Regular Exercise Training Increases the Number of Endothelial Progenitor Cells and Decreases Homocysteine Levels in Healthy Peripheral Blood

Endothelial progenitor cells (EPCs) are known to play an important role in the repair of damaged blood vessels. We used an endothelial progenitor cell colony-forming assay (EPC-CFA) to determine whether EPC numbers could be increased in healthy individuals through regular exercise training. The number of functional EPCs obtained from human peripheral blood-derived AC133 stem cells was measured after a 28-day regular exercise training program. The number of total endothelial progenitor cell colony-forming units (EPC-CFU) was significantly increased compared to that in the control group (p=0.02, n=5). In addition, we observed a significant decrease in homocysteine levels followed by an increase in the number of EPC-CFUs (p=0.04, n=5), indicating that the 28-day regular exercise training could increase the number of EPC colonies and decrease homocysteine levels. Moreover, an inverse correlation was observed between small-endothelial progenitor cell colony-forming units (small-EPC-CFUs) and plasma homocysteine levels in healthy men (r=-0.8125, p=0.047). We found that regular exercise training could increase the number of EPC-CFUs and decrease homocysteine levels, thus decreasing the cardiovascular disease risk in men.

Negative pressure wound therapy for inguinal lymphatic complications in critically ill patients / 대한외과학회지

PURPOSE: In this study, we investigated the therapeutic potential of regulated negative pressure vacuum-assisted wound therapy for inguinal lymphatic complications in critically ill, liver transplant recipients. METHODS: The great saphenous vein was harvested for hepatic vein reconstruction during liver transplantation in 599 living-donor liver transplant recipients. Fourteen of the recipients (2.3%) developed postoperative inguinal lymphatic complications and were treated with negative pressure wound therapy, and they were included in this study. RESULTS: The average total duration of negative pressure wound therapy was 23 days (range, 11 to 42 days). Complete resolution of the lymphatic complications and wound healing were achieved in all 14 patients, 5 of whom were treated in hospital and 9 as outpatients. There was no clinically detectable infection, bleeding or recurrence after an average follow-up of 27 months (range, 7 to 36 months). CONCLUSION: Negative pressure wound therapy is an effective, readily-available treatment option that is less invasive than exploration and ligation of leaking lymphatics and provides good control of drainage and rapid wound closure in critically ill patients.

A Case of Acute Graft versus Host Disease after Liver Transplantation / 대한이식학회지

The mortality rate of patients with acute graft versus host disease (GVHD) after liver transplantation is very high. Autoimmune hepatitis and diabetes mellitus (DM) is the risk factors of GVHD. Human leukocyte antigen (HLA)-homozygote donor with one way donor-recipient HLA matching is on the risk of fatal GVHD following living donor liver transplantation (LDLT). If recipient has more than one risk factors of GVHD and is going to LDLT, HLA typing is needed to identify donor-dominant one-way HLA matching and helpful to diagnose and treat early and survival of patient will be improved. We report a case of GVHD after liver transplantation for hepatocellular carcinoma and DM who received an allograft from his HLA-homozygous son.

Surgical Treatment of Inferior Vena Cava Invasion in Patients with Renal Pelvis Transitional Cell Carcinoma by Use of Human Cadaveric Aorta

We herein report a case of radical nephroureterectomy and replacement of the inferior vena cava (IVC) with ahuman cadaveric aortic graft for a patient with renal pelvis transitional cell carcinoma associated with IVC infiltration. In advanced disease, radical surgery is essential to achieve long-term survival. This case entails the use of another treatment option among the numerous options currently available for the management of patients with advanced renal cancer associated with IVC invasion.

More than 7-year survival of a patient following repeat hepatectomy for total 20 colon cancer liver metastases / 대한외과학회지

A 54-year-old man was transferred with sigmoid colon cancer combined with multiple bilobar liver metastases. Nine metastases were in the left lobe and 5 metastases were in the right lobe. After low anterior resection, all 9 lesions in the left lobe were completely removed by wedge resections. Because the remnant liver volume after multiple wedge resection of the left lobe was not sufficient to perform a right hepatectomy simultaneously, we planned a two-stage hepatectomy. Right portal vein embolization was performed one week after the first liver operation. A right hepatectomy was safely performed 22 days after the first hepatectomy. A recurrent mass developed in the segment III 18 months after the right hepatectomy. Radiofrequency ablation (RFA) was performed to remove that lesion. Five other metastases developed 18 months after RFA whereby multiple wedge resections were performed. The patient has survived for more than 7 years after the first liver operation.

