Long-term Complete Response with Lapatinib Plus Capecitabine in a Patient with HER2-Positive Breast Cancer Metastasized to the Pancreas / 이화의대지

A 37-year-old woman underwent a total mastectomy and adjuvant chemotherapy for HER2-positive breast cancer (pT1N0M), and then recurred in the right lung followed by the pancreas. Lung lobectomy and pylorus-preserving pancreaticoduodenectomy were performed, and systemic chemotherapies including trastuzumab were sequentially administered. However, metastasis to the pancreatic tail was detected. She underwent image-guided radiation therapy, but this was not effective. Lapatinib plus capecitabine combination was administered as forth-line treatment and the metastatic lesion was disappeared. She is continuing this regimen with a complete response for 48 months until now.

Hepatectomy, combined with intraoperative radiofrequency ablation in patients with multiple hepatocellular carcinomas

BACKGROUNDS/AIMS: We compared the efficacy and safety of a hepatectomy, combined with intraoperative radiofrequency ablation to those of wider extent hepatectomy, alone, in patients with multiple hepatocellular carcinomas (HCCs). METHODS: Between January 2004 and December 2013, 78 patients with multiple HCCs underwent surgery. 25 patients were treated by hepatectomy, combined with intraoperative radiofrequency ablation (RFA) (group A), and 53 underwent hepatectomy only (group B). We retrospectively analyzed medical records to compare the clinical features of these two groups. RESULTS: Patients in group A had more limited resections (less than 2 segments) than those in group B (p<0.001). Patients in group A also tended to have fewer red blood cell transfusions than those in group B (p=0.060). Liver function- and surgery-related complications occurred only in group B. There were no in-hospital mortalities in both groups. The overall survival and disease-free survival outcomes were not significantly different between groups A and B (p=0.177 and p=0.305, respectively). CONCLUSIONS: Hepatectomy combined with intraoperative RFA could be a safe and effective treatment option for patients with multiple HCCs, comparable to extended hepatectomy alone.

CD44 expression in patients with combined hepatocellular cholangiocarcinoma

PURPOSE: Combined hepatocellular cholangiocarcinoma (ChC) is a rare type of primary liver cancer, which is thought to have a poorer prognosis than hepatocellular carcinoma (HCC). Cancer stem cells are associated with tumorigenesis, tumor progression, recurrence, metastasis, and poor prognosis in several malignancies including HCC. The aim of this study was to investigate the expression pattern of cancer stem cell markers in ChC and HCC, and to evaluate whether this pattern correlated to patient prognosis. METHODS: Thirteen patients who underwent curative hepatic resection for ChC and 13 patients who underwent curative hepatic resection for HCC (matched control cases) were included. Immunohistochemical staining for cancer stem cell markers (cytokeratin [CK]7, CK19, C-kit, cluster of differentiation [CD] 44, CD133, and epithelial cell adhesion molecule) was performed and clinical outcomes were analyzed retrospectively. RESULTS: There was no significant difference in cancer stem cell marker expression between ChC and HCC. In ChC, the group that expressed CD44 showed earlier recurrence than the group that did not express CD44 (P = 0.040). CONCLUSION: The expression of cancer stem cell markers in ChC did not show a different pattern compared to that found in HCC. The expression of cancer stem cell marker CD44 was associated with poor prognosis in patients with ChC.

