The Value of Preoperative Magnetic Resonance Cholangiopancreatography (MRCP) in Patients Who will be Performed Laparoscopic Cholecystectomy

PURPOSE: The aim of this study is to evaluate the value of preoperative MRCP prior to laparoscopic cholecystectomy by analysis of postoperative outcomes. METHODS: Between 2009.12~2010.12, 283 patients underwent laparoscopic cholecystectomy for treatment of benign biliary disease. Among these patients, 125 underwent preoperative MRCP and were classified as the MRCP group. The remaining 158 patients who did not undergo MRCP were classified as the non MRCP group. We compared perioperative data, including the rate of bile duct injury, operative complication, conversion rate, hospital stay, and hospital cost between the two groups. In addition, we analyzed preoperative MRCP findings, including common bile duct (CBD) stones and bile duct anomaly. RESULTS: Findings on pre-operative MRCP scan revealed silent CBD stones in five patients (4.0%) and bile duct anomalies were identified in 17 patients (13.6%). Three cases of bile duct injury occurred in the non MRCP group, whereas, no bile duct injury occurred in the MRCP group. No significant statistical difference in postoperative complication was observed in either group. Mean duration of operation was 50.5 (+/-30.4) minutes in the MRCP group, and 52.2 (+/-29.9) minutes in the non MRCP group (p=0.630). Post operative hospital stay was 2.1 (+/-1.4) days (mean) in the MRCP group, and 2.5 (+/-2.5) days in the non MRCP group. No statistical difference was observed between the two groups (p=0.110). CONCLUSION: MRCP may be useful for evaluation of bile duct anomaly and identification of hidden bile duct stones. However, this modality did not show statistical benefits for postoperative outcomes in patients who underwent laparoscopic cholecystectomy.

An Imported Case of Cystic Echinococcosis in the Liver

A 25-year-old Uzbek male presented with right upper abdominal pain for 20 days. On radiologic studies, a huge cystic mass was noticed in the right liver which was suspected as parasitic. The patient received right hepatic segmentectomy (segment 7), and the surgically resected mass was confirmed as cystic echinococcosis (CE), measuring 10.5 cm in its diameter. The inner surface of the cyst was bile-stained. The patient was discharged on the 8th hospital day, and was rechecked 6 months after the surgical intervention without any evidence of recurrence. The present report describes findings of an imported case of CE which represented ultrasound images of the 'ball of wool'.

Laparoscopic Resection for the Treatment of Symptomatic Remnant Huge Cystic Duct with Stone after Laparoscopic Cholecystectomy

During laparoscopic cholecystectomy, the cystic duct is frequently divided closer to the gallbladder to avoid iatrogenic injury to the common bile duct. Postcholecystectomy syndrome can be considered if the patient complains of right upper abdominal discomfort after cholecystectomy. We report a case of a laparoscopic resection for the treatment of a symptomatic remnant huge cystic duct with stones after a previous laparoscopic cholecystectomy. A 46-year-old male was admitted to our hospital due to right upper quadrant abdominal pain. Five years earlier, the patient had undergone a laparoscopic cholecystectomy under the diagnosis of acute calculous cholecystitis but he subsequently suffered from intermittent right upper abdominal pain and fever. An abdominal computed tomography scan revealed a stone in a dilated remnant cystic duct. A laparoscopic remnant cystic duct resection was performed and apathologic diagnosis was made with chronic calculus cystic duct inflammation. The patient was discharged without complications and has been doing well without recurrent symptoms.

