Establishment of a Guideline for the Safe Management of Anatomical Hepatic Artery Variations While Performing Major Hepato-pancreatico-biliary Surgery

PURPOSE: Hepato-pancreatico-biliary (HPB) surgeons often must make decisions regarding hepatic artery (HA) resection while performing major HPB surgery. The purpose of this report was to review and summarize HA resection experience with a focus on vascular preservation during major HPB surgery and to develop a useful algorithm in dealing with these needs. METHODS: We reviewed 1,324 cases that had available computed tomographic and angiographic findings and summarized the problematic HA variations encountered in major HPB surgery. In reviewing our series and previous studies, we have created a set of guidelines that enables a pragmatic approach to the unique variations in HA and the risks of cancer invasion. RESULTS: Challenging HA variations during major HPB surgery were found in 25.7% of the cases and included variations of common HA from superior mesenteric artery (SMA), gastroduodenal artery (GDA), aorta, celiaco-mesenteric (CM) trunk or left gastric artery (LGA) (3.70%), the variations of the right HA from SMA, GDA, aorta, celiac axis (CA) including CM trunk or LGA (12.76%), the variations of the left HA from LGA, CA or GDA (4.46%), and the mixed types of the aberrant left medial HA and/or left lateral HA and/or right anterior HA and/or right posterior HA (2.11%). CONCLUSION: Surgeons should have knowledge of the anatomically variable vasculature of the HA when planning for major HPB surgery. Preoperative imaging studies can aid and should be performed in anticipation of potential HA variations during major HPB surgery.

Surgical Treatment and Outcomes of Primary Duodenal Adenocarcinoma

PURPOSE: Because of the rarity of primary duodenal adenocarcinomas, the factors affecting the management and survival of patients with this disease remain controversial. This study analyzed the nineteen-years of experience gained at one institution to define the surgical management and outcomes of patients with primary duodenal adenocarcinomas. METHODS: A retrospective review of 77 patients, who underwent surgery for a primary duodenal adenocarcinoma at Seoul National University Hospital, between May 1985 and April 2004, was undertaken. The dermographics symptoms, operative variables, surgical pathology and survival data were analyzed. RESULTS: A curative resection was performed in 40 patients (51.9%); a pancreaticoduodenectomies and/or resection of other organs, pancreas head resection with a duodenal segmentectomy and a segmental duodenectomy and resection of another organ in 37, 2 and 1, respectively. The remaining 37 patients underwent a palliative resection or bypass. The hospital mortality and complication rates were 2.6% (2 patients) and 42.9% (33 patients), respectively. The overall 5-year survival was 26.8%. The 5-year survival for the curative resection group was 42.7%, whereas that for the palliative surgery group was 0%. In a univariate analysis, nodal metastasis was found to have a significant negative impact on survival after a curative resection (P=0.028). The patients' age, sex, operative procedure, tumor size, histologic type, differentiation and tumor depth had no influence on survival. CONCLUSION: A curative resection is associated with increased survival in patients with a duodenal adenocarcinoma. Following a curative resection, nodal metastasis is an independent prognostic factor. Therefore, the early diagnosis should be sought to achieve a curative resection and increased survival. As a curative resection, a pancreaticoduodenectomy is usually required, and a segmental duodenal resection may be appropriate in selected patients, especially in early duodenum cancer.

Clinical and Epidemiological Analysis of Gallstone Patients: Focused on 25-year Experience of Surgically Treated Patients / 대한소화기학회지

BACKGROUND/AIMS: To investigate the epidemiologic changing patterns of gallstone diseases in Korea during past 25 years. METHODS: A total of 5,671 gallstone patients who underwent surgery in our center during 1981-2005 were analyzed. The patients were divided into 5 periods: period I (1981-1985, n=831), period II (1986-1990, n=888), period III (1991-1995, n=1,040), period IV (1996-2000, n=1,261) and period V (2001-2005, n=1,651). Korean literatures published from 1961 to 2005 were reviewed to elucidate the nationwide trends of gallstone diseases. RESULTS: Number of gallstone disease cases were gradually increasing. Female predominance was not noted (male/female ratio, 1.07-1.37). Patients with common bile duct (CBD) stone were older than those with gallbladder (GB) stone or intrahepatic duct (IHD) stone. During past 25 years, relative proportion of GB stone cases increased from 53.0% to 89.7%, while that of CBD stone cases decreased from 68.0% to 15.1%. Relative proportion of IHD stone patients remained stationary. In rural areas, tendency of increasing GB stone and decreasing CBD stone disappeared since period III. However, in urban areas, these tendencies remained till period V. Relative frequency of IHD stone group remained unchanged in two areas. The body mass indexes of the GB stone group, CBD stone group, and IHD stone group were higher than that of the average population. CONCLUSIONS: In gallstone disease, increasing tendency of GB stone and decreasing tendency of CBD stone in rural area have disappeared. However, relative frequency of IHD stone is still high in Korea.

