Cavernous Hemangioma of the Gallbladder: a Case Report

Cavernous hemangioma of the gallbladder is an extremely rare benign tumor. The tumor has only a few cases being reported in literature. However, to the best of our knowledge, no reports focusing on the MRI findings of cavernous hemangioma of the gallbladder have been published. This study reports a case of gallbladder hemangioma with pathologic and radiologic reviews, including MRI findings.

The Prevalence of Gallstone Disease Is Significantly Lower in Natives than in Migrants of Jeju Island / 가정의학회지

BACKGROUND: The eating habits of Jeju Island natives are quite different from those of the mainland people because of geographic isolation. Diet is a main factor affecting gallstone disease. We investigated the prevalence of gallstone disease in both Jeju Island natives and migrants and studied the risk factors affecting gallstone disease in the Jeju Island people. METHODS: A total of 20,763 subjects who underwent medical checkups at the Health Promotion Center of Jeju National University Hospital in Korea from January 2003 to December 2015 were enrolled in the study. Ultrasonography was used to determine the presence of gallbladder stones. Body mass index and biochemical parameters, including liver function test results, lipid profiles, and fasting blood glucose levels, were verified, and data on age, birthplace, and sex were collected from medical records. Univariate and multivariate analyses were performed to identify risk factors affecting gallstone disease. RESULTS: The prevalence of gallstone disease in the Jeju Island people was 4.0%: Jeju Island natives, 3.8% and migrants, 4.4% (P=0.047). After multivariate logistic regression analysis, the independent risk factors were older age, Jeju migrants, higher fasting blood glucose and alanine aminotransferase levels, and lower high-density lipoprotein cholesterol levels. CONCLUSION: The prevalence of gallstone disease was significantly lower in natives than in migrants from Jeju Island. Older age, Jeju migrants, higher fasting blood glucose and alanine aminotransferase levels, and lower high-density lipoprotein cholesterol levels contributed to gallstone disease prevalence in the Jeju Island people.

Partial Purification and Properties of a Cysteine Protease from Citrus Red Mite Panonychus citri

Several studies have reported that the citrus red mites Panonychus citri were an important allergen of citrus-cultivating farmers in Jeju Island. The aim of the present study was to purify and assess properties of a cysteine protease from the mites acting as a potentially pathogenic factor to citrus-cultivating farmers. A cysteine protease was purified using column chromatography of Mono Q anion exchanger and Superdex 200 HR gel filtration. It was estimated to be 46 kDa by gel filtration column chromatography and consisted of 2 polypeptides, at least. Cysteine protease inhibitors, such as trans poxy-succinyl-L-leucyl-amido (4-guanidino) butane (E-64) and iodoacetic acid (IAA) totally inhibited the enzyme activities, whereas serine or metalloprotease inhibitors did not affect the activities. In addition, the purified enzyme degraded human IgG, collagen, and fibronectin, but not egg albumin. From these results, the cysteine protease of the mites might be involved in the pathogenesis such as tissue destruction and penetration instead of nutrient digestion.

A case of variceal bleeding of the ascending colon associated with alcoholic liver cirrhosis / 대한내과학회지

We report a very rare case of colonic varix with massive bleeding. A 43-year-old male patient was transferred to our hospital for hematochezia. The patient had a history of chronic liver disease associated with alcohol use. The initial blood pressure was 93/73 mmHg, and the hemoglobin level was 8.4 g/dL. Severe hepatomegaly and periportal fatty infiltration were seen on abdominal computed tomography. Markedly ectatic veins protruded from the luminal side of the proximal ascending colon and drained to the dilated ileocecal and retroperitoneal veins. Emergent colonoscopy failed because of continuous hematochezia and hypovolemic shock, despite massive transfusion. Markedly dilated colonic varices were noticed around the ileocecal and ascending colon on superior mesenteric arteriography. An emergent right hemicolectomy was performed. The presumed bleeding focus was a protruding varix with a red clot on the top of a denuded vein on the anteromedial wall of the proximal ascending colon.

Delayed Gastrointestinal Bleeding from Traumatic Superior Mesenteric Artery Pseudoaneurysm

Acute onset of shock presented in a 23 years old male patient due to gastrointestinal bleeding. He had been in a car crash 49 days before presentation. On initial presentation, a small amount of intraperitoneal hemorrhage had been seen on a CT scan. An emergency selective superior mesenteric artery (SMA) arteriography revealed a pseudoaneurysm in the branch of SMA, but successive embolization of the terminal branch controlled the bleeding. It is hard to initially diagnose an aneurysm as the cause of spontaneous gastrointestinal bleeding in a patient that has suffered an abdominal trauma, so it poses a therapeutic challenge. Recognition of an aneurysm, and its early diagnosis based on the patient's past history, and its adoption as a judicious diagnostic tool are essential in the management of such patients.