The impact of old age on surgical outcomes after pancreaticoduodenectomy for distal bile duct cancer

BACKGROUNDS/AIMS: To compare surgical results and survival of two groups of patients, age > or =70 vs. age <70, who underwent pancreaticoduodenectomy and to identify the safety of this procedure for elderly patients for the treatment of distal common bile duct (CBD) cancer. METHODS: Between January 2003 and December 2009, 55 patients who underwent pancreaticoduodenectomy for the treatment of distal CBD cancer at Keimyung University Dong San Medical Center were enrolled in our study. RESULTS: Of 55 patients, 28 were male and 27 female. Nineteen were over 70 years old (older group) and 36 were below 70 years (younger group). The mean ages of the two groups of patients were 73.5 years and 60.5 years respectively. Although patients of the older group had significantly more comorbid diseases, perioperative results including operation time, amount of intraoperative bleeding, duration of postoperative hospital stay and postoperative complications were not significantly different. A higher level (more than 5 mg/dl) of preoperative initial bilirubin showed significant correlations with operative morbidity by univariate analysis, and age was not an independent risk factor of operative morbidity. Overall 5 year survival of older and younger groups were 45.9% and 39.5% respectively (p=0.671) and disease-free 5-year survival were 31.7% and 31.1%, respectively (p=0.942). CONCLUSIONS: Surgical outcomes of elderly patients were similar to those of younger patients, despite a higher incidence of comorbid disease. This results shows that pancreaticoduodenectomy can be applied safely to elderly patients.

Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

Prognostic Factors for Intrahepatic Cholangiocarcinoma Treated with Surgical Resection

PURPOSE: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy, but outcome studies are uncommon. The purpose of this study was to determine outcomes and prognostic factors after surgical resection. METHODS: We reviewed and analyzed retrospectively fifty four patients who were diagnosed as having intrahepatic cholangiocarcinoma and whose tumor was resected surgically between 2001 and 2009. Our analysis focused on survival and on significant prognostic factors affecting survival after surgical resection. RESULTS: Forty-one subjects (75.9%) were male and twelve (24.1%) were female. The average age was 59.4 years old. For predisposing factors, infestation of clonorchis sinensis plus hepatitis B antigen positivity were 11.1% respectively. Among tumor markers, CA 19-9 was elevated in 50.9% and CEA in 30%. Eighty percent were treated by major hepatectomy. Overall 3 & 5 year-survival rates were 41.8% and 36.2%, and 3 and 5 year disease free survival rates were 37.5% and 28.6%, respectively. By univariate analysis, significant prognostic factors affecting cumulative survival were tumor size, vascular invasion, tumor differentiation, serosal invasion, metastasis to the regional lymph nodes and tumor markers CEA and CA 19-9. By multivariate analysis, only differentiation and metastasis to the lymph nodes were significant. CONCLUSION: The prognosis of intrahepatic cholangiocarcinoma is poor but has been improved by curative surgical resection. Tumor factors, tumor differentiation and lymph node metastasis were elucidated as the most significant prognostic factors, and radical surgical resection is the only way to get a better outcome from IHC that has a notoriously poor prognosis.

The Complication Rate according to the Method of Pancreaticojejunostomy after Pancreaticoduodenectomy

PURPOSE: This study was designed to compare and analyze the complication rates of different anastomotic methods of pancreaticojejunostomy after performing pancreaticoduodenectomies by a single surgeon. METHODS: From January 2000 to August 2007, 92 patients underwent pancreaticoduodenectomy at a single institution. According to the texture of the pancreas and pancreatic duct size (below or above 3 mm), the type of pancreaticojejunal anastomosis was selected (either duct-to-mucosa pancreaticojejunostomy or end-to-side pancreaticojejunostomy with polyethylene tube). RESULTS: The pathologic diagnosis of the 92 patients included 81 patients with adenocarcinoma, five with chronic pancreatitis and three with GIST that developed in the duodenum. The adenocarcinomas include 33 distal CBD cancers, 18 pancreatic head cancers, 27 Ampulla of Vater cancers and 6 duodenal cancers. The pancreatic fistula rate was not significantly different between the duct-to-mucosa group and the end-to-side pancreaticojejunostomy group (nine of the 43 patients in the duct-to-mucosa group (20.9%) and six of the 46 patients in the tube insertion group (13.0%) (p=0.4). The rate of pancreatic fistula, as classified by three different consecutive periods (period I: 2000-2003; period II: 2004-2005; period III: 2006-2007), was markedly decreased and there were less complications with increasing experience (period I: 33.3%; II: 7.1%; III: 6.4%) (p=0.001). CONCLUSION: When performing pancreaticojejunostomy, both the duct-to-mucosa method and the tube insertion method were effective in decreasing the complication rate if the appropriate method was selected according to the texture of the pancreas and the size of pancreatic duct. The surgeon's experience and skill can affect the occurrence of pancreatic fistula after pancreaticojejunostomy. Enough experience is the most important factor to decrease the complication rate after pancreaticoduodenectomy.

