Clinical Outcome and Predictive Factor of Splenectomy in Patients with Idiopathic Thrombocytopenic Purpura

PURPOSE: Splenectomy is an important treatment modality for the patients with idiopathic thrombocytopenic purpura (ITP), but the response rate of splenectomy for ITP patients is variable and the predictive factors of the postoperative response are uncertain. The purpose of this study is to investigate the response rate of splenectomy and find the predictive factors of splenectomy in ITP patients. METHODS: We reviewed the medical records of 54 consecutive patients who underwent splenectomy and were followed up. A positive response to splenectomy was defined as a postoperative platelet count greater than 50, 000/microliter without medication. We analyzed the following variables to find the predictive factors for splenectomy; age, gender, disease duration, platelet count at diagnosis, preoperative platelet count, early response to steroid, IVIG response, operative method, accessory spleen and postoperative platelet count. RESULTS: The response rate of splenectomy was 60% at the 1st postoperative month, 46% at the 3rd postoperative month and 37% at the 6th postoperative month. The age of the splenectomy responders at the 6th postoperative month was significantly lower than that of the non-responder (33.4+/-14.5 years versus 48.7+/-17.1 years, p< 0.05). The platelet count at the time of discharge of the splenectomy responders was significantly greater than that of the non-responders (378, 429+/-272, 399/microliter versus 191, 731+/-151, 435/microliter, p< 0.05). These results were significant on multivariate analysis. CONCLUSION: The response rate of splenectomy is decreased according to the passage of time during the early postoperative period, so long term follow up is important to investigate the predictive factors. Young age for the patients and high platelet count at discharge can be used as the predictive factors for splenectomy in ITP.

Mesenteric Pseudocyst Causing Intestinal Obstruction

Mesenteric pseudocyst has a fibrous cystic wall without an endothelial lining. It can develop from an inflammatory reaction or from trauma. This lesion is difficult to diagnose preoperatively, and it is rarely symptomatic except when it is complicated by bleeding, rupture or infection. A 66-year old male presented with generalized abdominal pain for 3 days. In his past medical history, an appendectomy was done forty years ago. Three months after the operation, a mass was palpated in the left lower quadrant and size of the mass had gradually increased. Physical examination revealed a distended abdomen with diffuse tenderness. The non-tender mass, which was about 10 cm in size, was palpated in the left lower abdomen. A simple abdominal x-ray showed a mechanical obstruction of the small bowel. A CT scan showed a 10x9 cm sized cystic mass with a partially enhancing cystic wall. Surgical exploration revealed the 13 cm sized mass in the distal ileum about 40 cm proximal from the ileocecal valve, and the adjacent ileum was obstructed by this mass. The mass was a thick walled cyst that contained a non-clotting bloody material. Histopathological examination indicated that the cyst wall was composed of fibrosis with neutrophil infiltration, but there was no specific endothelial lining. The final pathological diagnosis was a mesenteric pseudocyst. Mesenteric pseudocyst with obstruction is rare and difficult to diagnosis, but it should be included in the differential diagnosis in the case of intestinal obstruction with mass.

Small Bowel Perforation by a Fish Bone in Intestinal Obstruction: A Case Report

Intestinal perforation by an ingested foreign body is uncommon, and less than 1% lead to intestinal perforation. The diagnosis of fish-bone-induced intestinal perforation is difficult because of the rare history of foreign body ingestion, various clinical presentations, and the radiolucent character of fish bone. Usually, the correct diagnosis is established after an operation. We experienced a rare case of small bowel perforation induced by a fish bone accompanying an intestinal obstruction due to previous operation. Foreignbody-induced perforation is relatively rare, but it should be considered in the case of an acute abdomen.