Cyclooxygenase-2 Expression in Bile Duct Cancer / 한국간담췌외과학회지

PURPOSE: Epidemiological studies have shown that regular ingestion of a nonsteroidal anti-inflammatory drug reduces the risk of fatality from colon cancer. Cyclooxygenase-2 (COX-2) has been found to be overexpressed in various types of tumor, including colorectal cancer. It has been suggested that the COX-2 enzyme may play an important role in carcinogenesis and tumor progression. The aims of this study were to find the relationship between COX-2 expression and bile duct carcinogenesis and its clinical significance in bile duct cancer. METHODS: The COX-2 expression was determined using three methods, reverse transcription polymerase chain reaction (RT-PCR), Western blotting and immunohistochemical staining. mRNA and proteins were extracted from the tissue specimens of 22 bile duct cancer patients. RESULTS: RT-PCR and western blotting found COX-2 expressions in all the cancers and their paired noncancerous tissues. Immunohistochemistry revealed the highest levels of COX-2 expressed in bile duct carcinoma cells, mainly in the cytoplasm, and a weak reactivity of the COX-2 protein was observed in noncancerous bile duct epithelial cells. CONCLUSION: Based on this study, it is postulated that the carcinogenesis mechanism of COX-2 expression may be initiated from a noncancerous condition, such as chronic inflammation, and may advance to bile duct cancer progression.

Hemorrhage Following Pancreatoduodenectomy

PURPOSE: Hemorrhage following pancreatoduodenectomy is a severe, life-threatening complication. This study was conducted to suggest methods of the prevention and management of hemorrhagic complications. METHODS: We reviewed medical records of 456 patients who had undergone pancreatoduodenectomy at Seoul National University Hospital between January 1991 and December 2000. RESULTS: Postoperative bleeding occurred in 21 patients. Early hemorrhage within the postoperative 5th day amounted 5 cases, which were caused by improper intra-operative hemostasis. Three of these patients were saved by prompt surgery and, in one patient, conservative management. Late hemorrhage after the postoperative 5th day included 16 cases, of which 12 patients (75%) were associated with pancreas anastomotic leaks and 8 patients displayed pseudoaneurysm. "Sentinel bleeding" was evident in 8 cases. Angiographic embolization was performed in 8 cases, achieving hemostasis in 7 cases. Reoperations were attempted in 7 cases with complete hemostasis in 2 cases. As a result, 15 of 21 patients obtained complete hemostasis and mortality rate from postoperative hemorrhage was 28.6% (6/21). CONCLUSION: Successful hemostasis was achieved by surgery in case of early hemorrhage and by angiographic embolization in late hemorrhage. In order to prevent hemorrhage following pancreatoduodenectomy, meticulous hemostasis and considerate operative techniques for avoiding pancreatic anastomotic leaks or vascular injury are essential.

Treatment of Retrohepatic Caval Injury using Total Hepatic Vascular Isolation and Venovenous Bypass / 한국간담췌외과학회지

Retrohepatic caval injuries are a difficult problem to surgeons as its mortality approaching 50~80%. Several bypass techniques was advocated to reduce operative bleeding and to improve the prognosis of the traumatized patients. We successfully managed a case of retro hepatic caval injury using venovenous bypass and total hepatic vascular isolation. A 28 year old female patients was admitted to Cheju Medical Center injured in a traffic accident. At exploration, a retrohepatic caval injury was suspected. So patient was emergently transferred to Seoul National University Hospital, after gauze packing. On arrival, vital signs were stable. Reexploration was undertaken. There was gush out of blood from retrohepatic space. After clamping suprahepatic and infrahepatic vena cava, venovenous bypass was introduced to left axillary vein and left femoral vein using Biomedicus pump. Systemic heparinization was not used. Avulsion between vena cava and common trunk of left and middle hepatic veins was repaired and left hepatectomy was done. Gauze packing was done due to ongoing oozing by coagulopathy from massive transfusion. Total venovenous bypass time was 30 min. On 10th operative day, reexploration was undertaken to assure hemostasis and to remove packed gauze. On 54th postoperative day patient discharged without any morbidity.

