Differences in Pilon Fractures According to Ipsilateral Fibular Injury Patterns: A Clinical Computed Tomography-Based Mapping Study

Background@#Preoperative verification of fracture morphology is essential for determining the definitive fixation strategy in the management of a pilon fracture. This study aimed to determine the correlation between fibular injury patterns and fracture morphologies and introduce clinical implications. @*Methods@#Computed tomography scans of 96 pilon fractures were retrospectively analyzed and divided into three types: intact fibula, simple fracture, and multifragment fracture. The principal fracture line and comminution zones were illustrated on a plafond template and diagrammatized on a 6 × 6 grid using PowerPoint software as fracture mapping. Correlations between fibular injury patterns and fracture morphologies, including comminution zones and principal fracture lines, were analyzed. @*Results@#The thickest comminution zone was most often located in the anterolateral quadrant. According to fibular injury patterns, the comminution zone of the multifragment group was placed two grids more lateral than that of other groups. Lateral exits of the principal fracture line in the multifragment group were much more concentrated within the fibular incisura. @*Conclusions@#In pilon fractures, a more complex fibular fracture pattern was related to the valgus position. Moreover, the articular fracture pattern of pilon fractures differed according to coronal angulation and fibular fracture pattern. These differences should influence the operative approach and placement of the plate.

Effectiveness of external drainage of the bile duct in pancreaticoduodenectomy: a single surgeon's experience

BACKGROUNDS/AIMS: The rates of surgery-related complications during and after pancreaticoduodenectomy (PD) remain very high, reaching up to 41%. They were primarily caused by leakage of pancreatic juice. We evaluated the effectiveness of external drainage of the bile duct using a pigtail drain to prevent pancreatic leakage in patients undergoing PD. METHODS: We evaluated 79 patients who underwent PD using a single-layer continuous suture between the pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis by a single surgeon from April 2005 to December 2008. Of the 79, 44 underwent external drainage (ED) of the bile duct using a pigtail drain, performed in the intraoperative field via a retrograde transhepatic approach, whereas 35 did not undergo ED. RESULTS: Age, sex distribution, number of total complications, pancreatic duct size, pancreatic texture and duration of hospital stay did not differ between patients who did and did not undergo ED. In groups with or without ED, 0 and 4 patients, respectively, showed leakage of pancreatic juice and the difference was statistically significant (p=0.02). CONCLUSIONS: The fact that none of the patients who underwent external drainage experienced pancreatic leakage, suggests that external drainage of the bile duct with a pigtail drain to decompress the jejunum and to drain pancreatic and bile juice is useful in preventing the complications of pancreatic leakage.

Living Donor Exchange Program for Adult Living Donor Liver Transplantation: Preliminary Experience at the Asan Medical Center, Korea / 대한이식학회지

PURPOSE: When performing donor screening for living donor liver transplantation (LDLT) for an adult patient with end- stage liver disease, ABO blood group incompatibility is the most common cause of donor exclusion. To cope with this problem without performing ABO-incompatible LDLT, living donor exchange program has been maintained at the Asan Medical Center, Seoul, Korea since September 2003. Here we introduce the clinical experience of 6 cases of adult LDLT allocated by living donor exchange program. METHODS: From February, 1997 to December 2006. 1208 cases of adult LDLT were performed in our institution. Among them, there were 6 cases allocating through donor exchange program to avoid ABO blood group mismatching. Three sets of 2 donor-recipient combination pairs were made after direct one-to-one donor-recipient matching. RESULTS: Two sets of donor exchange LDLT were performed on elective surgery basis, but one in emergency situation. Two living donors and 2 recipients underwent LDLT operations at the same time at the same institution. All 6 living donors recovered well. All of the 6 recipients are doing well to date although 1 recipient had undergone prolonged intensive care for surgical complications. There was no emotional or psychological conflict related to donor exchange program. CONCLUSION: This is the world-first report on donor exchange adult LDLT. Although this is a preliminary report with only 3 sets, donor exchange program for adult LDLT appears to be a feasible modality to promote LDLT. We believe it can be applicable to a wider population of LDLT after widespread consensus formation.