Clinical Results in the Treatment of Extrahepatic Bile Duct Cancer and Long-term Survivors' Characteristics after Surgical Resection / 한국간담췌외과학회지

BACKGROUND/AIMS: The objectives of this study were to analyze actual long-term survivors' characteristics and investigate what affect long-term survival after resection for extrahepatic bile duct cancer. METHODS: 151 patients of the total 282 patients with extrahepatic bile duct cancer underwent surgical resection between 1986 and 1996. During study period, 23 cases of hepatobiliary resection (HBR), 25 bile duct resection (BDR), and 103 pancreatoduodenectomy were performed respectively. We analyzed survival results and prognostic factors after surgical resection. We also investigated clinico-pathological features of actual long-term survivors. RESULTS: The 1-,3-,and 5-year survival rates were 72.9%, 41.1%,and 32.5% in the resection group, and the 1-, 3-year survival rates were 35.4% and 1.6% in the non-resection group (p<0.001). The differences of survival rates according to the types of resection were not significant (p=0.083). After surgical resection, tumor histology and lymph node metastasis were the independent prognostic factors in multivariate analysis. CONCLUSION: The prognosis of the extrahepatic bile duct cancer depends on the curative resection. Regardless of the types of resection and tumor location, if tumor histology might be favorable and no lymph node metastasis exist, long-term survival could be expected.

Unsuspected Gallbladder Cancer: Radical Second Operation vs Cholecystectomy Alone

PURPOSE: This study was designed to evaluate effectiveness of additional operation for gallbladder cancers (GBC) diagnosed after simple cholecystectomy. METHODS: Retrospective pathological review of 250 GBC (Mar. 1986~Nov. 2000) revealed that in 38 cases the malignancy had been proven by later pathologic study after the patients had initially undergone simple cholecystectomy. Twelve patients had a subsequent reoperation and the other 26 were observed. Types of reoperation were liver wedge resection (n=4), wedge resection with CBD resection (n=2), extended right lobectomy (n=2), wedge resection with Whipple's operation (n=1), hepatopancreaticoduodenectomy (n=1), bile duct resection (n=1) and open biopsy (n=1). We analyzed the clinical outcomes of these patients. RESULTS: (1) Patients with pT1 (n=19) survived without additional operation. (2) Five patients with pT2 lesion without reoperation and 5 patients with reoperation (LN(-): 4, LN(+): 1) were still alive without evidence of recurrence at an average of 35 months follow up (duration: 3~84 months). The remaining 3 patients with reoperation (LN(+)) died at postoperative 7, 11 and 20 months. (3) One patient with pT3 cancer without LN metastasis was alive at 80 months after reoperation. (4) Among 4 patients with pT3 lesion, 3 died while the other without reoperation (unknown LN status) was alive without recurrence at 80 months after reoperation. CONCLUSION: It was suggested that pT1 cancer can betreated with cholecystectomy alone. Additional operation should be applied to pT2 or more advanced cancers, and to cases of positive resection margin. Thorough gross examination of gallbladder specimens during cholecystectomy is essential to avoid missing hidden GBC.

Diagnositic and Prognoistic values of serum CEA and CA19-9 levels in Periampullary Cancer / 한국간담췌외과학회지

PURPOSE: The value of carcinoembryonic antigen(CEA) and carbohydrate antigen 19-9(CA19-9) in periampullary cancers have not been clearly established. Diagnostic and prognostic values of these two markers in resectable periampullary cancer were clarified in this study. METHODS: Preoperative serum levels of CEA and CA19-9, and clinicopathologic features were reviewed in 151 surgical patients with periampullary cancer who were admitted in department of General Surgery of Seoul National University Hospital from Feb. 1996 to Dec. 2000. Postoperative serum levels of these tumor markers were also reviewed. For comparison with benign disease, preoperative serum levels of these tumor markers in GB stone patients were reviewed. After resection, serial tumor markers had been followed up. Disease recurrence was confirmed by imaging study. RESULTS: The CA19-9 concentration was above the cut-off limit (37U/ml) in 60.8% and the CEA concentration was above the cut-off limit(5ng/ml) in 10.5% of the periampullary cancer. Preoperative serum CEA and CA19-9 did not demonstrate the TMN stage, pathologic differentiation and the tumor size. The difference between the survival curves of the preoperative serum CA19-9 level (cut-off 100U/ml) was highly significant (p<0.05) in ampullary cancer. After curative resection, the serum CEA and CA19-9 level were decreased below cut-off level (5ng/mg in CEA, 37U/ml in CA19-9) in 55.6% and 71.2% of total periampullary cancer patients respectively. The mean survival period of the group with normalized CA19-9 level after surgery was significantly longer than that of the group with persistent elevated serum CA19-9 level (52.18 vs 21month, p<0.005) in ampullary cancer. The recurrent sensitivities of the CA19-9 were 57%, 50%, 67% in ampullary cancer cancer, distal CBD cancer, pancreatic head cancer respectively. CONCLUSION: Serial check of serum levels of the CA19-9, CEA is useful in diagnosis and recurrence detection in periampullary cancer.

