A benign liver tumor mimics hepatic metastasis from colon cancer.

Background: Liver is the most common distant metastasized organ in advanced colon cancer. Surgical resection of metastatic lesions would offer the best chance of a long-term survival. An accurate diagnosis and evaluation of extent of disease is crucial in the management of liver metastasis. Objective: Report a benign hepatic condition mimicking liver metastasis in a colon cancer patient. Case presentation: A 53-year-old male with an early stage sigmoid colon cancer was treated with sigmoidectomy followed by adjuvant chemotherapy consisting of 5-FU, leucovorin, and oxaliplatin for six months. Annual computerized tomography of abdomen at two years after the surgery revealed three hypervascular nodules in the liver. Investigations including MRI of the liver and whole body FDG-F18 PET/CT demonstrated evidence consistent with non-metastatic liver nodules. Liver biopsy of one of the lesions led to the diagnosis of “focal nodular hyperplasia”. Conclusion: The possible etiology, diagnosis, and further management of this benign liver tumor, the focal nodular hyperplasia became clear.

Treatment outcome of hepatocellular carcinoma patients with high-risk vascular invasion: a retrospective analysis.

Background: Invasion of major hepatic vessels in hepatocellular carcinoma (HCC) generally prohibits the surgical treatment. Objective: Analyze outcomes of non-surgical approaches in this group of HCC. Methods: Retrospective review of medical records of 648 HCC admitted to King Chulalongkorn Memorial Hospital between January 2003 and December 2005 was carried out to select only patients who had unresectable HCC with vascular invasion and hepatic functions-Child-Pugh class-A. Vascular invasion was defined as involvement of portal vein, inferior vena cava (IVC), or their branches identified by imaging techniques. Non-surgical treatments were either transarterial chemoembolization (TACE) or systemic chemotherapy (SCT) in addition to general supportive care. Treatment outcomes of the patients were analyzed. Results: Out of 71 unresectable HCC patients enrolled, 57patients were treated with TACE, while 14 received SCT. In the TACE group, 39 (68%), 7 (12%) and 11 (19%) patients had portal vein, IVC, and both vessels invasion, respectively. In the SCT group; 11 (78%), 1 (7%) and 2 (14%) had invasion of portal vein, IVC, and both vessels, respectively. Median overall survival in both groups was 158 days. Univariate analysis demonstrated that AFP level <1000 ng/mL, tumor size <10 cm, and SCT treatment significantly influenced survival. Additional multivariate analysis confirmed that diameters of tumor, and SCT were independent prognostic factors for good survival. A survival analysis showed longer survival in the SCT group than that of TACE (210 vs. 149 days, p=0.03) group. Conclusion: Survival of HCC patients with major vessels invasion was better when treated with SCT compared to TACE. Future prospective study in larger populations to test the hypothesis is warranted.

Risk factors associated with major intraoperative blood loss in hepatic resection for hepatobiliary tumor.

BACKGROUND AND PURPOSE: Hepatic resection is the mainstay treatment of hepatobiliary tumor Nowadays, mortality is less than 6%. However, morbidity is still high. Bleeding is one of the most common problems during hepatic resection which can sometimes lead to catastrophe. The purpose of the present study was to investigate the risk factors associated with major blood loss during hepatic resection for hepatobiliary tumor. MATERIAL AND METHOD: A total of 69 consecutive patients who underwent elective hepatic resection for hepatobiliary tumor from May 2002 to April 2004 were enrolled into this retrospective study. The Patients were divided into 2 groups(group I and II) according to the intraoperative blood loss. Patients who had a blood loss of more than 1000 ml were defined as the major blood loss group(group I). Thirteen variable factors were analyzed to determine the risk of major intraoperative blood loss. Operative outcomes between the two groups were also compared. RESULTS: Of the sixty-nine patients, 36 patients were in group I and 33 patients were in group II. 75% of the patients in group I and 36.4% of the patients in group II were transfused. Median blood transfusion in group I and II were 3 and 0 units of packed red cell. Univariate analysis showed tumor size, extent of hepatic resection, tumor pathology and operative time were factors affecting major intraoperative blood loss. However, multivariate analysis showed only operative time and tumor size to be independent risk factors. Patients in group I had higher surgical morbidity and prolonged hospital stay compared with patients in group II. CONCLUSION: Blood loss is still a major concern in performing hepatic resection. From the present study, tumor size and operative time are the independent factors affecting major intraoperative blood loss. Proper screening or a surveillance program may enhance the chance to find small tumors. Refined operative techniques such as anterior approach and liver hanging would facilitate resection for large right sided tumors.

Acute mesenteric ischemia: still high mortality rate in the era of 24-hour availability of angiography.

BACKGROUNDS: Acute mesenteric ischemia (AMI) is a serious condition with high mortality rate due to difficult and late diagnosis. Early and aggressive evaluation in high risk patients by mesenteric angiography is the key to the reduction in mortality rate. However; many physicians hesitated to perform it because of its availability, the risk of complications and high negative results. This study reviewed outcome of AMI in term of mortality rate, factors associated with mortality and the rate of angiography in high risk patients. MATERIAL AND METHOD: The clinical data of the patients who were diagnosed as AMI were retrospectively reviewed. The clinical outcome was recorded and the factors associated with mortality were analysed. RESULTS: Thirty-five patients were enrolled into this study during 5 years. The mortality rate was 74.3%. There were 22 high risk patients for AMI. The rate of angiography performed in this group was 4.5% (1/22). The factors associated with mortality were age more than 60 years, patients with peritonitis, hypotension, arterial cause, time interval between admission and operation or treatment more than 24 hours, bowel gangrene >100 cms. However all these factors were not statistically significant. CONCLUSION: The mortality rate of AMI is still high even at the tertiary hospital where the angiography is available 24 hours. To decrease the mortality rate, the physicians must have the high index of suspicion in high risk patients and do not hesitate to perform early mesenteric angiography.