Clinical Outcome of Major Hepatobiliary Resections for Malignant Tumor of the Extrahepatic Biliary Tree

PURPOSE: A major hepatobiliary resection (MHBR), liver resection of more than one lobe, has been recommended by some surgeons for advanced carcinomas (Ca) of the gallbladder (GB) and the hilar bile duct (HBD). However, high operative mortality and morbidity have been reported and its survival benefit has not been clearly documented. METHODS: We report the results of MHBR for such tumors to determine the safety and the effectiveness of this operation, which has been performed for GB Ca invading the right hepatic pedicle or liver bed by 2 cm or more and for HBD Ca of Bismuth type III or IV. The cases of fifty consecutive cases who received MHBR for GB Ca (n=11) or HBD Ca (n=39) during a 5 year-period were reviewed. RESULTS: Thirty right-sided and 20 left-sided hepatectomies were performed. There was no operative or hospital death. Minor and major complications developed in 64% of the cases. All the complications improved with conservative management, except two in which re operations were required, one due to portal vein thrombosis and the other to bleeding of the retro peritoneal dissection site. No specific factors were associated with the high complication rate. The long-term outcome of HBD Ca was better than that of GB Ca. In HBD Ca, differentiated cancer and less transfusion were associated with a better prognosis. CONCLUSION: MHBR was conducted with acceptable morbidity and no mortality. In terms of the long-term outcome, MHBR is recommended for HBD Ca whereas it should be considered more carefully for GB Ca.

Clinical Outcome of Major Hepatobiliary Resections for Malignant Tumor of the Extrahepatic Biliary Tree

PURPOSE: A major hepatobiliary resection (MHBR), liver resection of more than one lobe, has been recommended by some surgeons for advanced carcinomas (Ca) of the gallbladder (GB) and the hilar bile duct (HBD). However, high operative mortality and morbidity have been reported and its survival benefit has not been clearly documented. METHODS: We report the results of MHBR for such tumors to determine the safety and the effectiveness of this operation, which has been performed for GB Ca invading the right hepatic pedicle or liver bed by 2 cm or more and for HBD Ca of Bismuth type III or IV. The cases of fifty consecutive cases who received MHBR for GB Ca (n=11) or HBD Ca (n=39) during a 5 year-period were reviewed. RESULTS: Thirty right-sided and 20 left-sided hepatectomies were performed. There was no operative or hospital death. Minor and major complications developed in 64% of the cases. All the complications improved with conservative management, except two in which re operations were required, one due to portal vein thrombosis and the other to bleeding of the retro peritoneal dissection site. No specific factors were associated with the high complication rate. The long-term outcome of HBD Ca was better than that of GB Ca. In HBD Ca, differentiated cancer and less transfusion were associated with a better prognosis. CONCLUSION: MHBR was conducted with acceptable morbidity and no mortality. In terms of the long-term outcome, MHBR is recommended for HBD Ca whereas it should be considered more carefully for GB Ca.

Effect of Endogenous Gastrin on Pancreatic Growth and Regeneration in Rat

PURPOSE: Gastrin is a candidate for the growth regulatory factors of the pancreas and may solve the problem of pancreatic atrophy after partial pancreatectomy. The purpose of this study was to evaluate the effect of endogenous gastrin on the normal growth and regeneration of the pancreas (after partial pancreatectomy) in rat. METHODS: Sixty Sprague-Dawley rats (200-230 g) were divided into 6 groups. Group (G)-I and II received sham operation (splenectomy only), and G-III, IV, V, VI received both 66% partial pancreatectomy (PPx) and splenectomy. Endogenous hypergastrinemia was induced in G-II, IV, VI by stomach gavage of 30 mg/kg.day of Lansoprozole (LSP) for 3 weeks. In G-V and VI, L365,260 (ML lab, UK) was given continuously in a dose of 50 microgram/kg/hour intraperitoneally using osmotic mini pump. The rats were sacrificed 3 weeks later, and serum gastrin, the weight and the amount of DNA, RNA, and protein in the remnant pancreas or corresponding part were checked. RESULTS: Serum gastrin concentration was 3-4 times higher in the groups received LSP. LSP stimulated growth of the pancreas (G-I: 11921 vs. G-II: 14220 mg/100 g body weight, p=0.047), and the effect was even greater in partial pancreatectomy groups (G-III: 14616 vs. G-IV: 17318 mg/100 g body weight, p=0.007). Total DNA, RNA, and protein amount in the remnant pancreas showed the same trends as the pancreas weight. The effect of LSP was totally abolished by L365,260 (G-V: 13517 vs. G-VI: 14313 mg/100 g body weight, p>0.047). CONCLUSION: Endogenous gastrin has a stimulatory effect on normal growth, and a much stronger effect on the regeneration of the rat pancreas after partial pancreatectomy. Further investigations including clinical trial should be needed.