Hepatic Resection for Hepatic Metastases from Gastric Adenocarcinoma

PURPOSE: The effects of hepatic resection on patients with metastatic tumors from gastric adenocarcinomas are unclear. Therefore, we analyzed early clinical outcomes in patients who underwent surgical resection for hepatic metastases from gastric adenocarcinomas. MATERIALS AND METHODS: From January 2003 to December 2010, 1,508 patients with primary gastric cancers underwent curative gastric resections at the Korea Cancer Center Hospital. Of these patients, 12 with liver-only metastases underwent curative hepatic resection. Their clinical data were analyzed retrospectively. RESULTS: The median follow-up period was 12.5 months (range, 1~85 months); no operative mortalities or major complications were observed. Three patients underwent synchronous resections, and 9 underwent metachronous resections. In the latter group, the median interval between gastrectomy and hepatectomy for hepatic metastasis was 10.5 months (range, 5~47 months). The overall 1- and 5-year survival rates of these 12 patients were 65% and 39%, respectively, with a median overall survival of 31.0 months; 2 patients survived for >5 years. CONCLUSIONS: Hepatic resection can be a feasible procedure for treating hepatic metastases from gastric adenocarcinomas. Although this study was small and involved only selected cases, the outcomes of the hepatic resections were comparable and long-term (>5 years) survivors were identified. Surgical resection of the liver can be considered a feasible option in managing hepatic metastases from gastric adenocarcinomas.

Extrahepatic recurrence of hepatocellular carcinoma after curative hepatic resection

BACKGROUNDS/AIMS: This study was designed to compare the recurrence patterns after curative hepatectomy, to compare the prognosis according to the initial site of metastasis, and to investigate the independent predictive factors associated with extrahepatic recurrence in hepatocellular carcinoma (HCC) patients after curative hepatectomy. METHODS: From January 2000 to July 2009, 307 patients underwent curative hepatectomies for HCC at our institution; 152 patients showed recurrences. Patients were divided into 2 groups according to their initial recurrence site: the intrahepatic recurrence (IHR) group and extrahepatic recurrence (EHR) group. The IHR group was comprised of 111 patients and the EHR group was comprised of 41 patients. The study investigated the preoperative, intraoperative, and postoperative factors related to the recurrence pattern retrospectively and compared the prognoses of the patients. RESULTS: A five-year survival rate after an initial recurrence was lower in the EHR group (21.5%) than the IHR group (36.3%) (p<0.001). The preoperative alpha-fetoprotein (AFP) level was an independent risk factor for extrahepatic recurrence (p=0.014). CONCLUSIONS: Patients with a preoperative AFP level greater than 200 ng/ml have a higher incidence of extrahepatic metastases after a curative resection of HCC. Increased level of preoperative AFP is an indication for a short-term follow up hepatectomy.

Fat Tissue Infiltration into the Pancreas Parenchyme and Its Effect on the Result of Surgery

PURPOSE: In Korea, there are few reports regarding the infiltration of fat tissue in pancreatic parenchyma in surgically resected organs. It is necessary to ascertain the correlation between the presence of fat tissue in the resection margin of the pancreas and the surgery outcome. METHODS: Fifty four patients who underwent pancreatic resection from Jan. 2007 to Nov. 2008 were enrolled in this study. Pathologic examination was performed to determine the presence of fat tissue in resected pancreatic parenchyma. Statistical correlation between the presence of fat tissue with clinical parameters and postoperative complication rates was analyzed. RESULTS: Among the specimens of all fifty four patients, fat tissue was found in 32 specimens of patients (59.3%). Female gender and patients whose body mass index exceeded 24 kg/m2 were statistically correlated with the presence of the fat tissue in pancreatic parenchyma. There was no statistical relationship between infiltration of fat tissue with postoperative complications. CONCLUSION: This study may serve as the base data for study in radiological imaging in detecting pancreatic tissue. A further larger scaled study is needed to validate the result of this study.

Hepatic Differentiation of Bone Marrow Derived Mesenchymal Stem Cell Using Fibrin Gels in 70% Hepatectomized Rat

