Impact of technical innovation on surgical outcome of laparoscopic major liver resection: 10 years' experience at a large-volume center

PURPOSE: Laparoscopic major liver resection (major LLR) remains a challenging procedure because of the technical difficulty. Several significant technical innovations have been applied in our center since 2012. They include routine application of bipolar electrocautery, initiation of temporary increase of intra-abdominal pressure during bleeding events from veins to balance the central venous pressure, and use of temporary inflow control of the Glissonean pedicle. This study evaluated the impact of these technique modifications in patients with major LLR. METHODS: Between January 2004 and February 2015, a total of 606 patients underwent LLR at Samsung Medical Center in Seoul, Korea. Major LLR was employed in 233 cases. All major LLR procedures were anatomical resections performed with a totally laparoscopic approach. We compared surgical parameters of right hepatectomy (RH), left hepatectomy (LH), and right posterior sectionectomy (RPS) before and after 2012. RESULTS: Open conversion rates of RH and LH and estimated blood loss in RPS significantly decreased after 2012. The postoperative complication rate of major LLR was 12.7% and was similar before and after 2012. Bile leakage was the most common complication (3.2%). CONCLUSION: The modifications of surgical techniques resulted in good outcomes for laparoscopic major LLR. We recommend routine application of these techniques to improve outcomes, especially in patients requiring major liver resection.

Static and dynamic prognostic factors for hepatitis-B-related acute-on-chronic liver failure

BACKGROUND/AIMS: Hepatitis-B-related acute-on-chronic liver failure has a poor prognosis. However, the advent of potent oral antiviral agents means that some patients can now recover with medical treatment. We aimed to identify the prognostic factors for hepatitis-B-related acute-on-chronic liver failure including the initial as well as the dynamically changing clinical parameters during admission. METHODS: Sixty-seven patients were retrospectively enrolled from 2003 to 2012 at Samsung Medical Center. The patients were classified into three categories: Recovery group (n=23), Liver transplantation group (n=28), and Death group (n=16). The Liver transplantation and Death groups were combined into an Unfavorable prognosis group. We analyzed the prognostic factors including the Model for End-Stage Liver Disease (MELD) scores determined at 3-day intervals. RESULTS: A multivariable analysis showed that the unfavorable prognostic factors were a high initial MELD score (> or =28) (odds ratio [OR] =6.64, p=0.015), moderate-to-severe ascites at admission (OR=6.71, P=0.012), and the aggravation of hepatic encephalopathy during hospitalization (> or =grade III) (OR=15.41, P=0.013). Compared with the baseline level, significant reductions in the MELD scores were observed on the 7th day after admission in the Recovery group (P=0.016). CONCLUSIONS: Dynamic changes in clinical parameters during admission are useful prognostic factors for hepatitis-B-related acute-on-chronic liver failure.

A Case of Nonalcoholic Steatohepatitis and Small Intestinal Bacterial Overgrowth with Peripheral Edema Caused by Intestinal Bypass Surgery and Relieved by Repair

Intestinal bypass surgery, particularly jejuno-ileal bypass surgery, performed for the purpose of weight reduction may cause an unexpected exacerbation of nonalcoholic steatohepatitis (NASH). Here, we report a case of NASH caused by small intestinal bacterial overgrowth, which developed after jejuno-colic bypass surgery and resolved dramatically after surgical correction.

Four patients with hepatitis A presenting with fulminant hepatitis and acute renal failure and who underwent liver transplantation / 대한간학회지

Hepatitis A is generally known as a mild, self-limiting disease of the liver, but in rare instances it can progress to fulminant hepatitis, which may require liver transplantation for recovery. Such cases are known to be related to old age and underlying liver disease. We report four cases of hepatitis A in which patients presented with fulminant hepatitis and acute renal failure and underwent liver transplantation. The following common features were observed in our cases: (1) occurrence in relatively old age (> or =39 years old), (2) association with acute renal failure, (3) presence of hepatomegaly, and (4) microscopic features of submassive hepatic necrosis.

A Case of a Lymphoepithelial Cyst of the Pancreas / 대한소화기내시경학회지

Lymphoepithelial cysts of the pancreas are extremely rare cystic lesion characterized by the presence of a mature, squamous epithelial lining surrounded by dense lymphoid tissue. They were first described in 1985 by Lchtrath and Schriefers. A 70-year-old male was admitted with a four month history of intermittent right upper quadrant abdominal pain radiating to the right subscapular area. Physical examination and laboratory studies did not show any abnormal findings. Computed tomography of the abdomen revealed a 2.7 cm well-circumscribed, uniloculated cystic lesion on the tail of the pancreas. Endoscopic retrograde pancreatography showed no abnormalities in the duct system. A distal pancreatectomy with a splenectomy was performed, with a suspected diagnosis of cystic neoplasms of the pancreas. Histopathologic diagnosis was a lymphoepithelial cyst of the pancreas. Although the histogenesis of lymphoepithelial cysts is not fully disclosed, they are benign and can be cured by local excision. This case is reported herein with a review of relevant literature.

