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.

The Usefulness of (99m)Tc-Ciprofloxacin Imaging in the Diagnosis of Acute Cholecystitis

PURPOSE: The diagnosis of acute cholecystitis is usually made by performing ultrasonography or biliary scintigraphy. We have introduced the (99m)Tc-ciprofloxacin (infecton) scan for diagnosing of acute cholecystitis. The main aim of this study was to evaluate the efficacy of (99m)Tc-ciprofloxacin imaging in comparison with ultrasonographic findings for the diagnosis of acute cholecystitis. METHODS: Sixteen patients who were thought to have acute or chronic cholecystitis, based on the clinical and sonographic findings, were included in this study. We gave intravenous (99m)Tc-ciprofloxacin to sixteen patients and we obtained the SPECT images after one hour. The final diagnosis of acute cholecystitis was made according to the pathologic reports. RESULTS: According to pathologic reports, out of the sixteen patients, twelve patients had acute cholecystitis and four patients had chronic cholecystitis. On the (99m)Tc-ciprofloxacin scans, twelve patients had positive images showing acute cholecystitis on account of the hot uptake in the gallbladder and four patents had negative images showing chronic cholecystitis due to the negative uptake in the gallbladder. Among them, one false positive case and one false negative case were observed. With performing ultrasonography, twelve and four patients were diagnosed as having acute and chronic cholecystitis respectively. Out of them one false positive case and three false negative cases were observed. Based on the pathologic reports, (99m)Tc-ciprofloxacin imaging has a sensitivity of 91.7% and a specificity of 75%. The ultrasonography had a sensitivity of 91.7% and a specificity of 25%. CONCLUSION: As a result of comparing the sensitivity and specificity of the (99m)Tc-ciprofloxacin scan with those of the ultrasonography, the (99m)Tc-ciprofloxacin scan is considered to be useful test method to diagnose acute cholecystitis.

Operative Management of the Prenatally Diagnosed Choledochal Cyst

Improvement in prenatal ultrasonography is leading to diagnose choledochal cyst before birth and before onset of classical symptom more frequently. But, there is a controversy about optimal timing for cyst excision of prenatally diagnosed asymptomatic choledochal cyst. To identify the most appropriate timing for surgery in prenatally diagnosed choledochal cysts, we analyzed 6 patients who had operation for choledochal cysts within 30days after birth at the division of Pediatric Surgery, Samsung Medical Center and Inha University School of Medicine, from June 1995 to June 2002. Males were four and females 2, the mean age at operation was 11.2 days, and the median age 8.0 days. The range of gestational ages of the antenatal diagnosis of bile duct dilatation was 24 weeks to 32 weeks, mean was 38.3 weeks, and mean birth weight was 3,298.3 g. After birth, abdominal ultrasonography, hepatobiliary scintigraphy, and magnetic resonance cholangiopancratography (MRCP) were performed. Mean age at operation was 11.2 days. All patients had the cyst excision and Roux- en-Y hepaticojejunostomy. Immediate postoperative complication was not found. During the median follow-up period of 41 months, one patient was admitted due to cholangitis, and the other due to variceal bleeding. Early operative treatment of asymptomatic newborn is safe and effective to prevent developing complications later in life.

Endoscopic Ultrasonography Versus Endoscopic Retrograde Cholangiopancreatography for the Diagnosis of Choledocholithiasis

PURPOSE: In order to reduce the rate of conversion to an open cholecystectomy, and to avoid the retention of bile duct stones, it is important to detect a choledocholithiasis prior to a laparoscopic cholecystectomy. The aim of this study was to compare the diagnostic accuracy of endoscopic ultrasonography (EUS) with endoscopic retrograde cholangiopancreatography (ERCP) in 150 patients who had an intraoperative cholangiography and choledochotomy with a choledocholithiasis performed. METHODS: Between January 2001 and February 2002, 150 patients who underwent an ERCP or EUS performed preoperatively and a cholecystectomy with intraoperative cholangiography or choledochotomy consecutively performed at the Inha University Hospital were reviewed. RESULTS: An ERCP was performed in 119 patients, and an EUS was carried out in 67 patients. Thirty six patients had both performed. The ERCP failed in 17cases (14.3%). The EUS identified the bile duct in all cases. There were five ERCP related complications (3 pancreatitis, 2 cholangitis), but no complications were encountered when using EUS. In 62 patients (41.3%), a choledocholithiasis was found. ERCP had a sensitivity of 89.5%, a specificity of 84.4%, a positive predictive value of 87.8%, and a negative predictive value of 86.4%. EUS showed a sensitivity of 88.9%, a specificity of 84.7%, a positive predictive value of 66.7%, and a negative predictive value of 95.3%. Concordance of ERCP and EUS was obtained in 90% of cases. CONCLUSIONS: EUS appears to be safer, more comfortable, and, as accurate as an ERCP detecting a choledocholithiasis.