PURPOSE: To investigate the differentiation of rat bone marrow-derived mesenchymal stem cells (MSCs) into hepatocytes by cell transplantation using fibrin gels in a 70% hepatectomized rat model. METHODS: MSCs were isolated from Sprague-Dawley rats. MSCs (1.5x10(7) cells) were mixed with fibrin gels and injected immediately into the abdominal cavity of 70% hepatectomized rats. Fibrin-gels consisted of 500 IU/ml of thrombin and 90 mg/ml of fibrinogen. Transplanted MSCs in the fibrin scaffold were retrieved from surgically opened peritoneal cavities of rats on days 5, 10, 15, and 21 after the operation. The specimens were analyzed histologically and immunohistochemically. RESULTS: On H&E staining, MSCs from hepatectomized rats had changed to a round shape, while MSCs of the control group kept their spindle shape. When the fibrin matrix was biodegraded at day 15, the morphology of the MSCs had changed to hepatocyte-like cells without sinusoids and the hepatocyte-like cells had formed a three-dimensional tissue permitting cell-to-cell contacts within the matrix. On immunohistochemistry, MSCs expressed the hepatocyte markers cytokeratin 18, albumin, and alpha-fetoprotein, after 15 days of transplantation. CONCLUSION: When bone marrow-derived MSCs are transplanted using fibrin gels in the 70% hepatectomized rat, MSCs differentiate into hepatocyte-like cells and are conglomerated so that they form three-dimensional tissue-like hepatocytes without sinusoids.

The Changes of Clinical Pattern of Patients Who Underwent Hepatectomies for Hepatocellular Carcinoma according to Chronological Periods

PURPOSE: The purpose of this study was to identify changes over several years in clinical patterns of patients who underwent hepatectomies for HCC. METHODS: There were 502 patients who underwent hepatectomies for HCC between January 1986 and July 2009 at the Korea Cancer Center Hospital, Seoul, Korea. Period 1 (n=206) extended from the beginning to December 2000. Period 2 from January 2001 to December 2004 (n=146). Period 3 from January 2005 to July 2009 (n=150). The data for the different periods were compared retrospectively or prospectively. RESULTS: Compared to patients from Period 1, Period 2 and Period 3 patients had operations >6 months from diagnosis (p=0.002), high levels of preoperative AST and ALT (p<0.001), and poor scores on the ICG R15 test (p=0.047). The Frequency of Transfusion during the operation was decreased (p<0.001), but there was no difference in postoperative complication rates (p=0.403). In Periods 2 and 3, there was a higher frequency of multiple tumors (p<0.001) and microvascular invasions histologically (p<0.001). Differences between periods in disease free survival rates were not significant. CONCLUSION: The reason for the higher frequency, in more recent periods, of patients presenting at surgery with advanced HCC stages is the longer interval between diagnosis and operative time, and an increase in the number of non-surgical treatments before surgery. Because of differences in follow-up intervals, it was difficult to evaluate the influence of period on survival rates. Hence, a longer follow-up period will be required for an accurate evaluation of changes in survival with time.

Graft-Versus-Host Disease after Liver Transplantation

PURPOSE: Graft-Versus-Host Disease (GVHD) is a rare (0.1~2%) but severe complication after liver transplantation (LT). It is the most lethal complication after LT and there are currently no effective preventive or therapeutic measures available. Approximately 90 such cases have been reported in the literature, but only one case has been reported in Korea. METHODS: We performed a retrospective analysis of 767 patients who underwent LT (living donor:deceased donor=554:213) at Seoul National University Hospital, Korea from 1998 to 2009. Four patients (4/767, 0.52%) with histologically proven GVHD were found. The diagnosis of GVHD was made according to observing macrochimerism in the peripheral blood and the affected tissue biopsy. RESULTS: Four patients underwent LT due to Hepatitis B virus-related liver cirrhosis and two of these patients had coexisting hepatocellular carcinoma. Three patients received livers from deceased donors and one received a liver from a live donor. All their blood matching were identical. The first diagnosed case underwent human leukocyte antigen (HLA) typing only after LT and it showed complete one-way donor-recipient HLA matching. The onset of GVHD occurred between 10 days and 55 days after LT. All the patients developed high-grade fever, skin rash, neutropenia, diarrhea and the main signs and symptoms related to GVHD. All the patients died because of sepsis despite intensive treatment. CONCLUSION: GVHD after LT is an extremely rare and fatal complication and it is difficult to diagnose. Therefore, we should perform pre-transplant HLA matching and try to establish an early diagnosis for patients who are clinical suspicious of having GVHD. Further study in this area is needed and physicians need to be alert to detect this malady.