Induced Hypergastrinemia Can Prevent the Pancreatic Atrophy after Pancreatoduodenectomy in Human

PURPOSE: Following a pancreatoduodenectomy, atrophy of the distal pancreas commonly occurs. It has been demonstrated that gastrin stimulates the regeneration of the pancreas in animals. This study was undertaken to determine whether gastrin has a similar effect in humans and in particular, whether it prevents the atrophy of the distal pancreas after a pylorus preserving pancreatoduodenectomy (PPPD). METHODS: Between March 1999 and May 2000, a randomized prospective study was performed in 56 patients who underwent PPPD for periampullary neoplasms. The patients were allocated to either a lansoprazole group (LG) or a control group (CG). The LG members were given oral lansoprazole (30 mg/day) over 12 weeks postoperatively to induce hypergastrinemia. During the study period, 19 patients were excluded for various reasons. Therefore, a total of 37 patients (LG: n=18; CG: n=19) were eligible for this study. The volume of the distal pancreas was determined using thin sectioned spiral CT data, the nutritional status, the endocrine (insulin level, glucose tolerance test) and exocrine function (stool elastase) of the pancreas. In addition, the serum gastrin level were measured prior to the operation and 3 months after the operation. The two groups were clinically comparable. RESULTS: The serum gastrin level was higher in the LG (P<0.05). In this group, the mean volume of the distal pancreas was reduced by 10% (63,954 mm3+/-57,069 mm3) after PPPD, whereas severe pancreatic atrophy occurred in the CG (71,446 mm3+/-39,753 mm3) (P<0.01). The postoperativeinsulin and stool elastase levels were higher in the LG than in the CG (insulin: 21.1milliunit/ml vs 6.9milliunit/ml; elastase: 59 microgram/g vs 23microgram/g). CONCLUSION: Induced hypergastrinemia prevents pancreatic atrophy after PPPD. This is probably because of the stimulated regenerative activity of the pancreas by gastrin. This has never been previously demonstrated in humans.

Forty-Year Experience with the Pancreatoduodenectomy

PURPOSE: We reviewed our experience of 700 pancreatoduodenectomies for 40 years to study the clinical characteristics and to find out any changing patterns according to the periods. METHODS: From the first pancreatoduodenectomy in 1961, 700 consecutive pancreatoduodenectomies have been performed in Seoul National University Hospital until August 1999. Annual number of cases, indications, resectability, complications, and survival were analyzed base on three periods (period I: '72-'84; period II: '85-'90; period III: '91-'99). RESULTS: We had got 5 cases or less per year until 1980; thereafter, the number of case increased reaching 70 cases per year recently. Since pylorus-preserving pancreato duodenectomy (PPPD) was introduced in 1990, the proportion of PPPD increased to 60% in 1998. Indications for a pancreatoduodenectomy were periampullary cancer in 85% of the case and other benign or malignant lesions in 15%. The overall resectability was 37% (ampullary: 86%; bile duct: 42%; duodenal: 28%; pancreas; 18%), and there has been an increasing tendency of resectability in pancreatic and bile duct cancer. Overall morbidity rate was 37%, which has been decreasing, however, pancreatic leakage is still an unresolved problem. The overall mortality was 4.7% and improved from 9.1% in period I to 2.5% in period III. There has been a remarkable improvement in the 5-year survival rate for ampullary cancer (period I: 31%; II: 54%; III: 65%) and for bile duct cancer (19%, 32%, 36%), whereas that for pancreatic cancer is still detrimental (7%, 14%, 16%). CONCLUSION: Pancreatoduodenectomy has been increasing probably due to increased incidence of the indications and aggressive resection. Morbidity and mortality have decreased remarkably, and survival has improved, especially for ampullary and bile duct cancer. Therefore, the role of pancreatoduodenectomy for the management of periampullary cancer has become more significant.