Report of a case of ischemic colitis with bilaterally patent internal iliac arteries after endovascular abdominal aneurysm repair / 대한외과학회지

During endovascular aneurysm repair (EVAR), interruption of the internal iliac arteries (IIAs) or the inferior mesenteric artery by stents or embolization is thought to cause colon ischemia. To minimize this risk, attempts have been made to preserve the IIAs using iliac branch devices or IIA revascularization. Here we present our experience of colon ischemia after EVAR in a patient with bilaterally patent IIAs without evidence of embolism. A 70-year-old man had abdominal pain and a ruptured abdominal aortic aneurysm was found. We performed EVAR with custom-made tube grafts preserving the bilateral IIAs. On postoperative day 2, the patient complained of abdominal pain, a sigmoidoscopy was performed revealing colon ischemia. On laparotomy, transmural infarction of the sigmoid colon was found and resected. Because IIA preservation cannot guarantee protection against colon ischemia, surgeons should maintain a high level of suspicion and use surveillance liberally after EVAR for early diagnosis of colon ischemia, even if both IIAs are preserved.

A First Experience of Rh(D) Incompatible Living Related Liver Transplantation in Korea / 대한수혈학회지

To expand the indications for living liver allograft, an increasing number of clinical trials of ABO incompatible liver transplantation have been reported in the literature. Administration of immunosuppressive drugs has resulted in decreased rates of mortality and graft loss in patients undergoing in ABO-incompatible living donor liver transplantation (LDLT). Rh incompatibility in liver transplantation has not been reported as frequently as that of ABO-incompatible LDLT. Rh-antigens are said to be located only on red blood cells, and have not been demonstrated on leukocytes or tissue cells. For this reason, the incompatibility of Rh antigen between the donor and the recipient has received significantly less consideration in organ transplantations. Here, we report on a case of Rh incompatible living related liver transplantation from a group O, Rh-positive donor to a group O, Rh-negative recipient. The recipient did not develop Rh alloimmunization after administration of immunosupressive drugs and Rh immunoglobin (RhIG).

A First Experience of Rh(D) Incompatible Living Related Liver Transplantation in Korea / 대한수혈학회지

To expand the indications for living liver allograft, an increasing number of clinical trials of ABO incompatible liver transplantation have been reported in the literature. Administration of immunosuppressive drugs has resulted in decreased rates of mortality and graft loss in patients undergoing in ABO-incompatible living donor liver transplantation (LDLT). Rh incompatibility in liver transplantation has not been reported as frequently as that of ABO-incompatible LDLT. Rh-antigens are said to be located only on red blood cells, and have not been demonstrated on leukocytes or tissue cells. For this reason, the incompatibility of Rh antigen between the donor and the recipient has received significantly less consideration in organ transplantations. Here, we report on a case of Rh incompatible living related liver transplantation from a group O, Rh-positive donor to a group O, Rh-negative recipient. The recipient did not develop Rh alloimmunization after administration of immunosupressive drugs and Rh immunoglobin (RhIG).

A Right Gastroepiploic Artery Aneurysm Treated by Surgical Excision

A 65-year-old male patient was referred to our hospital for postprandial abdominal pain. Computed tomography and angiography revealed 2 aneurysms of the right gastroepiploic artery, which were measured 0.8x1.3 cm and 1.9x3.4 cm. Excision of 2 saccular and fusiform aneurysms by laparotomy was performed. His hospital course was uneventful and symptoms disappeared after surgery. A gastroepiploic artery aneurysm can cause recurrent abdominal pain and surgical resection is warranted in symptomatic aneurysms.

Surgical Treatment of Inferior Vena Cava Tumor Thrombus in Patients with Renal Cell Carcinoma

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. Cephalic extension of the thrombus is closely related to perioperative morbidity. We purposed to design a safe and successful surgical strategy through a review of our surgical experience and treatment results in 35 patients (male:female=28:7, mean age=56 yr [32-77]) who underwent IVC thrombectomy with radical nephrectomy between January 1997 and December 2006. The limit of tumor extension was level I in 10 patients (28.6%), level II in 17 (48.6%), and level III and IV in 4 patients each (11.4%). Liver mobilization with hepatic vascular exclusion was performed in 12 patients and cardiopulmonary bypass in 7. Thirty-two primary closures, 2 patch closures, and 1 graft interposition were performed. One patient underwent simultaneous pulmonary embolectomy because of an operative pulmonary embolism. There was no operative mortality, and the overall survival at 5-yr was 50.8%. Complete thrombus removal without tumor fragmentation under long venotomy on fully exposed involved IVC is recommended for successful result in a bloodless operative field. The applicability of liver mobilization, hepatic vascular exclusion, and cardiopulmonary bypass, can be determined by the level of thrombus.