Outcomes of a Hepatic Resection for Colorectal-Carcinoma Liver Metastases

PURPOSE: Recent managements of liver metastasis from colorectal cancer consist of multi-disciplinary treatments. Although hepatic resection is the only curative treatment, for which long-term survival is expected, the recurrence rates is still high. Recently, liver resections, combined with chemotherapy and other additional therapy, have produced promising outcomes. We analyzed the outcomes of hepatic resection for liver metastasis from colorectal cancer. METHODS: From 1993 to 2007, we performed 116 hepatic resections for the treatment of liver metastasis from colorectal cancer. All patients received adjuvant chemotherapy. We reviewed their medical records and investigated the clinico-pathologic data retrospectively. RESULTS: One in hospital mortality occurred, and the postoperative morbidity rate was 37.5%, including major complication (11.7%). Five-yr overall survival rate and disease free survival rate were 33.2% and 25.0%, respectively. T stage and postoperative morbidity were independent prognostic factors for survival whereas metachronous metastases and postoperative morbidity were independent prognostic factors for recurrence. During the follow-up periods, 67 recurrences occurred. CONCLUSION: Hepatic resections for liver metastasis from colorectal cancer were safe and effective. The surgical T stage, complications, and metastasis type (metachronous or synchronous) may determine the results in patients with surgically-curable liver metastasis from colorectal cancer.

The Outcomes of Curative Resection for Ampulla of Vater Cancer

INTRODUCTION: The prognosis of peri-ampullary cancer is poor because of its low respectability and high recurrence rate. Yet cancer of the Ampulla of Vater(AOV) has a relatively good prognosis. The aim of this study is to investigate the outcomes and to determine the factors that affect the survival rate of patients who underwent curative resection for AOV cancer. METHODS: From August 1988 to January 2008, 54 patients underwent curative resection for AOV cancer. We retrospectively reviewed the clinocopathologic data. The median follow up period was 45 months. RESULTS: Twenty-seven pancreaticoduodenectomies (PD) and 27 pyrolus-preserving pancreaticoduodenectomies (PPPD) were performed. There was no hospital mortality, but 25 out of 54 patients (47.3%) experienced postoperative complications. The 5-year overall survival (OS) rate was 53.97% and the 5-year disease free survival (DFS) rate was 51.75%. On multivariate analysis, the variables that affected the overall survival rate and the disease free survival rate was poor histologic differentiation (p<0.001). CONCLUSIONS: Although the AOV cancer is one of the periampullary cancers that have a very poor outcome, long-term survival and favorable outcomes can be achieved after a curative resection. In this study, poor-histologic differentiation was the only independent factor for a poor prognosis.

Clinical Outcome of 457 Hepatic Resection Cases for the Treatment of Hepatocellular Carcinoma

BACKGROUND & PURPOSE: This purpose of this study was to determine the prognostic factors for hepatocellular carcinoma (HCC) in patients who received curative hepatectomies at our institution. PATIENT AND METHOD: A retrospective analysis was performed on 457 patients who had undergone hepatectomies between Mar 1987 and Feb 2008 for HCC at the Korea Cancer Center Hospital, Seoul, Korea. The number of males enrolled in the study was 366 and the number of females enrolled was 91. The mean age of the patients was 52.8 years old. Hepatitis B virus-related disease was the most frequent etiology (335/457 patients). Two hundred nine (209) patients had liver cirrhosis, and 93.9% of patients were classified in Child-Pugh Class A. RESULT: The complication rate was 30.6% (140/457) and the operative mortality was 1.5% (7/457). Reoperation was performed in 7 complicated patients. Five-and 10-year overall survival rates of the patients were 57.7% and 41.8% respectively. Poor prognostic factors of overall survival were Child B class, Edmonson-Steiner histologic grade 3 or 4, tumor vascular invasion, and postoperative complications. Five-and 10-year disease-free survival rates were 42.7% and 32.5%, respectively. Poor prognostic factors for disease free survival included the following an Edmonson-Steiner histologic grade of 3 or 4, tumor vascular invasion, and postoperative complications. CONCLUSION: Postoperative complication is independently a poor prognostic factor for overall and disease free survival in our study. We suggest that special care is needed while performing hepatic resections for the treatment of HCC in order to reduce postoperative complications.

