Omental Histiocytic Sarcoma: A Case Report

We report a case of perigastric histiocytic sarcoma (HS) involving the lesser omental sac in a 30-year-old man. HS is an exceedingly rare malignancy of mature tissue histiocyte. The tumor was a multi-lobulated, bulging enhancing mass in the lesser omentum with metastasis to lymph nodes and liver. The tumor consisted of diffuse non-cohesive proliferation of pleomorphic large oval to round neoplastic cells with giant cells showing vesicular chromatin and ample eosinophilic cytoplasm. In some areas, the tumor cells showed spindling with elongation of the nuclei and cellular shapes. Many of the tumor cells, especially giant forms contained phagocytosed lymphocytes. Immunohistochemical analysis of the tumor cells showed expression of leukocyte common antigen, CD68, lysozyme, vimentin, CD4, and CD163. Ki-67 index was 50-60%. After the operation, he was treated with chemotherapy, but the response was poor.

Safety and Efficacy of Early Steroid Withdrawal with Thymoglobuline Induction in Kidney Transplantation / 대한이식학회지

BACKGROUND: We report our experiences of early steroid withdrawal using thymoglobuline induction in kidney transplant patients to verify the efficacy and safety of steroid minimization protocol that can prevent long term complications of steroid. METHODS: From December 2002 to July 2007, 36 kidney transplants were performed at our institution using the steroid early withdrawal protocol with 5 doses induction of thymoglobuline (50 mg IV), and maintaining with tacrolimus/ cyclosporine and mycophenolate mofetil (MMF)/azathioprine. Control group was 80 kidney transplant recipients on conventional triple immunosuppression protocol without antibody induction. RESULTS: Donor and recipient's profiles in both groups were not different except more proportion of diabetic patients and immunosuppression using tacrolimus and MMF in PD free group. The rejection rate was 13.8% and 16.3% in PD free and PD groups respectively. Two years graft and patients survival rate were 96.4%/100% in PD free group and 97.5%/97.5% in PD group. Serum creatinine level was similar between the two groups and WBC count was lower in PD free group up to postoperative 6 months. 72.2% of PD free group remained steroid free by the last follow up. CONCLUSIONS: Early steroid withdrawal with thymoglobulin induction can be applied safely with acceptable success rate with minimizing adverse effects of steroid in kidney transplantation patients. But early steroid withdrawal protocol should be adopted cautiously in immunologically high risk patients.

Comparison of Spleen Preserving Laparoscopic Distal Pancreatectomy with En Bloc Laparoscopic Distal Pancreatectomy

PURPOSE: The purpose of this study is to compare the clinical results of spleen preserving laparoscopic distal pancreatectomy (SPLDP) with en bloc laparoscopic distal pancreatectomy (LDP). METHODS: From March 2005 to August 2008, 52 cases of SPLDP and 84 LDPs were performed at our institution and we retrospectively compared these cases. The enrollment period were chronologically divided to four eras of 10.5 months each. RESULTS: The demographics, including the patients' age, gender and BMI, were not different between the two groups. The final pathologic diagnosis was diverse, and it included cystic tumor, SPT, IPMT, cancer, endocrine tumor, etc and there was no difference between the two groups. The tumor location, operative time, tumor size, perioperative transfusion requirement, the length of the hospital stay and the postoperative complications were not different between the two groups. The mean operative time was gradually shortened by eras (Era 1: 236.3 min, Era 2: 223.6 min, Era 3: 188.8 min, Era 4: 187.9 min) and the proportion of SPLDP was increased by eras from 1.9% to 9.6%, 42.3% and 46.2%, respectively. CONCLUSION: SPLDP might be technically more difficult than LDP, and especially in the initial learning stage of performing laparoscopic pancreatic surgery. After overcoming the learning curve, SPLDP can be performed safely and possibly within a shorter time. SPLDP should be tried whenever possible so that the patients get the maximal benefits of minimal invasive surgery and especially for resecting the more distal pancreatic lesions.