TEE-guided Excision of Intravenous Leiomyomatosis with Right Atrium Extension through an Abdominal Approach: A Case Report

Intravenous leiomyomatosis (IVL) is a rare, benign tumor that originates from the uterus. IVL is usually confined to the pelvic venous system, but it travels into the inferior vena cava (IVC) in 10% of cases and even into the heart in 3% of cases. We present a case of successful resection of recurrent IVL with right atrium extension. We used only an abdominal incision and transesophageal echocardiography (TEE) guidance. A 40-year-old female patient visited our hospital with recurrent IVL. She had a history of total abdominal hysterectomy and right salpingo-oophorectomy due to IVL performed one year prior. On computed tomography (CT) and ultrasonography, IVL was found to involve both ovarian veins, the left renal vein, and the IVC extending to the right atrial junction. Using intraoperative TEE monitoring, we could see that IVL was not attached to the vascular wall. After creating a midline abdominal incision, we removed the tumor through the enlarged ovarian vein and ovary. The patient had an uneventful recovery and was discharged home on the ninth postoperative day.

The Relation between Distal Runoff and Clinical Outcome after Aorto-iliac Reconstruction Surgery

PURPOSE: We sought to evaluate the relationship between distal runoff and long-term graft patency in aorto-iliac occlusive disease. METHOD: A retrospective review was performed on 192 patients with aorto-iliac occlusive disease who underwent surgery between September 1995 and November 2005. Patients who underwent percutaneous angioplasty or stent placement were excluded. Preoperative angiograms were scored according to the SVS/ISVS Ad Hoc Committee guidelines. RESULT: The mean duration of follow-up was 50 months. Procedure indications consisted of claudication in 68 patients and critical limb ischemia in 124 patients. Procedures included 176 bypasses (50 aorto-iliac/aorto-femoral, 32 ilio-femoral, 46 axillo-femoral, and 48 femoro-femoral) and 16 endarterectomies with patch angioplasty. Overall 5-year patency rate was 84.1%. Higher primary patency was observed when the occlusion score of the superficial femoral artery (SFA) or deep femoral artery (DFA) was lower than 2 (P<0.05). Cox proportional hazard model showed run-off resistance values to be significant determinants of graft patency (p=0.000, Exp(B)=1.236). The group that underwent profundoplasty had significantly better long-term patency (P=0.009). CONCLUSION: Poor distal runoff score was related to lower primary patency. In patients with aorto-iliac occlusive disease and poor distal outflow, profundoplasty can improve primary patency.

Surgical Treatment of Primary Neuroendocrine Tumors of the Liver

PURPOSE: Primary neuroendocrine tumor (PNET) of the liver is a very rare neoplasm. This study was conducted to analyze the clinical experience of 8 hepatic PNET cases. METHODS: Four male and 4 female patients with a mean age of 50.4 +/- 9.5 years (range 37-64 years) underwent liver resection for hepatic PNET between January 1997 and December 2006. The diagnosis was confirmed histologically using light microscopy and immunohistochemistry in the absence of an alternative primary site RESULTS: Curative resection was achieved in 6 of the 8 patients, and 5 of the patients were alive and disease free after a mean follow-up period of 47.6 months. However, 3 patients died 3, 5 and 26 months after surgery due to multiple liver metastasis. A proliferative index of Ki67 appeared to indicate a significant risk factor for tumor recurrence. Additionally, recurrence occurred in 1 of the 6 patients that underwent curative resection during the follow-up period. Overall, both the 5-year recurrence rate and the 5-year survival rate were 50%. CONCLUSIONS: Active exclusion of an extrahepatic primary site is essential for diagnosis of hepatic PNET. The primary treatment for PNET is curative liver resection, and a proliferative index of Ki67 appears to be a prognostic factor for tumor recurrence.

Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma

PURPOSE: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis after hepatic resection have yet to be clarified. The purpose of this study was to analyze the outcome of sarcomatous HCC patients who underwent surgical resection. METHODS: From January 1997 to May 2005, 11 patients (1.1%) were diagnosed with sarcomatous HCC among 1,005 cases of HCC undergoing resection after pathology and immunohistochemical studies. RESULTS: All of the cases were male and their mean age was 55.8+/-8.1 years. R0 resection was achieved in nine of the 11 patients. The HCC lesions were classified as stage II in three, stage III in four, stage IVa2 in three, and IVb in one, according to the modified pTNM staging system. Extrahepatic metastases as the initial recurrence occurred in eight patients. Among the 11 patients, 10 died of a disease recurrence and only one is still alive. The overall 3-year survival rate was only 18%. CONCLUSIONS: The prognosis of sarcomatous HCC was very poor, showing widespread extrahepatic metastases and frequent early recurrence regardless of the tumor extent. Since some patients showed prolonged survival after a local recurrence, vigorous postoperative systemic surveillance appears to be beneficial for early detection and timely treatment of localized metastases.

Assessment of Technical Feasibility of Living Donor Liver Transplantation after Prior Major Liver Resection for Hepatocellular Carcinoma / 대한이식학회지

Purpose: Liver transplantation has been performed for recurrent hepatocellular carcinoma (HCC) or deterioration of liver function after prior primary liver resection. Prior major liver resection per se is an unfavorable condition for living donor liver transplantation (LDLT). We analyzed the technical feasibility of prior major hepatectomy-graft combinations for salvage LDLT. Methods: Of the 17 patients who underwent salvage LDLT, 5 underwent prior major liver resection. Results: Two patients with prior left lobectomy received right lobe graft, whereas, of the 3 patients with prior right lobectomy, 2 received right lobe graft and 1 received left lobe graft. During recipient hepatectomy, it was necessary to perform meticulous sharp dissection of the previous liver cut surface to attain full mobilization. Different methods of hepatic vein reconstruction were applied after the recipient inferior vena cava was fully dissected. Reconstruction of the portal vein, hepatic artery and bile duct were performed on case by case basis depending on the remnant hilar structures. Conclusion: In conclusion, every combination of recipient prior right or left lobectomy and living donor right or left liver graft seems to be feasible for salvage LDLT.

Surgical Treatment of Sclerosing Hepatocellular Carcinoma / 대한간학회지

BACKGROUND/AIMS: Sclerosing hepatocellular carcinoma (HCC) is an unusual subtype of HCC that is characterized by an embedded dense fibrous stroma in the tubular neoplastic structures. We aimed to assess the surgical approaches and outcomes of sclerosing HCC. METHODS: We retrospectively analyzed the clinicopathologic features of 6 patients with sclerosing HCC who underwent surgical treatment at Asan Medical Center between July 1989 and December 2005. RESULTS: Six HCC patients with sclerosing HCC were diagnosed out of the total 1390 HCC patients (0.43%) during the study period. The mean age was 58 years and 4 patients were male. Weight loss and abdominal pain were the most common symptoms. The serum calcium and phosphorus levels were normal in all the patients. All of them were hepatitis B surface antigen-positive, but none was positive for hepatitis C. All the lesions were solitary. The tumor size ranged from 45 to 150 mm in diameter (median size: 81 mm). We performed right trisegmentectomy (n=1), central bisegmentectomy (n=1), right anterior segmentectomy (n=1), ex-vivo resection and autotransplantation (n=1) and right posterior segmentectomy (n=2). The median overall survival and disease free-survival periods were 24 months and 9.5 months, respectively. CONCLUSIONS: The incidence of sclerosing HCC was very low. Sclerosing HCC was often not correctly diagnosed before an operation, but performing resection prolonged the patients' survival and their prognosis was not worse than that for ordinary HCC. Our experience implicates that aggressive surgical treatment for sclerosing HCC is beneficial for patient survival.

