Two Stage Operations in a Patient with Recurrent Klatskin Tumor

BACKGROUND: Reoperation for recurrent bile duct cancer is almost impossible. We report here on a successfully managed case of recurrent Klatskin tumor. METHODS: A 45-year-old male was referred to our hospital with a relapsed Klatskin tumor 7 months after performing resection of his extrahepatic bile duct for Bismuth type I Klatskin tumor. The CT scan showed type IV Klatskin tumor with peritoneal dissemination. However, the PETCT scan didn't find any evidence of tumor. We decided to perform exploratory laparotomy to check the operability and confirm the diagnosis. RESULTS: No peritoneal dissemination was found during the first operation. After massive adhesiolysis, the jejunum was detached from the hepaticojejunostomy (HJ) site, and frozen biopsy confirmed adenocarcinoma at the strictured HJ site. The preoperatively measured left lateral sector was too small. Therefore, right trisectionectomy and caudate lobectomy were performed with keeping intact the right and left side inflow and outflow. HJ was performed in the normal B2 and B3 segments. Portal vein embolization (PVE) was done one week after the first operation. The volume of the left lateral sector increased three weeks after PVE. We safely and completely removed the right trisector and caudate lobe one month after the first operation. He recovered well and was discharged 4 weeks after the operation. No evidence of recurrence was found 14 months after the last operation. CONCLUSIONS: Although there is a possibility of severe adhesion and tumor spreading due to two-staged operation, this procedure may be one of the alternative methods to prevent liver failure that is due to an inadequate liver volume in the case of performing unexpected, extended liver resection. The authors also confirmed that curative resection was feasible to perform in selected cases of recurrent bile duct cancer.

A Dumbbell-shaped Thoraco-lumbar Extradural Ganglioneuroma: Case Report

Ganglioneuromas commonly arise from sympathetic ganglia. These neoplasm may be located wherever ganglion cells are normally found from skull base to pelvis including adrenal gland. Ganglioneuromas in spinal cord are very rare. We report a case of dumbbell-shaped extradural spinal ganglioneuroma. A 7-year-old boy was admitted to our hospital with a 20 day-history of both leg pain and a 10 day-history of progressive paraparesis. On magnetic resonance image, there was a dumbbell-shaped extradural spinal cord tumor in T11-L4 level. Two stage operation(First : Laminoplastic laminotomy of T11-L4 to remove the extradural portion of the tumor in the spinal canal, Second : Right retroperitoneal approach for the removal of paraspinal tumor located in L2-3 level) was performed. Pathologic diagnosis was a ganglioneuroma and paraparesis improved postoperatively.

A Case of Tuberculous Spondylitis Combined with Schwannoma of Spinal Cord

The authors report a very rare case of tuberculous spondylitis combined with a schwannoma of spinal cord. A 39-year-old man was admitted because of paraparesis(G1/G2). MRI showed severe cord compression at two different levels. One was by the bulged soft tissue and subligamentous abscess extending from T7 to T9 and the other was by an intradural extramedullary cord tumor at the level of T1-2. At first operation, T8 corpectomy and T7-9 plate fixation with autogenous iliac bone graft were performed. After then, Paraparesis was improved(G2/G3) postoperatively. The second operation underwent two weeks later. The tumor was totally removed and shortly after second operation, paraparesis was markedly improved(G3/G4). Histological diagnosis were tuberculous spondylitis and schwannoma, respectively. The authors reviewed this case where good surgical outcome was obtained by two stage operation.

Overview of Surgical Result of Multiple Intracranial Aneurysmal Patients

From January 1990 to January 1996, we analyzed outcome according to the distribution of aneurysms, the type of surgical treatment, the timing of operation, and the patient's pre-operative status in a total of 54 cases of multiple intracranial aneurysms. The frequency of multiple intracranial aneurysms was 13.4% and the sex ratio was 1:2 with female being predominant. The frequency of aneurismal location was MCA(35.0%), P-comm. Artery(25.0%) and A-comm. Artery(15.0%) in that order. The number of ruptured aneurysms was in the order to MCA aneurysms. A-comm aneurysms, and P-comm aneurysms. The size of ruptured aneurysms was 6-10mm in 34 cases(64.2%). The unilateral distribution of aneurysms was 31 cases(57.4%) and the bilateral was 28 cases(42.6%). Depending on how many times the patient had the operation, these were 29(57.4%) cases of complete single operation, 17 cases(31.5%) of complete two-stage operation, and 8 cases(14.8%) of partial operation. Surgical outcome was good(GOS< or =4) in 42 cases(77.8%), and six patients(11.1%) expired. Based on the results of the above study we have concluded that initial Hunt-Hess grade has a close relationship with the outcome, but the operation type, the timing of operation, the number and distribution of aneurysms do not significantly effect the outcome.