Minimally invasive surgery training in soft cadaver (MIST-SC).

OBJECTIVES: The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver. SETTING: Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University. DESIGN: Prospective descriptive study. MATERIAL AND METHOD: 2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation. RESULTS: The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results. CONCLUSION: The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.

Preoperative portal vein embolization in hepatobiliary tract malignancy: an experience at King Chulalongkorn Memorial Hospital.

BACKGROUND: Major hepatic resections are increasingly performed for both primary and secondary liver cancers nowadays. However, morbidity from these operations is still high. One of the dreadful complications, sometimes lead to fatality, is postoperative liver failure. There are many factors which are associated with this complication such as chronic liver disease, low residual liver volume after resection. Portal vein embolization (PVE) is the procedure which increases the liver volume of the non-embolized lobe. Now, PVE has gained acceptance in many centers to overcome or reduce this complication. This report described the authors' experiences of PVE since 2001 at King Chulalongkorn Memorial Hospital. MATERIAL AND METHOD: The records of 10 patients who had PVE were reviewed CT volumetry of the liver was done before and after procedure. The authors calculated future liver remnant from CT volumetry and compared this volume to standard liver volume. The postoperative complications and hospital courses of these patients were also recorded. RESULTS: Mean growth of future liver remnant (FLR) ratio after PVE was 13.7 +/- 6.2% (median 13, range 4-25). There was no major complication after PVE. Six patients underwent liver resection and there was no major complication or mortality. No one had persistent hyperbilirubinemia 2 weeks after operation. CONCLUSION: The PVE is the useful and safe optional procedure to increase future liver remnant volume. It not only reduces the postoperative liver failure but increases the chance for curative resection.

A germline mutation in a Thai family with familial multiple endocrine neoplasia type 1.

Multiple endocrine neoplasia type 1, caused by the mutation in the MEN1 gene, is an autosomal dominant disorder with over 95% penetrance characterized by hyperparathyroidism, pancreatic endocrine tumor and pituitary tumor. The authors performed a molecular analysis to identify a mutation in a Thai man with MEN1. He was found to be heterozygous for IVS6 + 1G to A. Two of his three children were also found to carry this mutation. The newly available genetic test for patients with MEN1 in Thailand makes it possible to accurately DNA-based diagnose clinically suspected individuals and their presymptomatic members, which has important therapeutic impacts on them.

Outcome of colorectal liver metastases.

OBJECTIVE: To determine the median survival of colorectal liver metastatic (CRLM) patients treated at King Chulalongkorn Memorial Hospital over the past 10 years and to determine the outcome of the various treatment modalities (surgery, chemotherapy and supportive treatment). MATERIAL AND METHOD: Between January, 1992 and December, 2001, 86 consecutive patients were recorded. Of whom 26 (30.23%) received liver resection, 39 (45.34%) received chemotherapy and 21 (24.41%) received supportive treatment. All the patients were followed up to December 31, 2001 or death. Survival was calculated by Kaplan-Meier method and studied for statistical differences between various treatment groups with Cox regression model. The 95% confidence intervals for median assessment were determined. RESULTS: Overall survival of CRLM patients was 18 months. Significant differences in survival were seen among the three groups of patients. Median survival was 33 months in the liver resection group, 17 months in the chemotherapy group and 5 months in the supportive treatment group. Three-year survival in the liver resection group was 23% while it was 7.6% in the chemotherapy group. Type of treatment, primary tumor staging and extrahepatic metastasis were the three independent determinant factors of survival. CONCLUSION: Survival of patients with colorectal liver metastases depends on the type of treatment. Liver resection is the best treatment which offers long term survival to the patients in selected cases.

Result of orthotopic liver transplantation at King Chulalongkorn Memorial Hospital: the first series from Thailand.

Liver transplantation is one of the best treatments for advanced liver disease since it can prolong the patient's survival. In Thailand, the first liver transplantation was performed in 1987 at King Chulalongkorn Memorial Hospital. Up till now the authors have transplanted the most in Thailand, having done more than 30 cases. From 1997 to 2002, there were 20 cases of liver transplantation and this is the result presented. The authors classified the patients into 2 groups, according to primary indications for transplantation. Patients with cirrhosis were included in group I and patients with hepatocellular carcinoma were included in group II. The one year survival in group I and II was 64 per cent and 29 per cent respectively. Mortality rate in the cirrhotic group was high during the first 3 months post transplant. The reason for a high mortality rate in the hepatocellular carcinoma group may be secondary to the advanced stage of cancer and the poor condition of the patients. However, the acute rejection rate in the present series of 25 per cent is relatively low compared to other series and this may need further study. The one year survival rate in patients who received a new liver from 1997 to 1999 compared to 2000-2002 was 33 per cent and 54 per cent respectively. This showed an improvement in the result of liver transplantation in Thailand. In conclusion, this report showed a satisfactory result of liver transplantation. The main problem with liver transplantation in Thailand is that potential donors do not understand the problems which leads to few donors. There is also a shortage of skilled personnel, budget, and the appropriate instruments.