Isolated Unconjugated Hyperbilirubinemia after Liver Transplantation

PURPOSE: In our experience, post-LT persistent isolated unconjugated hyperbilirubinemia (IUH) has been frequently observed even after liver transplantation (LT) from normal donors. The present study was performed to evaluate the incidence and clinical significance of post-LT IUH. METHODS: Eighty-five patients were enrolled, and they had undergone adult-to-adult living donor LT between Jan 1999 and Jun 2003 and they had been followed-up for more than 2 years. Persistent post-LT IUH was defined as the case that showed repeated IUH 3 times or more per year. We excluded those cases that had other liver function abnormality, biliary complication, active infection or hemolysis. The donor's condition and the long-term prognosis of the post-LT IUH patients were investigated. RESULTS: Sixteen patients (18.8%) showed post-LT IUH. Seven of them underwent LT from donors who had IUH preoperatively. Nine (10.6%) of them, however, underwent LT from normal donors, that is, there was newly developed IUH postoperatively. There was no clinical factor associated with post-LT IUH for those nine patients, yet they developed no graft failure and major complications. A gradual increasing tendency of the bilirubin level during follow-up duration was observed for 3 of these 9 patients. CONCLUSION: Although about 10% patients developed post-LT IUH from normal donors, they all showed a good prognosis. Therefore, post-LT IUH was likely to be benign. However, close observation may be required because a gradual increasing tendency of bilirubin level was observed in some patients.

Optimal Number of Hepatocytes per Microcarrier in Spheroid Culture using Cytodex 3 Microcarrier

PURPOSE: The mass cultivation of functional hepatocytes is a key factor of a bioartificial liver. Combining spheroid and microcarrier cultures has been applied for enhancing the cell viability and metabolic activities. Hence, the optimal number of hepatocytes per microcarrier was investigated. METHODS: Firstly, spheroid cultures were carried out with 1 g Cytodex 3 microcarrier plus 2 x 10(9), 4 x 10(8) and 8 x 10(7) viable hepatocytes per flask. The numbers of hepatocytes per microcarrier were approximately 666.7, 133.3 and 26.7, respectively. The control group consisted of a spheroid culture of 4 x 10(8) hepatocytes without any microcarrier. According to the primary experimental results, spheroid cultures with 1 x 10(8) of hepatocytes plus 1 g, 2 g and 3 g of the Cytodex 3 microcarrier were performed. The numbers of hepatocytes per microcarrier were approximately 33.3, 16.7 and 11.1, respectively. The control group consisted of a spheroid culture of 1 x 10(8) hepatocytes. The cell viabilities were assayed using a Cell Counting Kit-8; with the albumin production assayed using ELISA. RESULTS: According to the primary experiment, the group consisting of 26.7 hepatocytes per microcarrier showed the highest viability (P<0.01). However, there was no statistical difference in the albumin production between the groups (P=0.744). The second Experiment showed the groups consisting of 11.1 and 16.7 hepatocytes per microcarrier had higher viabilities than the other hepatocyte and control groups (P<0.01). The albumin production was similar for each group (P=0.187). CONCLUSION: With respect to their application to a bioartificial liver, about 130 hepatocytes per microcarrier was appeared to be good for the mass cultivation of a hepatocytes spheroid culture using the Cytodex 3 microcarrier.