Clinical Analysis of Multiple Intracranial Aneurysms

Author reviewed the 31 cases of multiple intracranial aneurysms clinically from January 1981 to July 1987, at Inje College Busan Paik Hospital. The results obtained were as follows: 1) The incidence of multiple intracranial aneurysm was 7.8%. In most cases(94%), the number of aneurysm was two. 2) Approximately over 70% of patients were 6th and 7th decades, male to female ratio was 1:3.4. 3) The location of multiple intracranial aneurysms was in order, on the opposite side(39%), on the same side(26%), one in the midline and one on the side(29%). The location of indivisual aneurysms was in order, P-com. A(36%), MCA(25%), A-com. A(17%), ICA(13%). 4) The site of the ruptured aneurysm was determined by CT finding(55%), focal mass effect and spasm in angiography(29%), and others. The accurary was 97%. The possibility of rupture at each location was A-com. A(73%), P-com. A(57%), ICA(38%), MCA(31%). 5) 12 cases among them were treated with one-stage operation and 9 cases with two-stage operation. The post-operative favorable outcome was estimated in 13 cases(54%), the surgical mortality was 13%. There was no statistical difference between two groups.

Clinical Analysis of Multiple Intracranial Aneurysms

Author reviewed the 31 cases of multiple intracranial aneurysms clinically from January 1981 to July 1987, at Inje College Busan Paik Hospital. The results obtained were as follows: 1) The incidence of multiple intracranial aneurysm was 7.8%. In most cases(94%), the number of aneurysm was two. 2) Approximately over 70% of patients were 6th and 7th decades, male to female ratio was 1:3.4. 3) The location of multiple intracranial aneurysms was in order, on the opposite side(39%), on the same side(26%), one in the midline and one on the side(29%). The location of indivisual aneurysms was in order, P-com. A(36%), MCA(25%), A-com. A(17%), ICA(13%). 4) The site of the ruptured aneurysm was determined by CT finding(55%), focal mass effect and spasm in angiography(29%), and others. The accurary was 97%. The possibility of rupture at each location was A-com. A(73%), P-com. A(57%), ICA(38%), MCA(31%). 5) 12 cases among them were treated with one-stage operation and 9 cases with two-stage operation. The post-operative favorable outcome was estimated in 13 cases(54%), the surgical mortality was 13%. There was no statistical difference between two groups.

Stereotaxic Thalamotomy in the Management of Parkinson's Disease

A retrospective analysis was done on twenty-nine patients with Parkinson's disease who underwent thirty-five stereotaxic thalamotomies during the past 21 years. Eighteen patients received unilateral surgery, and six received two-staged bilateral surgery. Five had second stage operation after contralateral operation at other hospitals. Thirteen patients were followed-up for a period of six months to 12 years but the remainder were lost to follow-up. Parkinsonism scoring scale was designed and used to investigate postsurgical results and progress of patients. Clinical symptoms improved in 94.7% immediately after surgery. Only one patient had permanent neurological deficit resulting from the operation. A long-term follow-up study, with statistical analysis, suggested that progressive worsening after surgery was not ue to recurrence of tremor and rigidity but aggravation of bradykinesia and axial symptoms in the natural course of the disease. After unilateral surgery, 53.3% of patients had progressive aggravation of symptoms in contralateral side. It is believed that surgical treatment should be considered in patients presenting symptoms of tremor and rigidity. Bilateral surgery is indicated in patients who have bilateral symptoms or contralateral aggravation of symptoms after an initial operation.

Two Stage Operation for Large Cerebral Arteriovenous Malformation

This report describes three cases of large arteriovenous malformation which were removed totally with two stage operation. When a large arteriovenous malformtaion had to be removed, prediction of profuse bleeding and brain swelling could be made. We clipped large feeding arteries and arteires and made a cleft around the AVM during the first operation, and the progressive reduction of the shunt flow by clipping the dominant peduncles on after the other diminished the risk of profuse bleeding and brain swelling. 7 to 10 days later, we removed AVM totally as the second operation. All three lesions were resected by microsurgical techniques, and the results were excellent. The rationale for the two stage operation for large cerebral AVM is discussed.