Clinical Analysis for the Postoperative Complications of Pancreaticoduodenectomy in the Recent 5 Years

PURPOSE: Pancreaticoduodenectomy (PD) is known to have high morbidity and mortality rates among the various abdominal operations, but there have been few reported current series of pancreaticoduodenectomy from large volume medical centers. The purpose of this study is to analyze the postoperative complications of PD and to assess the risk factors for postoperative morbidity. METHODS: A total of 398 cases of PD were performed by two surgeons from January 2003 to December 2007 at our institution and we retrospectively reviewed the medical records of these cases. RESULTS: 186 (46.7%) of 398 patients underwent pylorus preserving pancreaticoduodenectomy (PPPD) and 212 patients (53.3%) underwent a classic Whipple procedure. The most common indication for this procedure was pancreatic cancer (151 cases, 37.9%) and the second most common was intraductal papillary mucinous tumor (78 cases, 19.6%). The mean age was 57.2 years, ranging from 12 to 81. The mean postoperative hospital stay was 24.7 days. The most common complication was delayed gastric emptying (11.8%) and next was pancreatic fistula (10.3%), bleeding (6.5%) and new onset diabetes mellitus (DM) (4%). Four patients (1%) died of hospital mortality. The patients' age, gender, DM history, hypertension history and serum bilirubin level had no significant influences on the postoperative morbidity rate. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely with an acceptable complication rate and minimal mortality if the surgeon has sufficient surgical experiences and with the advance in anesthesia and postoperative care.

Clinical Application of Renal Autotransplantation in Renovascular and Urologic Disease: 21 Cases / 대한이식학회지

BACKGROUND: Renal autotransplantation is a kidney preserving procedure in various clinical situations otherwise requiring nephrectomy or renovascular disease that can not be treated by intervention. The purpose of this study is to report our experiences of renal autotransplantation. METHODS: A total 21 patients, 9 male and 12 females, underwent renal autotransplantation from May 1995 to July 2008 at our institution and were reviewed retrospectively by medical records. RESULTS: The mean age of the patients was 46.9 years (21~63). The indications for renal autotransplantation were 6 cases of renal artery aneurysms (28.5%) including 1 renal allograft aneurysm, 6 ureteral obstructions (28.5%), 4 renovascular hypertensions (19%), 2 renal cell carcinomas (9.5%), 2 ureteral cancers (9.5%) and others. The mean operative time was 409.2 minutes (145~689) and mean cold ischemic time was 85.4 min (11~215 min). Renal artery was anastomosed to internal iliac artery in 81% and to external iliac artery in 19%. All kidneys were preserved successfully after removal of lesions and renal artery reconstruction. There were no differences in pre- and post- operative creatinine levels and creatinine clearance. The mean follow up duration was 2.1 years (0.1~11.3) and 1 patient died from the recurrence of ureteral cancer 9 months after operation. CONCLUSIONS: With the advance of micro-surgical technique and standardization of kidney transplantation technique, possibility of renal preservation with renal autotransplantation has increased more than before. Therefore, renal autotransplantation should be considered as one of the treatment options and performed in appropriately selected patients.

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.

Three cases of pancreas allograft dysfunction

We present dincopathologic features of three cases of biopsy-proven pancreas allograft dysfunction in Korea. All patients had advanced insulin-dependent diabetes mellitus (IDDM). Case 1 was a 30-year-old woman who underwent a simultaneous pancreas-kidney transplantation. Urinary infection developed 6 days after the operation, which remitted and reappeared, when urine amylase level was normal. Since the 55th day after the operation, intermittent hematuria has persisted. Cytomegalovirus inclusions were detected on the urinary bladder and grafted duodenal mucosa. The graft was removed due to perforation of the grafted duodenum and panperitonitis. Case 2 was a 27-year-old man undergoing pancreas transplantation alone (PTA). Ten days after the transplatation, the level of 24 urine amylase decreased and the graft was not delineated by 99mTc DTPA scintigraphy. Allograft needle biopsy revealed multiple acinar cell necrosis and mild lymphocytic infiltration which were compatible with mild acute rejection. Case 3 was a 25-year-old man undergoing cadevaric PTA. Three months after the transplantation, graft was removed due to gastric perforation associated with cytomegalovirus and angiodestructive fungal infection. Various causes of pancreas allograft dysfunction can be diagnosed by needle biopsy, thus appropriate biopsy specimen should be taken using improved biopsy technique.

