Classification of Intrahepatic Duct Stones and Analysis of Operation Methods

PURPOSE: Intrahepatic duct stones have been known to be a benign disease but because of the associated serious complications and the high recurrence rate, the management of the hepatolithiasis is very difficult. This purpose of this study was to classify the patterns of intrahepatic duct stones, and to evaluate the effect of surgical treatment according to their type and the residual stones that were present. METHODS: The clinical records of 212 patients who underwent a hepatic resection or drainage procedures between January 1988 and December 2000 were reviewed. RESULTS: We classified the intrahepatic duct stones as being either a localized simple type, a localized complicated type, a diffuse simple type, or a diffuse complicated type. Hepatic resections were performed in 177 (83.5%) cases. Among these we performed a hepatic resection along with drainage procedures in 41 cases (19.3%). In 35 (16.5%) cases, only drainage procedures were performed. Of a total of 25 cases of postoperative residual stones (25 cases), 13 (52%) cases were removed completely or partially by choledochoscopic procedures in 13 (52%) cases and in 15 (60.0%) cases they were removed completely or partially by spontaneous drainages. CONCLUSION: Our conclusions were that the, localized type of the IHD stones were treated successfully by a hepatic resection and the localized complicated type and the diffuse type IHD stones were treated effectively by hepatic resection and drainage procedures which reduced the opportunity for residual stones to develop following an accurate preoperative diagnosis of the location of the stones. Therefore, treatment methods should be individualized for each type of stone and by surgical treatments that combine endoscopic and resolution methods.

Recurrence and Complications from the Surgical Procedure for Treating a Papillary Thyroid Carcinoma

PURPOSE: Papillary thyroid carcinoma is the most common endocrine malignancy. Despite the recent advances in diagnosis, controversy still remains concerning the surgical management. In order to select the appropriate surgical treatment, the outcome of different types of surgical procedures were reviewed. METHODS: 435 patients with papillary thyroid carcinoma who underwent surgery from January 1988 to December 1999 were retrospectively reviewed. The 12 years were divided into two periods; period 1 was from 1988 to 1993 (234 patients) and period 2 was from 1994 to 1999 (201 patients). The recurrence and complication rates according to the operation method, including a neck lymph node dissection, were analyzed. RESULTS: Twenty-six (10.7%) and 13 patients (6.5%) had a recurrence in period 1 and 2, respectively. Eighty-one (34.6%) and 51 patients (25.4%) had a postoperative complication including hypoparathyroidism and hoarseness in period 1 and 2, respectively. 271 patients (62.3%) had a lymph node metastasis, and the anterior neck was the most common site of metastasis (60.2%). CONCLUSION: A total thyroidectomy with a routine central node dissection reduces both the incidence and number of postoperative complications.

Efficacy of Stented Pancreaticojejunostomy and Jejunojejunostomy after Pancreaticoduodenectomy

PURPOSE: A pancreaticoduodenectomy is the procedure of choice for patients with resectable carci nomas of the pancreatic head, duodenum, or periampullary region. Although the morbity and the mortality are decreasing now, but there are still high. Leakage of the pancreatic duct remains the major source of death and complications after a pancreaticoduodenectomy. Thus, the authors used a stented pancrea ticojejunostomy and jejunojejunostomy after a pancreaticoduodenectomy to decrease leakage of the pancreatic duct. METHODS: The authors studied retrospectively 44 consecutive patients who had a pancrea ticoduodenectomy with a stented pancreaticojejunostomy and jejunojejunostomy at Kwangju Christian Hospital between 1993 and 1998. RESULTS: Leakage of the pancreaticojejunostomy was diagnosed in one of the 44 patients (2.5%). There were two deaths after the pancreaticoduodenectomy, one from compli cation of leakage of the pancreaticojejunostomy and the other from UGI bleeding. CONCLUSION: The stented pancreaticojejunostomy and jejunojejunostomy is an effective and safe method for use with a pancreaticoduodenectomy. However, the leakage that might occur despite the stented pancreaticojeju nostomy and jejunojejunostomy can be managed less invasively.