Clinical Analysis of Prognostic Factors in Hepatocellular Carcinoma

PURPOSE: Although the resectability of hepatocellular carcinoma has increased due to recent advances in diagnostic methods and surgical techniques, the long-term results are unsatisfactory due to their invasiveness and frequent association with cirrhosis. This study was designed to identify the prognostic factors affecting the long term survival and recurrence of tumors in patients having undergone a hepatic resection for a hepatocellular carcinoma. METHODS: Between June 1996 and March 2002, 51 consecutive patients underwent a hepatic resection for a hepatocelluar carcinoma at the Inha University Hospital. The overall cumulative and disease free survival rates for these patients were analysed. Twenty-five clinicopathological factors were evaluated by univariate and multivariate analyse to determine any significant prognostic factors. RESULTS: The cumulative 1, 3 and 5-year survival rates were 84, 70 and 58%, respectively. There were 26 recurrences, and the 1, 3 and 5-year disease free cumulative survival rates were 60, 53 and 31%, respectively. From the univariate analysis, all the factors associated with ascites (P=0.0000), total bilirubin (P=0.0015), albumin (P=0.0271), prothrombin time (P=0.0392), HBe antigen (P=0.0283), Child classification (P=0.0000), celluar differentiation (P=0.0043) were found to correlate with the overall survival. From a Cox regression analysis, the HBe antigen (P=0.019), ascites (P=0.028) were found to be independent prognostic factors of the overall survival. The only factor with an independent effect on disease free survival was the HBe antigen (P=0.037). CONCLUSION: Because prognosis of HBe antigen-positive patients with ascites is poor, frequent postoperative follow up surveys in these patients are needed.

Study of the Relationships between Cyclin D1 and Known Prognostic Factors in Breast Cancer

PURPOSE: Cyclin D1, which is known as a cell regulatory protein in G1-S phase, is overexpressed in 30-90% of breast cancers. Published data on the relationships between cyclin D1 and the established clinicopathologic factors of breast cancer have been controversial, so we investigated the clinical significance of cyclin D1 and its associations with established clinicopathologic factors in 103 primary breast-cancer patients. METHODS: Cyclin D1 overexpression was measured by using immunohistochemical assays, and the results were compared with clinicopathologic factors. RESULTS: Expression of cyclin D1 was detected in 60.2% (62/103) and cyclin D1 was significantly correlated with the estrogen receptor, the progesterone receptor, lymph-node metastasis, histologic grade, and nuclear grade. But there were no associations between cyclin D1 and tumor size, tumor stage, vascular invasion of tumor, DNA ploidy and S phase. CONCLUSION: We found that breast cancer with cyclin D1 overexpression was associated with predictive factors such as the estrogen receptor and the progesterone receptor. Thus, we suggest that aggressive treatment is needed in breast cancer with cyclin D1 overexpression. For cyclin D1 to become a more informative clinical prognostic factor, more prospective studies with large sample sizes are needed.

Anorectal Manometry in Normal Neonates

Anal pressure profiles and resting pressures were evaluated in 46 normal neonates, 28 boys and 18 girls, in order to estimate the normal values of anal canal pressure status. All of them had meconium passed within 24 hours after birth and had more than 2.4kg of birth weight. Age at evaluation of manometry was less than 6 days old. There were no differences between boys and girls in birth weight, birth height, gestational age, birth age, and Apgar score (p<0.05). As results of 46 manometric evaluation, We had the anal sphincter length 18.6+/-3.9mm, the high pressure zone (HPZ), 9.2+/-3.6mm, the vector volume, 2027.2+/-2440.7mmHg2cm, the maximum pressure, 42.3+/- 17.4mmHg, and the position of the maximum pressure, 6.0+/-2.4mm. Among them, only HPZ of boys was longer than girls (p=0.005). In squeezing state, HPZ and the position of maximun pressure were not changed from resting state and boys had greater values in HPZ, vector volume, and maximum pressure than girls. As the birth weight increased, the anal sphincter length (p=0.001) and the HPZ increased (p=0.047). The resting pressures of anal canal were evaluated in three portions; upper portion, 12.8+/-8.6 mmHg, middle portion, 20.3+/-10.8 mmHg, and lower portion, 26.1+/-12.9 mmHg. We have the normal values of anal pressure status in normal neonate and We hope that the results would be useful to evaluate, diagnose and treat the pathologic, preoperative, and postoperative condition of anal canal in neonates.