Mucin-Producing Bile Duct Tumor

BACKGROUNDS: A mucin-producing bile duct tumor is a rare disease causing diffuse bile duct dilatation and intermittent obstructive jaundice due to mucin accumulation in the bile duct. A massive amount of mucin in the dilated bile duct is confirmed during surgery, endoscopic drainage, or percutaneous drainage. These tumors are usually slow-growing, well-differentiated papillary adenocarcinomas that shows intraductal spreading or an intraductal papillary growth pattern. PURPOSE: The purpose of this study was to evaluate the clinical, radiological, and histopathological characteristics of mucin-producing bile duct tumors. METHODS: We treated 10 patients with mucin-producing bile duct tumors during the recent 5 years. Clinical features were reviewed, including symptoms and signs, radiologic characteristics, operative findings, and pathological characteristics. RESULTS: The main clinical symptoms were recurrent abdominal pain, fever, chill, and intermittent jaundice. The characteristic radiologic findings were marked dilatation of the bile ducts distal to the tumors on computed tomography (CT) and ultrasonography and multiple, large, amorphous filling defects on cholangiography. In three cases, percutaneous transhepatic cholangioscopy (PTCS) was useful not only in making a diagnosis but also in delineating the extents of the tumors. In seven of ten cases involved (70%), the tumors were located mainly in the left intrahepatic duct. Pathologically, six (60%) cases were differentiated papillary adenocarcinoma. CONCLUSIONS: A mucin-producing bile duct tumor should be suspected if the patient has diffuse bile duct dilatation without definite evidence of stones, and it can be confirmed by a large amount of mucin secretion. If this type of tumor is suspected, careful preoperative evaluation, including PTCS, should be considered for making an accurate preoperative diagnosis and for determining the extent of the tumor.

Alpha-Fetoprotein-Producing Carcinoma of the Gallbladder: A case report

We experienced a case of a gallbladder carcinoma detected incidentally by elevated serum alpha- fetoprotein. The patient had a symptom of mild intermittent indigestion, and a routine medical examination revealed elevation of serum alpha-fetoprotein. A mass, 4 cm 3 cm, was located in the gallbladder and it had not infiltrated the liver. The serum level of alpha-fetoprotein decreased after a cholecystectomy. The gallbladder mass was an adenocarcinoma of hepatoid differentiation. Cytoplasms of the tumor cells had positive reactivity to immunohistochemical staining of alpha-fetoprotein. In the course of postoperative follow up, the serum alpha-fetoprotein level increased continuously, and abdominal CT scanning proved multiple intrahepatic metastases.

Pancreaticoduodenectomy for Benign Disease

BACKGROUND: Perioperative morbidity and mortality following a pancreaticoduodenectomy have decreased markedly over the last two decades, so many surgical centers advocate expanding the indications for a pancreaticoduodenectomy to include benign lesions other than periampullary malignancies. METHODS: Between 1990 and 1997, 22 patients underwent a pancreaticoduodenectomy (9 classical Whipple's operations, 10 pylorus-preserving pancreaticoduodenectomies and 3 duodenum preserving resection of the head of the pancreas) for benign disease from among a total of 306 patients receiving pancreaticoduodenectomy. The postoperative morbidity and mortality were analyzed retrospectively. RESULTS: The sites of the lesions were the pancreatic head (n=12), the common bile duct (n=5), the duodenum (n=3) and the ampulla of Vater (n=2). The most frequent indication for pancreaticoduodenectomy was a suspicion of malignancy. There was no immediate postoperative mortality, and perioperative complications occurred in 50% of the patients (11/22 patients). During the follow-up period (mean follow-up: 23.8 month), there were no complications or mortalities related to either disease or the operation. CONCLUSIONS: This study suggests that a pancreaticoduodenectomy should be recommended for periampullary benign disease if malignancy cannot be excluded or if the lesion cannot be removed without the procedure. However, perioperative morbidity and mortality are still higher for a pancreaticoduodenectomy than for other procedures, so patient selection and perioperative management should be careful, also, a more conservative procedure than the classical Whipple's operation should be considered for benign lesions, if possible, for better quality of life.