Risk factors for early recurrence after surgical resection for hepatocellular carcinoma / 대한간학회지

BACKGROUND/AIMS: Early recurrence (ER) after liver resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). This study aimed to identify the factors associated with ER after curative hepatic resection for HCC. METHODS: From the July 2000 to July 2006, 144 patients underwent hepatic resection for HCC at a single institution. After excluding those with ruptured HCC, combined or mixed HCC, and who died during admission, 116 patients were analyzed. Patients with ER (defined as within 1 year) were compared with those who remained free of disease for more than 1 year. Various clinical characteristics including tumor and operative factors were evaluated to determine the factors predicting postoperative ER using univariate and multivariate analyses. RESULTS: ER occurred in 51 patients (44%). In the univariate analysis, tumor size (P=0.001), microvascular invasion (P=0.003), portal vein invasion (P=0.001), TNM stage (P=0.010), serum levels of alpha-fetoprotein (AFP) (P=0.002) and aspartate aminotransferase (AST) (P=0.011), and operative time (P=0.033) were significantly associated with ER. AFP and AST were the independent predictors of ER in the multivariate analysis (P<0.05). CONCLUSIONS: Preoperative serum AFP and AST levels were the independent risk factors for ER after surgical resection for HCC. Close postoperative surveillance is recommended for early detection of recurrence and additional treatments in patients with these factors.

The Current Status of Treatment for Patients with Severe Acute Pancreatitis

INTRODUCTION AND AIM: Acute pancreatitis is an inflammatory process of varying severity, ranging from a mild, self-limiting form to severe acute pancreatitis, which leads to complications such as necrosis, pseudocyst formation, and organ failure. This highly lethal condition should be differentiated from acute abdomen caused by other diseases as early as possible so appropriate management can be carried out. PATIENTS AND METHODS: A survey was carried out to determine the current status of management for this particular disease in Korea. A total of 269 patients were collected from 13 university hospitals during a four and a half year period (January 2000 to June 2004). RESULTS: Of the 269 patients, 103 (38.3%) were managed with surgery, and 166 (61.7%) were managed with conservative treatment. The most commonly performed surgical procedure was debridement of necrotic tissue with closed drainage. The most common etiology was alcohol, with 143 cases (53.4%), followed by gallstones, with 48 cases (17.9%). E. coli was the most commonly cultured bacterium. The mortality rate in surgically managed patients was 9.7%. The mortality rate in conservatively treated patients was 7.2% . CONCLUSION: Patients with infected pancreatic necrosis should be managed with surgical necrosectomy and drainage. However, patients with sterile necrosis should be managed conservatively unless organ complications or severe clinical deterioration develops despite intensive therapy. Patient survival is improved through early diagnosis, followed by adequate drainage in combination with intensive care.

Surgical Site Infection and Surveillance

During the second half of the 19th century many operations were developed after anesthesia was introduced but advances were limited for many years because of the high rate of infection and the high mortality rate that followed infections. After the introduction of the principle of antisepsis, postoperative infectious morbidity decreased substantially. With the introduction of antibiotic therapy in the middle of the 20th century, a new adjunctive method to treat and prevent surgical infections was discovered. However, not only have postoperative wound and hospital required infections continued, but widespread antibiotic therapy has often made prevention and control of surgical infections more difficult. Based on National Nosocomial Infection Surveillance (NNIS) system reports, SSIs (Surgical Site Infections) are the third most common nosocomial infection, accounting for 14% to 16% of all nosocomial infections among hospitalized patients. It is also a significant source of postoperative morbidity, resulting in increased hospital length of stay and increased cost. Determination of risk factors for the development of SSI has been a major focus of surgical research. To reduce the rate of SSIs we have to eliminate risk factors of SSIs and keep a continuous surveillance with feedback of information to surgeons and other relevant staff. A successful SSI surveillance program includes standardized definition of infection, effective surveillance method, and stratification of the SSIs rates according to risk factors. Because SSIs may be the most preventable of nosocomial infections, health care facilities should make special efforts to reduce the risk of development of these surgical complications. The evaluation of infection control programs and the development of more effective infection control strategies should be established and surgeons should be more concern about SSI control.