Ligation of Left Renal Vein for Splenorenal Collateral Shunt to Prevent Portal Flow Steal in Adult Living Donor Liver Transplantation / 대한이식학회지

PURPOSE: To assess the safety and role of ligation of left renal vein (LRV) to avoid portal flow steal to the partial liver graft when living donor liver transplantation (LDLT) is performed for the cirrhotic patients with large spontaneous splenorenal shunt (SRS). METHODS: Between 2001 and 2005, 44 portal hypertensive patients with large SRS who underwent ligation of LRV were retrospectively reviewed. RESULTS: After ligation of LRV, thirty four patients of 44 pateints (77.3%) revealed hypo-attenuation of left kidney on computed tomography but 10 patients (22.7%) showed normal attenuation. Proteinuria and hematuria occurred in 22 patients (50%) and 43 patients (97.7%) respectively after operation, but nearly all of them recovered. Decreased urine outputs (less than 1,000 mL per day) appeared in 4 patients (9.1%), but disappeared after dialysis for 6+/-5.4 days. Serum creatinine increased in 43 patients (97.7%), but decreased to normal range in 40 patients (90.3%). During study period, portal flow steal to the liver graft did not occur after ligation of LRV, and liver regeneration was satisfactory. CONCLUSION: It seems to be a good graft salvage procedure for the portal hypertensive patients who demonstrate large SRS after partial liver engraftment.

Management of Biliary Problem in Dual Living Donor Liver Transplantation / 대한이식학회지

PURPOSE: For the safety of donor and recipient in living donor liver transplantation, Asan Medical Center had attempted dual living donor liver transplantation (DLDLT) for the first time in the world. But bleeding chance and biliary problem occurred twofold in DLDLT, because DLDLT was used dual grafts. We analyzed the clinical features, the diagnosis, and management of biliary problem in DLDLT. METHODS: We retrospectively analyzed the cases of 61 patients had undergone DLDLT between July 2003 and June 2004. The cases with biliary problem was diagnosed by serologic examination (glutamic oxaloacetic transaminase/ glutamic pyruvic transaminase/alkaline phosphatase/total bilirubin) and image study (computed tomography and hepatobiliary scan). RESULTS: Among 61 cases had undergone DLDLT, 19 cases had biliary problem included biliary stricture only (14 cases), biliary stricture and bile leakage (5 cases). The major clinical manifestations of biliary problem were fever (12 cases), asymptomatic and/or increased liver enzyme (7 cases). Among 19 cases with biliary problem, 18 cases showed image study positive and serologic examination positive and/or symptomatic findings, and 1 cases showed image study positive and serologic examination negative and asymptomatic findings. The treatments of biliary stricture were endoscopic (naso/retrograde) biliary drainage (4 cases), percutaneous transhepatic biliary drainage (17 cases). In cases of bile leakage, we treated intraabdominal fluid collection with operative management (1 cases) and conservative managements (4 cases). Mortality rate related with biliary problem was 0%. CONCLUSION: Systemic and active postoperative management in biliary complication can help patients to minimize economic loss and sequelae.

Mechanical Intestinal Obstruction after Appendectomy for Perforated Appendicitis in Children

Intestinal obstruction secondary to intraabdominal adhesion is a well-known postoperative complication occurring after appendectomy. The aim of this study was to measure the incidence and clinical manifestations of mechanical intestinal obstruction after appendectomy for perforated appendicitis. We reviewed all of the children (age <16 years) who had been treated for appendicitis at Asan Medical Center between January 1996 and December 2001. Inclusion criterion included either gross or microscopic evidence of appendiceal perforation. Exclusion criteria were interval appendectomy, and patients immune compromised by chemotherapy. Associations of intestinal obstruction with age, sex, operation time, and use of peritoneal drains were analyzed. Four hundred and sixty two open appendectomies for appendicitis were performed at our department. One hundred and seventeen children were treated for perforated appendicitis (78 boys, 39 girls). The mean age was 8.9 years (range 1.5 to 14.8 years). There were no deaths. Eight patients were readmitted due to intestinal obstruction, but there was no readmission due to intestinal obstruction in patients with non-perforated appendicitis. The interval between appendectomy and intestinal obstruction varied from 12 days to 2 year 7 months. Four patients needed laparotomies. In three of four, only adhesiolysis was performed. One child needed small bowel resection combined with adhesiolysis. There was no significant association between age or sex and the development of intestinal obstruction. This was no association with operative time or use of peritoneal drain. Patients who required appendectomy for perforated appendicitis have a higher incidence of postoperative intestinal obstruction than those with nonperforated appendicitis. For the patients with perforated appendicitis, careful operative procedures as well as pre and postoperative managements are required to reduce adhesions and subsequent bowel obstruction.