Impact of Anti-HCV(+) on Renal Transplantation

BACKGROUND: A high incidence of chronic liver disease is reported in end-stage renal failure patients due to hemodialysis and blood transfusion. An average of 20% of the patients who received renal hemodialysis are infected with hepatitis C virus, but the incidence of infection in these patients varies widely according to geographic location and the diagnostic methods used. Controversy exists regarding the impact of pretransplantation HCV infection on the outcome of renal transplantation. We measured the seroprevalence of the antibody to hepatitis C (anti-HCV) in renal transplant candidates and compared the prevalence of posttransplantation liver disease, graft, and patient survival among renal transplant recipients with and without anti-HCV at the time of the transplantation, and we attempted to define the possible factors affecting the clinical course following renal transplant in positive HCV patients. METHODS: Between June 1990 and December 1997, 634 patients underwent renal transplants at our institute. Viral infection with hepatitis were analyzed in these patients by using anti-HCV positivity using first, second, and third generation EIA, and RT-PCR. RESULTS: Twelve (12) of the 634 (1.9%) had positive anti-HCV before renal transplantation. During a mean follow-up of 29.4 months, viral mRNA was detected in the pretransplantation serum in 3 out of 8 (37.5%) positive anti-HCV patients. Among the 12 patients with positive anti-HCV, 2 (16.6%) showed early liver dysfunction, and 1 (8.3%) showed histologic progression to chronic hepatitis leading to hepatic failure and death. Graft loss occurred in 1 of the 12 (8.3%) patients with positive anti-HCV and in 62 of the 622 (9.8%) patients with negative anti-HCV. Three (3) out of the 12 (25%) patients with positive anti-HCV, and 121 of the 622 (19.6%) patients with negative anti-HCV had episodes of rejection. One (1) of the 12 (8.3%) patients with positive anti-HCV and 26 of the 622 (4.2%) patients with negative anti-HCV died after kidney transplantation. There were no statistical differences in patients or graft survival between the positive anti-HCV (+) and the negative anti-HCV patients. CONCLUSION: From these results, we can assume that the presence of anti-HCV without advance liver disease should not be a contraindication for kidney transplantation.

Surgical Treatment of Chronic Pancreatitis

BACKGROUND: Currently, the incidence of chronic pancreatitis is increasing due to the change of diet and high alcohol consumption in our country. Regarding more effective treatment of chronic pancreatitis, surgical intervention is favored for the control of intractable pain, various complications from the pancreatitis, suspected malignancy, and amelioration of progressively deterioratory exocrine and endocrine pancreas functions. We attempted to evaluate the various indications for an operation, various surgical treatments, and their results. METHODS: We retrospectively reviewed the clinical records of 50 patients with chronic pancreatitis who were managed surgically between July 1989 and Feb. 1998. RESULTS: The indications for operation were intractable pain in 25 cases, suspected malignancy in 12 cases, biliary obstruction in 4 cases, pancreatic pseudocyst in 7 cases, and treatment of Diabetes Mellitus in 2 cases. We performed 11 drainage procedures, 8 Peustow-Gillesby operations and 3, DuVal operations 2 combined denervations, 28 pancreatic resections 12 pancreaticoduodenectomies, duodenum-preserving resection of the pancreas head 12, distal pancreatectomies, 3 total pancreatectomies and a combined denervation, 9 bypass procedures and 2 pancreas transplantations in 2 cases. The follow-up period were from 1 month to 9 years and 7 months with a mean of 2 years and 11 months. The results were good in 23 cases (51 .1%), fair in 16 cases (35.6%) and poor (no change or aggravation) in 6 cases (13.3%). Postoperative mortality developed in 1 case due to postoperative aspiration pneumonia and sepsis after the bypass procedures. Late mortality occurred in 2 cases, one due to sepsis from uncontrolled DM and the other is rupture of the pseudoaneurysm of the anastomotic vessel after transplantation. CONCLUSIONS: Surgical procedures are the mainstays of definite treatment modality in chronic pancreatitis. Operations should be selected properly for each case. Pancreas or islet transplantation is another treatment option for the control of irreversible exocrine and endocrine pancreatic dysfunction.

Clinical experiences of osseous genioplasty

No abstract available.