Analysis of the Perioperative Outcomes after Surgical Resection for 145 Patients with Hepatocellular Carcinoma

PURPOSE: Surgical resection for the hepatocellular carcinoma (HCC) is the only proven curative treatment modality. Most of these patients have chronic hepatitis with or without cirrhosis; therefore, curative resection with enough of a safety margin is always challenging for hepatic surgeons. The aim of our retrospective study was to analyze the correlation of the complications with the patient factors, the tumor factors and the surgical factors. MATERIALS & METHOD: A total of 145 patients who had hepatocellular carcinoma were resected surgically during the five year and nine months period between September 2000 and June 2006. We collected the database prospectively and we analyzed the perioperative outcomes from the accumulated database. RESULT: Anatomical resection, standard hemihepatectomy or systematic segmentectomy after injection of methylene blue dye into the portal vein branch was performed in 89 patients, and nonanatomical resection was done in 56 patients. The number of major resections that was more than two sections was 72, and the number of minor resection less than two sections was 73. The mean operative time was 270 minutes, the amount of bleeding was 669ml and the mean time of performing the Pringle maneuver was 31.5 minutes. Perioperative complication were noted in 20.0% of the patients and there were five mortalities (3.4%). The only one significant factor that affected a higher complication rate was the ICG15 and the significant factor that affected the mortality rate was the duration of the Pringle maneuver. CONCLUSION: Type oriented hepatic resection that achieves an adequate surgical resection volume is dependent on the status of the tumor and the hepatic reservoir function with limited bleeding, and these factors will help selected patients obtain a very good outcome with an acceptable complication rate and low mortality.

Isolated Inferior Vena Cava Thrombosis after Traumatic Hepatic Injury

The incidence of acute deep vein thrombosis after multiple trauma has been reported to range from 1.7 to 10%. In general, a thrombus of the calf vein migrates to the proximal vein. An isolated inferior vena cava (IVC) thrombosis without a peripheral venous thrombosis is rare. A 35-year-old woman was admitted as a result of a large subcapsular hematoma in the right hepatic lobe after a blunt injury caused by an automobile accident. The thrombus in the IVC was detected incidentally during a follow up CT scan three weeks after the trauma. A compression of the IVC by the displaced hepatic parenchyme as a result of a large subcapsular hematoma is a possible mechanism for the IVC thrombosis because there was no distal venous thrombosis and no evidence of hypercoagulability. A retrievable caval filter (Gunther-Tulip(TM), Cook Inc. Bloominton, USA) was placed in the suprarenal vena cava via the right internal jugular venous approach. After placing the retrieval caval filter, aspiration thrombectomy was attempted through the right femoral vein. The luminal patency of the IVC was restored immediately after retrieving the thrombus. The subcapsular hematoma in the right hepatic lobe disappeared two months later and there was no evidence of a residual thrombus in the inferior vena cava.

Sclerosed Hemangioma of the Liver

Hepatic hemangioma is one of the most frequent benign neoplasm of the liver. Its radiologic findings are easily identified to peripheral strong contrast enhancement in the early phase of dynamic comupted tomography (CT) and progressive contrast fill-in on the delay phase. Nevertheless, sclerosed hemangioma is a very rare disease and a regressed form of cavernous hemangioma. Therefore, its differential diagnosis is very difficult. It should be included in the differential diagnosis of other hepatic lesions such as hepatocellular carcinoma, intrahepatic peripheral cholangiocarcinoma and metastatic hepatic tumor. The treatment of sclerosed hemangioma should be conservative management, if diagnostic confirmation was made preoperatively. In this report, we present a case of a 48-year-old male who was treated for hepatic resection. We were not able to identify the sclerosed hemangioma preoperatively.