Split Liver Transplantation / 대한이식학회지

PURPOSE: Split liver transplantation (SLT) offers an effective way of increasing the donor pool. However, it is often difficult to perform SLT under current allocation system. We retrospectively analyzed the outcome of the patients who had undergone SLT in Seoul National University Hospital. METHODS: From the first case of SLT in Korea on November 4, 1998, 8 patients underwent SLT in our center. Three adult patients received extended right liver graft and five child patients received left lateral section graft. All liver were split by in-situ method. RESULTS: All adult patients were alive. One adult patient developed hepatic artery thrombosis one month after SLT and underwent retransplantation due to graft failure. Another patient developed biliary leakage and had to undergo operative bile duct revision. Two of child patients were died of pneumonia and hepatic failure due to HBV hepatitis, respectively. One child patient suffered from hepatic venous stricture and persistent ascites and received interventional therapy. Overall 3-year patient survival rate was 87.5% and graft survival rate was 75.0%. No primary nonfunction developed and three patients (37.5%) suffered form vascular or biliary complications. CONCLUSION: The results of SLT were similar to that of conventional deceased donor liver transplantation. Although SLT is technically difficult and increase the risk of vascular or biliary complications just like living donor liver transplantation (LDLT), its result might be acceptable and it could be a successful method to expand the donor pool if it would be performed in the center experienced in LDLT.

Auxiliary Partial Orthotopic Liver Transplantations for One Pediatric Patient with Complement Factor H Deficiency and Two Adult Patients / 대한이식학회지

We have performed 3 cases of APOLT in one child and two adults. The child recipient had suffered from complement factor H deficiency since 3 months after birth and at the age of 30 months, APOLT was undertaken. Living donors of two adult recipients were affected by severe hepatic steatosis and the grafts were relatively small-for-size. After left hemihepatectomies, left lateral section and left hemilivers were transplanted orthotopically. The child recipient died of heart failure due to sepsis 7 months after transplantation, but factor H level remained nearly normal until his death. Although one adult suffered from hepatic venous stricture postoperatively, all adult recipients are alive with normal liver function for 11 and 8 months. In conclusion, although APOLT is technically demanding, APOLT may be a suitable surgical procedure in non-cirrhotic metabolic liver disease and a feasible solution for marked steatotic living donor grafts and small-for-size grafts.

Clinical Significance of Vancomycin Resistant Enterococcus in Liver Transplantation / 대한이식학회지

Purpose: Recently the incidence of vancomycin resistant enterococcus (VRE) infection and colonization has increased in the hospitalized patients. The purpose of present study is to examine the clinical significance of VRE infection and colonization in liver transplantation (LT) patients and to investigate the outcome. Methods: Among 194 patients who underwent LT from January 2001 to July 2004, 15 patients had at least one report of culture positive of VRE (VRE(+)). We compared the clinical outcome of 15 VRE(+) patients with those of VRE(-) patients. Results: One year mortality was higher in VRE(+) patients than VRE(-) patients (27% vs 4%; P=0.0001). Causes of death were primary graft non-function, infective endocarditis, MRSA sepsis and CMV pneumonitis. Mean duration of hospital stay was 102+/-63 days in VRE(+) patients, which shows significant difference with 51+/-30 days in VRE(-) patients (P=0.008). Cases who underwent gastroscopy (1.00+/-1.51 vs. 0.12+/-0.47; P=0.04) and percutaneous catheter drainage (1.33+/-1.49 vs. 0.40+/-1.05; P=0.03) were significantly more frequent in VRE(+) patients. The findings of gastroscopy were upper gastrointestinal bleeding (n=4), and bile duct obstruction (n=1). The contents of percutaneous catheter drainage were hematoma (n=3), bile juice (n=3) and ascites (n=1). Conclusion: VRE infected patients experienced more frequently gastrointestinal tract complications including bleeding or biliary complication and they showed higher 1-year mortality rate, although these patients died of causes other than VRE infection.

The Assessment of the Method of Monitoring in Liver Transplant Recipients Treated with Microemulsion Cyclosporine (Neoral(R)) and Mycophenolate Mofetil (CellCept(R)) / 대한이식학회지

