Ten Year Disease-free Survival of a Patient after Modified Hepatoligamentopancreatoduodenectomy for Diffuse Hilar Cholangiocarcinoma with Paraaortic Lymph Node Metastases: A Case Report

A 39-year-old female patient presenting with epigastric discomfort and jaundice was diagnosed as diffuse hilar cholangiocarcinoma with vascular tumor invasion. After preoperative management with percutaneous transhepatic biliary drainage and right portal vein embolization, the patient underwent modified hepatoligamentopancreatoduodectomy; this included extended right hepatectomy, caudate lobectomy, portal vein segmental resection, enbloc resection of hepatoduodenal ligament together with proper hepatic artery resection and with leaving a replaced left hepatic artery from the left gastric artery, and paraaortic lymph node dissection. Intraoperative frozen histologic examination revealed multiple paraaortic lymph node metastases, which was generally regarded as definite distant metastasis. There was no postoperative complication except for persistent drainage of ascites that occurred only during the immediate postoperative period. She did not receive postoperative adjuvant chemotherapy or radiotherapy. The patient is now living well 11 years 2months after surgery without recurrence. Although this patient revealed hilar vascular invasion and paraaortic lymph node metastasis, she survived more than 10 years without tumor recurrence. This implicate that aggressive surgical treatment of hilar cholangiocarcinoma can result in long-term survival even in the presence of paraaortic lymph node metastasis.

Long-Term Results of a Hepatopancreatoduodenectomy for Biliary-Tract Cancer

PURPOSE: The majority of carcinomas of the biliary tract are often diagnosed at an advanced stage, despite improved diagnostic capabilities. Aggressive surgery is generally recommended in an attempt to cure the advanced disease because only complete resection of the tumor can provide a chance to improve the survival rate. Thus, the purpose of this research was to assess the effectiveness of a hepatopancreato duodenectomy (HPD) in patients with both advanced gallbladder cancer directly invading adjacent organs and diffuse bile-duct cancer by analyzing the long term results of an HPD. METHODS: Forty patients underwent an HPD at Asan Medical Center from December 1993 to May 1999, and their cases were retrospectively reviewed. Gallbladder cancers was present in 14 of the patients and bile-duct cancers in 24 cases; the other 2 cases were benign. Cancers were classified by using the criteria of the American Joint Commission on Cancer (AJCC). Survival curves were calculated by using the Kaplan-Meier method. The median follow-up was 35 months. RESULTS: Hepatectomies varied from a right trisegmentectomy to an S4aS5 subsegmentectomy. There were 19 (47.5%) major postoperative complications, including intraabdominal bleeding, intestinal obstruction, liver abscess, and others. Of the 14 patients experiencing tumor recurrence, 7 (50%) cases involved the remnant liver. There were 4 (10%) perioperative mortalities. The 5 (22.7%) patients who with stage IVa and IVb cancer (22 cases) survived more than 3 years are all still alive and without tumor recurrence. The 1-and 3-year cumulative survival rates for gallbladder cancer were 83.3% and 48.5%, respectively, and those for bile-duct cancer were 83.3% and 49.7%. The differences in survival between the groups was not statistically significant, excluding perioperative deaths. The median survival was 13.7 months. CONCLUSION: An HPD is indicated for either advanced gallbladdercancer or diffuse bile-duct cancer because complete resection through this surgical procedure can provide a chance to improve survival. It is necessary to decrease perioperative mortality and morbidity by complete preoperative evaluation, meticulous operative manipulation, and intensive postoperative care.

Hepatocellular Carcinoma with Extensive Hepatic Artery Injury: Transcatheter Arterial Chemoembolization through Collaterals after Coil Embolization of Gastric Arteries

PURPOSE: To evaluate the efficacy and safety of transcatheter arterial chemoembolization(TACE) after coil embolization of the gastroduodenal artery in hepatocellular carcinoma cases with multiple collateral arteries caused by proper hepatic artery injury. MATERIALS AND METHODS: Between March 1997 and November 1998, a prospective trial of transcatheter arterial chemoembolization (TACE) was performed through collaterals from the gastroduodenal artery of 31 hepato-cellular carcinoma patients with extensive proper hepatic artery injury due to repeated TACE. Among this number, 16 (group A) underwent TACE after coil embolization of the right gastric and gastroduodenal artery. The other 15 patients (group B) underwent TACE without coil embolization. The two groups had the same T-NM stage and Child-Pugh status. During the follow-up period, group A underwent additional TACE 3.3 times, and group B 2.8 times. The therapeutic effect of TACE was evaluated with computed tomography and by measuring alpha-fetoprotein levels. Complications were evaluated by means of gastrofibroscopy, laboratory data, and evalvation of the patients clinical symptoms. The results obtained after six months and one year were compared within and between each group. RESULTS: At six months follow-up, CT findings had improved or were unchanged in 11 patients(69 %) in group A, and four patients(27 %) in group B(p=0.032). In ten patients in each group, the level of alpha-fetoprotein was above 200 ng/ml. Its level was decreased in five patients(50%) and three patients(30%), respectively. The six-month survival rate was 81 %(13/16) in group A and 67 %(10/15) in group B (p=0.43), while the one-year survival figures for these two groups were 50 %(8/16) and 20%(3/15), respectively(p=0.135). In group A, the CT findings were steady in five out of eight patients(63%), while in group B, CT findings showed that tumors with increased alpha-fetoprotein levels had increased in size and/or number. In group A, it was found that in two (33 %) of six patients whose initial alpha-fetoprotein level was over 200ng/nl, this level had decreased. Acute gastric ulcer was found in two patients in group A, and mild acute pancreatitis in one. One patient in group B was also found to have an acute gastric ulcer. CONCLUSION: In view of the advanced disease stage of patients for whom a long period has elapsed since initial diagnosis, TACE after coil embolization of gastric arteries may be a safe and acceptable method for use in the treatment of hepatocellular carcinoma with extensive hepatic artery injury.