Preventive Effects for Wound Infection of Intra-incisional Metronidazole Infiltration Preoperatively in Appendectomy

PURPOSE: The aim of this prospective study was to evaluate the effect of metronidazole for wound infection by using intra-incisional infiltration before appendectomy. METHODS: From January to May 2000, 176 patients with acute appendicitis received appendectomy. All patients were randomly divided into two groups. Group I (n=50) was the treatment group and group II (n=126) was the control group. After anesthesizing the patients of group I, 7.5 mg/kg of metronidazole was injected into subcutaneous tissue and muscle. All patients of group I and II were given intravenous injection of cephalosporin and intravenous or intramuscular injection of aminoglycoside. RESULTS: In the 50 cases of group I, the rate of wound infection was 2% and the rate of wound infection in the 126 cases of group II was 4.8%. The rate of anaerobic bacteria of organisms cultured from wound of patients with infection was 0% in group I and 33% in group II. The statistical analysis using chi-square test was not significant (p=0.676) but the rate of wound infection was reduced, especially in infection caused by anaerobic bacteria. CONCLUSIONS: The rate of wound infection was not significant statistically but it was reduced after intra-incisional infiltration of metronidazole. Therefore we suggest that this method can be one of methods that reduce the rate of wound infection after appendectomy.

Clinical Features of Small Intestinal Atresia

PURPOSE: Intestinal atresia is a well-recognized cause of bowel obstruction in the newborn. The management of neonates with intestinal atresia has improved in recent decades due to refinements in neonatal intensive care, operative techniques, use of total parenteral nutrition (TPN), and neonatal anesthesia. More recently, the survival rate has risen rapidly up to 90%. METHODS: Twenty-five (25) cases of intestinal atresia were encountered at Kwangju-Christian Hospital between January 1985 and December 1998. We reviewed sex, gestational age, body weight, clinical manifestations, associated ano malies, causes, interval to operation, preoperative complications, operative methods, and postoperative complications. RESULTS: Sites involved were the duodenum (n=10; 40%), the jejunum (n=5; 20%), and the ileum (n=10; 40%). The sex distribution was male predominant (1.8:1). The overall survival rate in our hospital was 76%. CONCLUSION: Refinements in neonatal intensive care and perioperative management were important in decreasing postoperative mortality.

Closure of the Colostomy

PURPOSE: To investigate the timing of colostomy closure and the associated risk factors that affect the development of complication after colostomy closure. METHODS: We have reviewed and analyzed the results of 28 patients with colostomy closure at the Kwangju Christian Hospital from January 1993 to December 1997. We investigated to associated literatures on this subject for timing of colostomy closure, preparing a patient for colostomy closure, suture technique, wound management, underlying disease process related to the incidence of complication and experience of surgeons. RESULT: Wound infection developed in 4 patients (14.4%). Anastomotic leakage occurred in one patient (3.6%). Small bowel obstruction developed in two patients (7.2%). Overall incidence of complication was 25%. The incidence of complications in patients with trauma who underwent colostomy was 44.4% and patients without trauma, 15.8%. Complication rate was 16.6% for loop colostomies and 40% for end colostomies. The morbidity was 40% for colostomies on the left side, 18.7% for transverse colostomies, and 0% for colostomies (2 ileostomies) on the right side. The morbidity rate for closures within 6 weeks for the initial operation was 50%; for those within 6 to 12 weeks, 8.3%; and for those after 12 weeks, 16.6%. CONCLUSION: The optimal timing of closure varies from patient to patient, but closure within 6 weeks of the initial operation significantly increased the morbidity. Colostomies on the left side are associated with a higher morbidity rate than transverse colostomies or colostomies on the right side.