A clinical study and short-term outcame of low-grade gastric MALT lymphoma / 대한내과학회지

Low-grade gastric MALT lymphoma arises from long-standing Helicobacter pylori(Hp) infection. High remission rates for these lymphoma have been observed after H. pylori eradication. There was debates on the optimal treatment of low-grade gastric MALT lymphoma. The purpose of this study is to investigate clinical and endoscopic characteristics of primary low-grade gastric MALT lymphoma and to assess short-term clinical outcome of various modalities of treatment. METHODS: 30 patients(14 male, 16 female, mean age 44.9 years, range 26-76, mean follow-up 22.9 months) with primary low-grade gastric MALT lymphoma, diagnosed at the Samsung Medical Center from March 1995 to September 1998, were evaluated in a retrospective study. We evaluated patient's presenting symptoms, endoscopic finding, Hp status, staging by Musshoff system, and recurrence rate according to treatment mordalities. RESULTS: The most common symptom is epigastric discomfort or pain(36.7%). Endoscopic appearances of gastric MALT lymphoma shows the wide variation from mucosal thickening to overt malignancy. The most common site of gastric MALT lymphoma is the gastric antrum and lower body(9 and 6 patients). Histologically, 70% were found to be Hp infected. Of 21 Hp(+) patients, 11 patients were clinical stage IE and received Hp eradication by PPI-based triple regimens. 81.8%(9/11) showed complete remission. Among 11 patients, 6 patients studied by PCR. After Hp eradication, 5 in 6 patients showed persistent IgH rearangement by PCR. The mean follow-up time is 22.8 months(range 3 to 36 months), One patient, who showed complete histologic regression during second endoscopy, relapsed MALT lymphoma after 6 months. The other one patient showed no change of lymphoma and underwent surgery. 12 patients underwent surgical treatment and showed no evidence of relapse. The mean follow-up time is 35.9 months. 2 patients received chemotherapy with CHOP regimen and showed complete remission. The mean follow-up time is 6.7 months. 2 patients received radiotherapy and showed no evidence of relapse. The mean follow-up time is 15 months. CONCLUSION: Our study shows that complete remission rate after Hp eradication is as high as some studies recently reported. This suggest that Hp eradication may be considered as first-line therapy of low-grade gastric MALT lymphoma of stage IE.

The Prevalence and Characteristics of Colorectal Polyps found by Sigmoidoscopy in Asymptomatic Korean Adults / 대한내과학회지

OBJECTIVES: Colorectal polyps play an integral role in the development of colon cancer. The prevalence of colorectal polyps in Korea was reported to be 5-12%. However, these results were obtained from retrospective studies, in which the subjects were symptomatic patients. Therefore, we performed a prospective study in asymptomatic Korean adults to determine the prevalence, characteristics, and risk factors of colorectal polyps. METHODS: Flexible sigmoidoscopy was done during the period between August 1994 to November 1995 in 2,985 aymptomatic individuals who visited Samsung Medical Center for health check-ups. RESULTS: 1) Polyps were found in 590 subjects (20.4%) out of 2,985 individuals. The prevalence rate increased with age. 2) In histologic findings of colorectal polyps, there were 369 cases (45.8%) of adenomatous polyps, 245 cases (30.4%) of hyperplastic polyps and 5 cases of carcinomas. 3) Moderate to severe dysplasia was found in 15.4% of adenomatous polyps and the grade of dysplasia increased with polyp size. 4) The prevalence rate of polyps increased according to obesity, blood cholesterol and triglyceride level, the frequency of alcohol consumption and the amount of smoking in cases. Conclusions : Screening by sigmoidoscopy is considered to be beneficial for detection of colorectal polyps in asymptomatic Korean adults, especially in individuals with risk factors such as obesity, heavy smoking and alcohol consumption.

Various causes of dyspepsia: to determine organic and functional cause of dyspepsia / 대한소화관운동학회지

BACKGROUND/AIMS: Dyspepsia is very common in the community. The aim of this study was to assess the frequency of various causes of dyspepsia. METHODS: Two hundreds nine patient with dyspepsia were investigated. Basic laboratory screening, ECG, Upper gastrointestinal endoscopy or upper gastrointestinal barium study, upper abdominal ultrasound were performed in every dyspeptic patients. RESULTS: Functional dyspepsia was the cause of symptoms in 92.3%, peptic ulcer in 2.9% (duodenal ulcer in five patients, gastric ulcer in one patient), reflux esophagitis in 0.5%, esophageal ulcer in 0.5%. Of dyspeptic patients, gallstone was found in 1.4%, gastric submucosal tumor in 1.0%, fatty liver in 1.9% (two of four patients with fatty liver had elevated transaminase), upper gastrointestinal cancer in 0%. Of functional dyspepsia patients, women was 60.3%, men was 39.7%. CONCLUSIONS: The most common cause of dyspepsia was functional dyspepsia. Various causes of organic dyspepsia was peptic ulcer, reflux esophagitis, and esophageal ulcer.