Pancreatic Head Resection with Segmental Duodenectomy

PURPOSE: Duodenum-preserving resection of the head of the pancreas (DPRHP) requires meticulous dissection to preserve vascular circulation to the parapapillary area and has high risks for ischemia of these organs and associated complications. Pancreatic head resection with a segmental duodenectomy (PHRSD) is introduced to overcome technical difficulty and high risk. METHODS: A PHRSD was performed in 4 patients, one each with duodenal mucosa cancer, intraductal an papillary mucinous neoplasm of the pancreas, a villotubular adenoma of the papilla, and a serous cystadenoma of the pancreas. A bilateral subcostal incision was used for the laparotomy. By using Kocher's maneuver and dividing the adjacent ligament, we achieved full mobilization of the duodenum with the pancreas head, and confirmed a pathologic lesion. The superior pancreatiocoduodenal arteries were ligated and divided at the root with preservation of the gastroduodenal and the right gastroepiploic arteries. The anterior inferior pancreaticoduodenal artery was also preserved. The pancreatic head was resected using a 3- to 5-cm segmental duodenectomy at level 6 cm below the pyloric ring. After resection, reconstruction was performed using a pancreaticogastrostomy, duodenoduodenostomy, choledochoduodenostomy. RESULTS: No transfusions were required, and the mean operation time was 357 minutes. After this operation, no serious complications were developed. Minor pancreatic leakage developed in one case and was easily cured by conservative management. All patients were followed up without any clinical problems till now. CONCLUSION: A PHRSD can be recommended for the management of benign or low-grade malignant lesions of the pancreatic head and can also be used for the treatment of early cancer or polypoid lesions, which cannot be removed by using endoscopy, located in the duodenal second portion or the papilla.

Clinical and Histopathologic Analysis of Ductaol Carcinoma In Situ

A retrospective analysis was performed on 69 follow-up cases of ducal carcinoma in situ(DCIS) treated from Jan. 1981 to Dec. 1995 at Department of Surgery, Seoul National University Hospital. The results are as follows. The mean age was 45.4 years that ranged from 28 to 68. The proportion of DCIS to breast cancer was increased from 1.3% to 7.2% for 15 years. Clinical presentations of DCIS were mass, nipple discharge and suspicious mammographic findings. Patients presenting mass were decreased, while mammographically detected DCIS were increased. In 49.3% of cases, the tumor size was smaller than 2cm and in 21.3% of the cases, the tumor was not palpable. Treatment modality was changed to more conservative procedures. All of the patients survived well without local recurrence or distant metastasis for a mean follow-up of 36.3 months(range 7 to 146). Histopathologic review was also performed on 52 cases of which paraffin blocks were saved, by one pathologist and diagnosis was confirmed. Pure DCIS composed 16 cases(30.8%), and DCIS with microinvasion was 36 cases(69.2%). Clinical presentation of DCIS, such as age, nipple discharge, calcification on mammography and mass size were not related to the microinvasion, but mass palpability was related to microinvasion(p=0.018). There was no histopathologic features to predict progression to invasive carcinoma, regardless of comedo type, histologic grade and nuclear grade. The expression of cathepsin-D, nm23, p53 and c-erbB-2 protein, was also evaluated using immunohistochemical methods. The relationship between expression of immunohistochemical antibodies and prognostic variables such as tumor size, histologic grade, nuclear grade, and microinvasion was assessed. The overexpression of c-erbB-2 protein was associated with lower nuclear grade(p=0.033), and a strong correlation was seen between tumor size and cathepsin-D and p53 protein(p=0.035, p=0.016). In this study, we conclude that the fine classification and analysis of DCIS subtype, not only by histopathologic but also by immunohistochemical study can be helpful to predict biological behaviour of DCIS and decide the modality of treatment.