Branchial Anomalies in Children

PURPOSE: Congenital lesions account for more than half of the excised cervical masses in children, and 20% of these cervical masses are caused by branchial anomalies (BA). BA can present as a cyst, sinus, fistula or skin tag and they are the result of maldevelopment of the branchial apparatus during the embryonic period. In this study we sought to review the presentation, work-up, treatment and outcome of BAs in a pediatric population. METHODS: Forty-two pediatric patients who were treated for BA over an 11-year period starting from June 1997 at Keimyung University Dongsan Medical Center were investigated to assess the relative frequency of the type of BA, the preoperative manifestations, the preoperative diagnostic modalities and the surgical complications. RESULTS: There were 21 (50%) branchial sinuses, 12 (29%) branchial cysts, 6 (14%) branchial fistulas and 3 (7%) skin tags with a cartilaginous remnant. Among the 42 BAs, 13 (31%) were previously infected. Based on embryological classifications, there were 32 (76%) second BAs, 5 (12%) 3rd and 4th BAs, 1 (2%) 1st BA, and 4 (10%) unclassified BAs. We experienced 1 postoperative recurrence and 1 temporary facial nerve palsy that developed during excision of a 1st branchial cyst. Histopathological study of the lining epithelium demonstrated squamous epithelium in 19 BAs (45%), respiratory epithelium in 8 BAs (19%), squamous and respiratory epithelium in 4 Bas (10%), no epithelium with fibrosis in 8 BAs (19%), and others in 3 BAs (7%). CONCLUSION: Branchial sinuses are most common by morphology and 2nd branchial anomalies by embryology. The preoperative infection rate was 31%. The every effort to find out the exact anatomical location of the lesions is necessary to minimize postoperative recurrence by complete excision.

Continuous Peritransplant Assessment of Consciousness using Bispectral Index Monitoring for Patients with Fulminant Hepatic Failure

PURPOSE: Deterioration of consciousness is the most critical problem in patients with fulminant hepatic failure (FHF). Electroencephalography (EEG) is a standard procedure to determine the brain activity in unconscious patients. The bispectral (BIS) index derived from EEG was primarily developed to monitor the depth of unconsciousness. METHODS: A prospective study was performed to assess the clinical utility of peritransplant BIS monitoring in 11 fulminant hepatic failure (FHF) patients who were undergoing emergency living donor liver transplantation (LT) with using a right liver graft. All the patients recovered their consciousness after LT. RESULTS: There was a significant correlation between the BIS index values and the derived GCS score (r2=0.634, p <0.001). Timing of eye opening to voice command matched the BIS index value of 64+/-9.5, which was after 14+/-9.4 hours passing BIS index of 50. All the patients with endotracheal intubation during the early posttransplant period showed progressive increase of their BIS index, which appeared slightly earlier and more evident than the rise of derived GCS scores. CONCLUSION: BIS monitoring is a noninvasive, simple and easy-to-interpret method and it also appears to be a useful to assess and predict the recovery of a patient's consciousness level after LT. Therefore, we concluded that BIS monitoring can be an indispensable component of the peritransplant intensive care for patients with FHF and who require emergency LT.

Analysis of Survival Predictors After Surgical Resection of Hilar Cholangiocarcinoma (HCCC) In a Single Institute With Large Volume

PURPOSE: Although curative resection of hilar cholangiocarcinoma (HCCC) remains a difficult challenge, only curative resection with tumor free margins can guarantee a favorable outcome. In this report, we retrospectively analyzed the survival data after surgical resection of HCCC to determine the survival rate and the related factors at a single, large-volume medical institute. METHODS: Between June 1989 and June 2005, surgical intervention with curative intent was performed on 301 patients. We retrospectively analyzed the survival data via a review of the medical record. RESULTS: Among the 259 cases of resection, curative (R0) resection with tumor-free margins was achieved in 186 cases (71.8%). Of these 186 cases, 177 patients underwent various types of hepatectomy with caudate lobectomy and bile duct resection. Combined pancreatoduodenectomy was performed in 19 patients and portal vein resection was performed in 51 patients. In-hospital mortality developed in 11(4.3%) of the 259 patients who underwent resection. The 1-, 3- and 5-year survival rates of patients who underwent R0 resection were 83.3, 42.0 and 29.3%, respectively. Univariate analysis revealed that curability, T stage, lymph node involvement, histologic differentiation and perineural invasion were associated with patient survival. Multivariate analysis showed that curability and lymph node involvement were statistically significant prognostic factors. CONCLUSION: Tumor-positive margins and lymph node involvement resulted in poor outcomes. Intensive perioperative management and a surgeon's aggressive efforts to attain clearance of tumor can minimize the postoperative mortality and maximize survival for patients with HCCC.