Auxiliary Partial Orthotopic Liver Transplantations for One Pediatric Patient with Complement Factor H Deficiency and Two Adult Patients / 대한이식학회지

We have performed 3 cases of APOLT in one child and two adults. The child recipient had suffered from complement factor H deficiency since 3 months after birth and at the age of 30 months, APOLT was undertaken. Living donors of two adult recipients were affected by severe hepatic steatosis and the grafts were relatively small-for-size. After left hemihepatectomies, left lateral section and left hemilivers were transplanted orthotopically. The child recipient died of heart failure due to sepsis 7 months after transplantation, but factor H level remained nearly normal until his death. Although one adult suffered from hepatic venous stricture postoperatively, all adult recipients are alive with normal liver function for 11 and 8 months. In conclusion, although APOLT is technically demanding, APOLT may be a suitable surgical procedure in non-cirrhotic metabolic liver disease and a feasible solution for marked steatotic living donor grafts and small-for-size grafts.

Pancreaticopleural Fistula : Complication of Chronic Pancreatitis

A 64 year-old male, with a history of alcoholism, presented at our hospital with dyspnea. He had a history of admission to hospital for treatment of chronic pancreatitis 4 month ago. Chest radiography showed a marked amount of right pleural effusion. Thoracentesis revealed an exudate of amylase-rich fluid. After conservative management he was discharged, but 1 month later increased right pleural effusion was detected. A pancreaticopleural fistula was detected on ERCP and abdomen CT. After 2 months of conservative management, there had been no improvement of the fistula; therefore, the authors decided to operate. The pancreas was hard and atrophic, with severe adhesion to adjacent tissues. Several pancreatic duct stones were found intraoperatively, with a pseudocyst was also found at the body portion. A suspicious fistula tract was observed at the posterior aspect of the body, which was subsequently ligated. A distal pancreatectomy, with a lateral pancreaticojejunostomy, and an additional side-to-side choledochojejunostomy were performed. A small amount of right pleural effusion was detected, with thoracentesis performed on the 8th postoperative day. The pleural effusion did not show a pancreatic juice nature, with amylase and protein levels of 9 U/L and 2,127 mg/L, respectively. No further increase in the amount of pleural effusion was observed, and the patient was discharged on the 16th postoperative day, without any complications. There was no evidence of recurrence at the 6 month follow up.

The Assessment of the Method of Monitoring in Liver Transplant Recipients Treated with Microemulsion Cyclosporine (Neoral(R)) and Mycophenolate Mofetil (CellCept(R)) / 대한이식학회지

PURPOSE: Cyclosporine (CsA) dosing is traditionally based on trough levels (C0) rather than area under the concentration- time curve (AUC), although AUC correlates better with post- transplantation acute rejection and toxicity. It was reported that C2 (2-hour post-dose blood level) is an accurate single- sample marker for AUC0-4 in patients receiving CsA. No trials of C2 monitoring have been carried out in liver transplant recipients who are immunosuppressed with the combination of CsA and Mycophenolate Mofetil (MMF). The purpose of this study was to evaluate the correlation between C0, 1, 2, 3, 4 levels and AUC0-4 and define recommended target C2 in liver transplant recipients who are treated with CsA and MMF. METHODS: Thirty adult living donor liver transplant recipients were followed up 12 weeks after transplantation. CsA and MMF were administered in all recipients. CsA dose was reduced to the half level of target C0 in recipients treated solely with CsA. C0 and C2 were measured during in-patient period post-transplant. RESULTS: The best correlation between CsA concentration at various time points and the AUC0-4 was found at C2 (r2=0.931) (P<0.05). Mean C2 was 543.2+/-260.1 ng/mL (mean+/-SD). We observed complications associated with the immunosuppressants in six patients (20%). But, only one patient experienced acute rejection proven by biopsy and, there is no the graft loss and nephrotoxicity. CONCLUSION: In early post-transplant days, AUC0-4 was strongly correlated with C2. Reduced CsA dosing can be attempted in recipients who are immunosuppressed with the combination of CsA and MMF. The optimal target C2 probably can be suggested as about 543.2+/-260.1 ng/mL (mean+/-SD). During the in-patient period, C0 matched with target C2 can be decided. Target C0 can be individualized because C0 matched with target C2 differs in each recipients and C2 can't be checked routinely during the out-patient period.

Ectopic Paragonimiasis Presented as Omental Cystic Masses

Ectopic paragonimiasis has been diagnosed in many organs, such as the mesentery, peritoneum, omentum, diaphragm, pleura, liver, ovary, central nervous system and subcutis. However, simultaneous involvement of the peritoneum, mesentery and omentum is relatively unusual. A 52 years old woman, who visited our hospital because of abdominal pain, is the subject of this report. A CT scan showed an approximate 3.9x9.0 cm sized omphalomesenteric duct cyst in the left paraumbilical area of abdomen. An explorative laparotomy was performed, and the pathologic diagnosis was nonspecific chronic inflammation, with diffuse foreign body granuloma due to parasitic eggs. Postoperatively, the immunoserologic test for paragonimus wetermani was positive. A case of peritoneal, mesenteric and omental paragonimiasis, presenting as omental cystic masses, is presented, with a brief review of the literature.

Torsion of Ovarian Cyst in the Fetal Period: a Case Report

Ovarian cyst is found in 32% of necropsies in neonates, and can be visualized during gestation by ultrasonography. The clinical evolution of these cysts is variable, but in most cases the prognosis is favorable. Ovarian torsion, bleeding, rupture, and peritonitis have been described as complications. We report a newborn girl with torsion of ovarian cyst. A cystic mass measuring 41.9x31.9 mm on left side of abdomen was identified at 32 weeks of gestation by fetal ultrasonography. Surgery was performed after birth.