Feasibility of Left Hemi-hepatectomy for the Treatment of Left Intrahepatic Duct Stones

PURPOSE: The definite modality for the treatment of intrahepatic duct stones (IHS) is a hepatic resection, which can achieve two goals; removal of the stones and stricture of the bile duct, thus reducing the risk of recurrent intrahepatic duct stones. As a procedure, a left lateral sectionectomy has usually been applied, according to the disease location. However, in patients having had a left lateral sectionectomy, the postoperative results have shown increased complication rates. In this study, we investigated the better results of a left hemi-hepatectomy compared to a left lateral sectionectomy for the treatment of left IHS in terms of postoperative complications. METHODS: Thirty two patients, who were treated with a hepatic resection for their IHS, between January 2001 and November 2003, were analyzed. The patients were divided into two groups according to the operative procedure, as follows; group I had a left lateral sectionectomy and group II a left hemi-hepatectomy. The amount of bleeding, duration of surgery, postoperative results and complications were compared between the two groups. RESULTS: There were 22 and 10 females and males, respectively, with a mean age of 56.9 (+/-10.0) years. Of the patients, 14 and 18 were placed into groups I and II, respectively. The duration of surgery in groups I and II were 220.0 (+/-41.6) and 255.0 (+/-49.8) minutes, respectively. The volume of bleeding was 294.6 (+/-345.5) and 406.0 (+/-177.0) ml in groups I and II, respectively (p> 0.05). The incidence of complications (bile leakage, abscess and occurrence of inflammatory pseudotumors) after a left hemihepatectomy were significantly lower than those after a left lateral sectionectomy (p< 0.05). CONCLUSION: This study revealed that a left lateral sectionectomy has greater complications compared to a left hemihepatectomy for the treatment of left IHS. This may be caused by anatomic variations in bile duct drainage from the left medial segment. If the anatomy of the medial segmental duct was not identified preoperatively, a standard left hemi-hepatectomy should be considered.

Outcomes of Hepatic Resection Using Intermittent Hepatic Vascular Inflow Occlusion with Low Central Venous Pressure / 한국간담췌외과학회지

PURPOSE: Blood loss and transfusions during a liver resection are associated with higher morbidity and mortality rates. With applying hepatic vascular inflow occlusion (Pringle maneuver), persistent bleeding during a hepatic transection is caused by back flow from the hepatic veins. Therefore, low central venous pressure facilitates to reduce-bleeding from the hepatic veins by lowering the back flow pressure gradient. An intermittent hepatic vascular inflow occlusion was applied, with a lowering of the central venous pressure, during a hepatic resection in our series of patient. The effect of these maneuvers in reducing bleeding and the postoperative complication rates were analyzed. METHODS: Between December 2000 and September 2003, in 153 hepatic resection patients, where this technique was used, the intermittent vascular inflow occlusion and maintenance of the central venous pressure as low as possible were accrued in this study. The overall outcomes of patients that had a hepatic resection, focusing on the amount of bleeding, blood product transfusion and complication rates, were analyzed. RESULTS: The median blood loss was 652.5 ml, and 111 patients (72.5%) required no perioperative blood transfusion. The median units of blood required in the patients who needed a transfusion were 2.3 U. There was no evidence of renal derangement related with low blood flow into the kidney by keeping central venous pressure as low as possible. There were minor complications in 34 patients (22.4%) and two in-hospital mortalities (1.3%) associated with hepatic failure in cirrhotics. CONCLUSION: A hepatic resection, with an intermittent Pringle maneuver and a low central venous pressure, is a very simple and effective modality to reduce bleeding during a hepatic transection, with low morbidity and mortality rates and without hepatic and renal dysfunctions.