Analysis of Survival After Portal Vein Resection (PVR) In Combination With Hepatectomy For Hilar Cholangiocarcinoma: An Audit of 51 Cases

PURPOSE: Although a portal vein resection (PVR) can increase the chance for a successful curative resection, there is debate concerning the balance between the risk of the procedure and the effect on survival in patients with hilar cholangiocarcinoma. Therefore, we performed a retrospective study to determine the safety and survival after PVR for hilar cholangiocarcinoma. METHODS: We analyzed the cumulative survival rate and the associated clinical factors in 301 patients undergoing surgical intervention between June 1989 and June 2005. We divided 259 patients undergoing resection into two groups (51 PVR+ and 208 PVR-) and compared the survival and clinicopathological data. RESULTS: The 1-, 3- and 5-year survival rate of 186 patients undergoing curative resection was 83.3, 42.0 and 29.3%, respectively. The Bismuth-Corlette type IV, the infiltrative type, presence of perineural invasion, lymphovascular tumor emboli and lymph node metastases were more frequent in the PVR+ group. The survival rate was significantly lower in the PVR+ group but seven patients have survived for more than 5 years. Five (9.8%) operative mortalities occurred. However, the mortality directly related to the PVR was present in only one case. The morbidity and postoperative liver function were not different in comparisons between the two groups. In the PVR+ group, tumor invasion into the portal vein was observed in 28 of 51 patients. The tumor invasion on pathological examination did not affect survival in the PVR+ group. CONCLUSION: The results of this study showed that PVR in combination with hepatectomy, for hilar cholangiocarcinoma, could be performed with acceptable safety. Although the PVR has a negative impact on survival, a hepatectomy combined with a PVR can offer long-term survival to a few patients with advanced hilar cholangiocarcinoma.

Analysis of Outcomes after Curative Resection of Ampullary Carcinoid Tumor

PURPOSE: Ampullary carcinoid tumors are rare and therefore the clinicopathologic characteristics and prognosis after radical surgery have yet to be clarified. The goal of this study was to analyze the outcome of ampullary carcinoid tumors in patients who underwent radical curative resection. METHODS: From January 1998 to December 2005, 10 patients (3.4%) were diagnosed with an ampullary carcinoid tumor among 294 patients who underwent pancreatoduodenectomy for various ampullary neoplasms. The clinical findings from these 10 patients were retrospectively analyzed. RESULTS: The mean patient age was 58.0 +/- 13.4 years and seven were male. A standard pancreatoduodenectomy was performed in three patients and pylorus-preserving pancreatoduodenectomy in seven. An R0 resection was achieved in all 10 patients. The mean tumor size was 2.1 +/- 1.3 cm. Synaptophysin staining was positive in 10 and chromogranin staining was positive in eight patients. The overall and disease-free survival rates were 90% and 80% at 1 year and 64% and 56% at 3 years, respectively. Univariate analyses revealed that a maximum tumor diameter > or = 2 cm and tumor invasion beyond the ampulla were significant risk factors for tumor recurrence. CONCLUSIONS: The results of this study showed that performing a radical resection is the treatment of choice, with the intention of total tumor removal and the possibility of cure.

Treatments of Proximal Bile Duct Necrosis and Stricture from Iatrogenic Bile Duct Injury of Laparoscopic Cholecystectomy

PURPOSE: Most bile duct injuries can be recognized intraoperatively, or within a few days after a laparoscopic cholecystectomy, with a favorable prognosis following proper management. However, a significant delay in the diagnosis, improper management, or other risk factors can lead to serious intractable biliary complications. Herein, the clinical courses of these serious biliary complications were analyzed to find their optimal treatment methods. METHODS: Between 1998 an 2003, 9 cases of serious biliary complications were encountered following a laparoscopic cholecystectomy. Patients detected early and with uneventful biliary reconstruction were excluded. Their mid- and long-term clinical courses were retrospectively analyzed. RESULTS: Their treatment methods undertaken to them were divided as follows: Primary hepaticojejunostiomy (HJ) to the necrotic proximal bile duct (n=3) : delayed stricture occurred in 1 patient among them; HJ to the delayed-onset proximal bile duct stricture (n=2) : There was no recurrence; Right lobectomy and HJ to the proximal bile duct stricture after right portal vein embolization (n=3) : There was no recurrence; And, induction of parenchymal atrophy applied to the isolated right posterior duct injury through portal vein embolization and sequential bile duct occlusion (n=1). CONCLUSION: Necrosis and stricture of the injured proximal bile duct should be managed by a case-by-case basis because every patient revealed different clinical features. Long- term surveillance over 5 years is recommended to detect late- onset biliary stricture.