Clinical Analysis of Surgical Treatment for Mid and Lower Rectal Cancers

PURPOSE: The aim of this retrospective study was to evaluate the risk of local recurrence such as patients who were treated for Dukes stage B and C low rectal cancer by abdominoperineal resection (APR) or low anterior resection (LAR). METHODS: From 1985 to 1995, 81 patients with low rectal cancers which were within 3~8 cm from the anal verge were treated by curative resection, 38 by APR and 43 by LAR. The present study examined clinical and tumor characteristics, type of intervention as potential predictors of local recurrence. Retrospective data were analysed by univariate Chi-square tests. RESULTS: Local recurrence was diagnosed in 17 of 81 patients with a median follow-up period of 24 months. The local recurrence rate was 23.6% (9 of 38) after APR and 18.6% (8 of 43) after LAR. There was no difference in local recurrence between patients who had APR and LAR (P=0.58). Also we could not find any significant differences among age (65 years, P=0.53), sex (M vs F, P=0.57), sized of tumors (5 cm, P=0.32), distance from anal verge (5 cm, P=0.57), Dukes stage (B vs C, P=0.22), histological grade (well and moderate vs poorly, P=0.17), distance from distal resection margin (2 cm, P=0.35). CONCLUSIONS: The tumor factors such as Dukes' stage were more critical for pelvic recurrences than other patient factors.

Trend in Surgical Management for Thyroid Diseases

PURPOSE: Thyroid disease is the most common form of endocrinologic disease. Despite recent advances in diagnosis, controversy still remains concerning the surgical management of thyroid disease. The aim of this study was to analyze the clinical distribution and the inclination of surgical treatment for thyroid disease. METHODS: The medical records from 1,743 patients who had undergone thyroid resections for thyroid diseases between January 1989 and December 1998 at Kwangju Christian Hospital were reviewed retrospectively. RESULTS: Of the 1,743 patients with thyroid diseases, 1,285 had benign diseases and 458 had carcinomas, resulting in a 26.3% prevalence of malignancy. Female patients were predominate, being 6.89 times the number of males. The peak incidence of age was the 4th decade for patients with benign diseases (29.4%) and the 5th decade for those with malignant diseases (26.0%). Both benign (39.4%) and malignant diseases (42.1%) were more prevalent on the right lobe. The incidence of carcinomas was 28.9% in solitary nodules and 29.3% in multinodular goiters. In the histopathologic study, the most common type was a papillary carcinoma (84.5%) in malignancies and an adenomatous goiter (48.8%) in benign diseases. The most commonly performed surgical procedures were a total thyroidectomy (75.4%) for malignancies and a lobectomy for benign diseases (63.3%). Postoperative complications were 3.1% in patients with benign diseases and 29.7% in those with malignancies. Regional recurrence or distant metastases appeared in 5.5% of the patients during the 10 years following treatment. CONCLUSION: The treatments of choice were a thyroid lobectomy for patients with benign diseases and a total thyroidectomy for those with malignant diseases. However, the decision to perform a surgical resection should be based on the age and the general condition of patient.

Clinical Evaluation of Recurred Thyroid Cancer

BACKGROUND: Thyroid cancer is the most common tumor with a endocrine gland origin, and it has a gradually increasing incidence rate. An operative procedure is useful to obtain good results for this disease. Howevers, the selection of operation method remains controversial. Thus, we reviewed the variable prognostic factors which influence thyroid cancer recurrence in order to determine the treatment methods which reduce the recurrence rate. METHODS: We retrospectively reviewed the cases of 383 thyroid cancer patients who had received operations from January 1988 to December 1993. The review looked at age, sex, operation methods, lymph-node metastasis, histologic types, mass size and capsular invasions, and the correlations between these factors and recurrence were analyzed by using Chi-square and SAS trend tests. Complications which developed after various operation methods were also reviewed. RESULTS: Thyroid cancer recurred in 33 (8.6%) patients. Age, sex, lymph-node metastasis, histologic types and capsular invasions did not influence the cancer recurrence rate significantly. However, mass size and operation method were potential factors for recurrence. CONCLUSIONS: If thyroid cancer is diagnosed, a total thyroidectomy with lymph-node dissection is the best method for reducing the cancer recurrence rate. By careful management, complications can be prevented after a total thyroidectomy.