Analysis of Clinical Features and Factors Predictive of Malignancy in Intraductal Papillary Mucinous Tumor of the Pancreas: Multi-center Analysis in Korea / 한국간담췌외과학회지

BACKGROUND/AIMS: Despite of increasing numbers of reports on intraductal papillary mucinous tumor (IPMT), there is still difficulty in its' diagnosis, treatment and prediction of prognosis. The purpose of this multicenter study was to evaluate the clinico-pathological features of IPMT in Korea and suggest the prediction criteria of malignancy in IPMT. METHODS: We retrospectively reviewed the clinico-pathological data of 208 patients who underwent operations with IPMT between 1993 and 2002 at 28 institutes in Korea. RESULTS: Of the 208 patients with a mean age of 60.5+/-9.7 years, 147 were men and 61 were women. 124 patients underwent pancreatoduodenectomy, 42 distal pancreatectomy, 17 total pancreatectomy, 25 limited pancreas resection. Benign cases were 128 (adenoma (n=62), borderline (n=66)) and malignant cases were 80 (non-invasive (n=29), invasive (n=51)). A significant difference in 5-year survival was observed between benign and malignant group (92.6% vs. 65.3%; p=0.006). Of the 6 factors (age, location, duct dilatation, tumor appearance, main duct type, and tumor size) that showed the statistical difference in univariate analysis between benign and malignant group, we found three significant factors (tumor appearance (p=0.009), tumor size (p=0.023), and dilated duct size (p=0.010)) by multivariate analysis. CONCLUSION: Although overall prognosis of IPMT is superior to ordinary pancreatic cancer, more curative surgery is recommended in malignant IPMT. Tumor appearance (papillary), tumor size (> or =30 mm) and dilated duct size (> or = 12 mm) can be used as preoperative indicators of malig-nancy in IPMT.

The Impact of the Number and Size of Gallstone on the Suppuration of Gallbladder and Conversion Rate to Open from Laparoscopic Cholecystectomy / 한국간담췌외과학회지

BACKGROUND/AIMS: The progression of the inflammation to suppurative cholecystitis may depend on the number and size of gallstone. This is a comparative study of correlation between the nature of gallstone (number and size) and progression of suppurative cholecystitis and effect to the difficulty in surgery. METHODS: We analyzed 1,235 patients who were treated with laparoscopic cholecystectomy for the gallstone disease including acalculus cholecystitis and acute suppurative cholecystitis with or without gallstones. One hundred and twenty nine patients were acute suppurative cholecystitis. The patients were grouped four arms according to the size of stones as follows; group I has no stone, group II or =2 cm. Also the patients were grouped to four groups according to the number of stones; group A has no stone, 1 or =7. RESULTS: Conversion rate to open laparotomy was 17.1% (22/129). In case of suppurative cholecystitis, six patients were included in arm I, 57 patients in arm II, 35 patients in arm III, nine patients in arm IV. And six patients were included in group A, 44 patients in group B, three patients in group C and 54 patients in group D of laparoscopic cholecystectomy. Of the 22 patients who were converted to open cholecystectomy, one patient was included in arm I, 14 patients in arm II, four patients in arm III, three patients in arm IV. And one patient was included in group A, eight patients in group B, one patient in group C and 12 patients in group D of open conversion group. There was no statistical significance of the groups (p>0.05). The mean size of stones of the patients with suppurative cholecystitis (129 patients) and simple cholecystitis patients (312) was 0.97 versus 0.91 cm (p>0.05). There was no statistical difference of the number and size of gallstones between simple and suppurative cholecystitis (p>0.05). CONCLUSION: The number and size of gallstone for the patients who were treated by cholecystectomy was not contributing factors to develope suppurative cholecystitis and conversion to open from laparoscopic cholecystectomy.