The Imaging Findings of Small(< or =15mm) Portal Defects in the Liver on CT Arterial Portography: Evaluationwith CT Hepatic Arteriography and Lipiodol CT

PURPOSE: To assess the malignant potential of small(< or =15mm) portal defects seen on CT arterial portography,the findings of CT hepatic arteriography and lipiodol CT CT were reviewed. MATERIALS AND METHODS: In 91 patientswho underwent both CTAP and CTHA, small portal defects were re-viewed for frequency, multiplicity and location. Weprospectively evauluated changes in the size and enhance-ment pattern of malignant lesions on follow up CTaccording to density on CTHA, location, lipiodol deposits on lipiodol CT, and multiplicity. RESULTS: Among the 91patients, 102 small defects were defected in 42 patients(46%). Small portal defects were benign, malignant, and ofundetermined malignant potential in 77%, 20% and 3% of cases, respectively. Small portal defects that werehyperattenuated on CTHA, and lipiodol deposits on lipiodol CT, were malignant in 42% and 70% of cases,respectively. Location and multiplicity did not show statistically significant variation between benign andmalignant defects. CONCLUSION: Small portal defects are common and there is a high probability that portaldefects smaller than 15mm are benign, even in patients with a known hepatic mass and defect that washyperattenuated on CTHA. If a small defect showed lipiodol deposit on lipiodol CT, malignancy must be suspected.

Treatment of Arteriovenous Fistula Failure: Surgical Revision Versus Interventional Radiologic Procedure A prospective randomized study on secondary angioaccess procedure

There are over 10,000 individuals in Korea who require chronic hemodialysis treatment. Vascular access with an adequate blood flow and good long-term patency are important to have adequate dialysis. Thrombosis is the most common cause of angioaccess failure and is usually due to outflow stenosis. A thrombolysis using urokinase has been used frequently in recent years for treatment of a thrombosis, but its efficacy is not well documented in the literature. The authors report a prospective randomized study comparing a surgical revision versus a thrombolysis with and without luminal balloon angioplasty. The long-term patency and the total cost of treatment to the patient were compared.

Coil Embolization of Supecrior Mesenteric Arterio Venous Fistula: 1 Case Report

We recently encountered a case of posttraumatic SMAVF(Superior mesenteric arteriovenous fistula), which has treated by coil embolization. He had history of stab wound and emergent operation. Operative diagnosis was gastric perforation and mesenteric laceration which was simply repaired. After history of abdominal stab woung and operation, he developed palpitation and thrill in left upper abdomen. Recentrly he have experienced syncope twice. On superior mesenteric arteriogram, early visualiation of superior mesenteric vein and portal vein was noted. We embolized the SMAVF by using coils. Since coil embolization, palpitation and thrill disappreared.

Percutaneous Cholecystostomy : 60 Cases of Experience

PURPOSE: To review the effectiveness and complication of percutaneous cholecystostomy(PCCS). MATERIALS AND METHODS: We performed PCCS in 60 patient who presented with acute cholecystitis. The causes of acutecholecystitis were as follows : acalculous cholecystitis(n=8), calculous cholecystitis(n=23), GB hydrops(n=3), GBempyema(n=15), septic cholangitis(n=11). Of 60 patients, 36 patients had high risk factor for cholecystectomy :underlying malignancy(n=13), severe trauma(n=2), liver cirrhosis(n=3), diabetes mellitus(n=6), end stage renal disease(n=3), cardiac disease(n=3) and others(n=6). Cholecystostomy was done under ultrasonographic and fluoroscopic guide. RESULTS: The cholecystostomy was successfully in 59 patients, and failed in 1 patients. 15 patients improved without other procedure. 16 patients underwent cholecystectomy after improvement of their general condition. Severe complications of PCCS are as follows : bile peritonitis(n=6), hemoperitoneum(n=1), subphrenic abscess(n=1). Mild complication, such as pain, occured in most patients. Emergency operation was done in one patient who developed bile peritonitis. DISCUSSION: Cholecystostomy is effective and safe, especially incases of in operable patients who represent acute cholecystitis. Percutaneous cholecystostomy may substitiute surgical cholecystostomy.