeal nerve palsy. CONCLUSION: These data suggest that gasless ET using an anterior chest wall approach is safe and feasible in selected patients for treating benign thyroid tumors. This technique may offer good operative working space when performed by surgeons with relatively low-volume ET practices.

Extrapulmonary Small Cell Carcinoma of the Liver: Clinicopathological and Immunohistochemical Findings

Patients with primary small cell carcinoma of the liver have rarely been described in medical literature. Knowledge of clinical, pathological and immunohistochemical properties remains limited. We described an 82-year-old female patient with primary small cell carcinoma of the liver. Histologically, the tumor showed typical morphology of a pulmonary small cell carcinoma. Immunohistochemically, the tumor revealed neuroendocrine differentiation; positive reaction for chromogranin, synaptophysin, CD56, and neuron specific enolase. The tumor was also positive for TTF-1 and c-kit but completely negative for hepatocyte, carcinoembryonic antigen, cytokeratin 7; 19; and 20. Herein, we discussed the clinical, pathological and immunohistochemical findings of extrapulmonary small cell carcinoma of the liver and reviewed the relevant literature.