Surgical Treatment of Pancreatitis

PURPOSE: The most common cause of acute pancreatitis is alcohol abuse, followed by gallstones and pancreatic trauma. Pancreatitis is treated nonoperatively by inhibiting the causes, which include prohibition of alcohol abuse and cholecystectomy for the removal of gallstones. However, in case of a pseudocyst formation, necrotizing pancreatitis or abscesses remained as the complications of severe pancreatitis. Adequate surgical drainage is very important for the treatment of the complications. Adequate surgical procedure for treatment of chronic pancreatitis, causing intractable pain, pseudocyst, and obstruction of pancreatic or bile ducts, should be considered, not only for the patients physical and psychological recovery from a chronically debilitating status, but also in its differentiation from a malignancy. METHODS: Between July 1997 and January 2002, a review and analysis was undertaken of 33 pancreatitis patients, who had been treated, by surgical intervention, for the complications of acute pancreatitis, chronic pancreatitis, and benign pancreatic disease. RESULTS: For the treatment of the various complications in the 33 patients, 20 drainage procedures and 13 surgical resections were used. There were minor complications in 6 patients (21%), and two mortalities, one from multiple organ failure, due to necrotizing pancreatitis, and the other from a surgical complication, due to a duodenum preserving pancreatic head resection. CONCLUSION: The timely surgical drainage, and/or debridement, is critical for patients with complications due to acute pancreatitis. It is difficult to differentiate chronic pancreatitis from a malignancy. Adequate surgical procedures for the different stati ('type oriented surgery') are required for chronic pancreatitis. A resection of cystic lesions, with the possibility of a malignancy, should be considered. We can confirm the diagnosis, and treat the disease, by adequate operative and drainage procedures, or by resection of the main lesion.

Functioning Paraganglioma Manifested Cerebral Hemorrhage and Combined with Coronary Arterio-Venous Fistula

Extra-adrenal pheochromocytomas, also called functioning paragangliomas are uncommon retroperitoneal tumor, manifesting with similar symptoms and signs to adrenal pheochromocytoma. In this report, we present a case of a 46-year-old women who had had paroxysmal hypertension and palpitation for four years. An abdominal mass, the size of an adult fist, was noted, with symptom of a cerebral hemor rhage and cardiac ischemia caused by a coronary arterio-venous fistula. The cerebral hemorrhage symptoms were improved spontaneously. The abdominal mass determined to be a functioning paraganglioma by complete resection. The coronary arterio-venous fistula was surgically corrected a month after resection of the tumor. The patient was freed from the symptoms and signs of a pheochromocytoma, including palpitations and hypertension. There has been norecurrence for a year and half following the removal of the mass.

Survival Analysis of Gallbladder Cancer according to the Pathologic Type and Staging / 한국간담췌외과학회지

BACKGROUND/AIMS: The gallbladder cancer shows highly malignant potential and very poor prognosis. Most of patients who have gallbladder cancer are asymptomatic and have far advanced stage when it was diagnosed. Recently early detection rate of gallbladder disease was increased by common use of screening ultrasonography. For the patients with early staged cancer, we can achieve cure of the disease even with laparoscopic cholecystectomy. Instead, for the patients with advanced stage of gallbladder cancer, extended surgery is required for increased survival rate. METHODS: The authors analyzed the clinical manifestation, diagnosis, therapeutic modality and survival rate for the patients of gallbladder cancer who were treated with surgical resection. From 1993 to 2001, we analysed 55 patients who had gallbladder cancer that was proven pathologically. RESULTS: The mean age of 55 patients was 62.6 years old. The clinical manifestations were RUQ abdominal pain (50.9%), jaundice (12.7%), anorexia (10.9%), epigastric discomfort, palpable mass, ascites and so on. Seven (12.7%) of the patients were asymptomatic. For diagnostic modalities, untrasonography was used for all of the patients, abdominal CT, MRI and ERCP were used selectively. Among 55 patients, 18 patients were diagnosed as benign lesion preoperatively. The sensitivity rate of detecting malignancy was 67.3%. The operative procedure included laparoscopic cholecystectomy, open cholecystectomy, cholecystectomy with regional lymph node dissection, cholecystectomy with combined hepatectomy and hepatopancreatoduodenectomy (HPD). Pathologic findings showed infiltrating type in 27 patients (49.1%) and fungating type in 28 patients (50.1%). Three and five year survival rate of each type were 39.8%, 14.2% and 62.1%, 48.3%. Three and five year survival rates of patients who had negative lymph nodes metastasis were 60.7% and 23.2%, instead positive lymph nodes metastasis were 18.3% and 0%. CONCLUSION: In order to get better survival rate of the patients with gallbladder cancer, early detection and appropriate operative procedures are important, so that minimal invasive surgery for early cancer and extended surgery for advanced stages.