PURPOSE: Cyclosporine (CsA) dosing is traditionally based on trough levels (C0) rather than area under the concentration- time curve (AUC), although AUC correlates better with post- transplantation acute rejection and toxicity. It was reported that C2 (2-hour post-dose blood level) is an accurate single- sample marker for AUC0-4 in patients receiving CsA. No trials of C2 monitoring have been carried out in liver transplant recipients who are immunosuppressed with the combination of CsA and Mycophenolate Mofetil (MMF). The purpose of this study was to evaluate the correlation between C0, 1, 2, 3, 4 levels and AUC0-4 and define recommended target C2 in liver transplant recipients who are treated with CsA and MMF. METHODS: Thirty adult living donor liver transplant recipients were followed up 12 weeks after transplantation. CsA and MMF were administered in all recipients. CsA dose was reduced to the half level of target C0 in recipients treated solely with CsA. C0 and C2 were measured during in-patient period post-transplant. RESULTS: The best correlation between CsA concentration at various time points and the AUC0-4 was found at C2 (r2=0.931) (P<0.05). Mean C2 was 543.2+/-260.1 ng/mL (mean+/-SD). We observed complications associated with the immunosuppressants in six patients (20%). But, only one patient experienced acute rejection proven by biopsy and, there is no the graft loss and nephrotoxicity. CONCLUSION: In early post-transplant days, AUC0-4 was strongly correlated with C2. Reduced CsA dosing can be attempted in recipients who are immunosuppressed with the combination of CsA and MMF. The optimal target C2 probably can be suggested as about 543.2+/-260.1 ng/mL (mean+/-SD). During the in-patient period, C0 matched with target C2 can be decided. Target C0 can be individualized because C0 matched with target C2 differs in each recipients and C2 can't be checked routinely during the out-patient period.

Correlations between the Rate of Decrease in Preoperative Bilirubin and Postoperative Complications after Biliary Drainage for Distal Common Bile Duct Cancer

PURPOSE: This study was aimed at comparing the rate of decrease in preoperative serum bilirubin after biliary drainage and the postoperative complication rate in patients with distal common bile duct (CBD) cancer. METHODS: Forty six patients who had undergone pancreaticoduodenectomy due to distal CBD cancer were included in this study. The patients were divided into the complicated and uncomplicated groups. For the patients who underwent preoperative biliary drainage, the preoperative bilirubin level and the rate of decrease in serum bilirubin were measured and compared between the two groups. RESULTS: The postoperative complication and mortality rates were 43.4% (20/46) and 6.5% (3/46), respectively. The complication rates were not different between the drainage and non-drainage groups (p=0.48). The preoperative serum bilirubin levels were also not different between the complicated and uncomplicated groups (p=0.214). In the uncomplicated group, the rate of decrease in the serum total bilirubin level tended to be higher than in the complicated group, but this was not statistically significant (mean: 0.82 vs 0.27 mg/dl/day, respectively, p=0.117). Patients with a higher preoperative bilirubin decrease rate showed a larger bilirubin decrease in the immediate postoperative period (from POD 1 to POD 7, r=0.371, p=0.05). CONCLUSION: The preoperative biliary drainage and the serum bilirubin level were not correlated with the postoperative complication rate. Patients with higher preoperative bilirubin decrease rates showed a larger bilirubin decrease in the immediate postoperative period, which can be interpreted as having a faster recovery of their liver function. Further study with a larger number of cases is required to see if the preoperative bilirubin decrease rate could be used as a prognostic indicator after pancreaticoduodenectomy.

Surgical Clips Found at the Hepatic Duct after Laparoscopic Cholecystectomy: a Possible Case of Clip Migration

Surgical clip migration and subsequent stone formation in the common bile duct is a rare, but well-established complication after laparoscopic cholecystectomy. There are some suggestions about the mechanisms of the migration process, but the details are still unclear. We report here on a case in which common bile duct stones were formed around surgical clips, and other clips were found to have penetrated into the common hepatic duct, which we believe were in the process of migration after laparoscopic cholecystectomy. The patient required a laparotomy to retrieve the bile duct stones due to the distal bile duct stricture, and another laparotomy was necessary to remove the penetrating clips, which were deeply embedded in the bile duct wall. Although a variety of endoscopic and percutaneous interventional procedures are available in this era of modern medical technology, it is sometimes impractical to apply these procedures in such cases as ours, and exploratory laparotomy is sometimes required to correctly treat the patient. This case shows that the metallic surgical clips can penetrate into the intact bile duct wall through serial maceration, and we believe that careful application of clips may be the only way to prevent their migration after laparoscopic cholecystectomy.