Chronic Non-granulomatous Ulcerative Jejunoileitis Assessed by Wireless Capsule Endoscopy / 대한소화기학회지

Chronic non-granulomatous jejunoileitis is a rare disease characterized by malabsorption, abdominal pain, and diarrhea that causes shallow ulcers in the small bowel. The etiology of chronic non-granulomatous jejunolieitis remains unknown. A 69-year-old man complained of abdominal pain and lower extremity edema. A 99m-Tc albumin scan showed increased radioactivity at the left upper quadrant, suggesting protein-losing enteropathy. A small bowel follow-through did not disclose any lesions. Wireless capsule endoscopy revealed several small bowel ulcers and strictures. A jejunoileal segmentectomy with end-to-end anastomosis was performed, and the histologic examination revealed non-granulomatous ulcers with focal villous atrophy. Ruling out all other possible diagnoses, we diagnosed our patient with chronic non-granulomatous ulcerative jejunoileitis. Postoperatively, the patient's abdominal pain and lower extremity edema improved, and the serum albumin normalized. This is the first case of chronic non-granulomatous ulcerative jejunoileitis localized by wireless capsule endoscopy and treated successfully with segment resection.

Leiomyosarcoma of the Ovarian Vein: a Case Report with Radiological Findings

Leiomyosarcomas of the ovarian vein are very rare. Four cases have been reported in the English language clinical literature. We present a case of leiomyosarcomas where the use of multi-detector CT had a substantial role in the establishment of the preoperative diagnosis. The radiological images as well as intraoperative features are illustrated. We also discuss the radiological findings of the ovarian vein leiomyosarcoma in comparison with those of other venous or retroperitoneal leiomyosarcomas. We expect that the use of multi-detector CT will be the choice for the diagnostic work-up of vascular leiomyosarcomas.

Study of CpG Methylation of the p16 and MGMT Promoter in Hepatocellular Carcinoma

PURPOSE: The aims of this study were to examine the methylation status of the p16 and MGMT promoters in hepatocellular carcinoma (HCC), and to evaluate the relationship between the loss of gene expression, the promoter methylation status and hepatocarcinogenesis. METHODS: We included 24 HCC tissues and their adjacent non-tumorous tissues and 5 normal liver tissues in our study, and all the specimens were obtained by hepatectomy. The methylation status of the p16 and MGMT promoter regions were evaluated by methylation-specific polymerase chain reaction (MSP) and quantitative analysis by using a Gel-pro analyzer (Media Cybernetics, CA, USA). We also analyzed the p16 and MGMT gene expressions by performing immunohistochemical staining of the HCC tissues. RESULTS: Methylation of the p16 promoter was detected in HCC (100%, 24/24) and the adjacent non-tumorous tissues (79.2%, 19/24), but not in the normal liver tissues. Methylation of the MGMT promoter was detected in the HCC (8.3%, 2/24) and the adjacent non-tumorous tissues (4.2%, 1/24), but not in the normal liver tissues. Methylation positive HCC samples showed the loss of p16 expression in 58.3% (14/24). The loss of the p16 expression in the HCC tissues was well correlated with the increased rate of p16 promoter methylation (p=0.009). When the p16 promoter methylation status of the HCC tissues was higher than that of the adjacent non-tumorous tissues, 77.8% of the cases showed the loss of the p16 expression (p=0.002). No correlation was observed between MGMT promoter methylation and the loss of the gene expression in the HCC tissues. CONCLUSION: These results suggest that methylation of the p16 promoter and the resulting loss of p16 protein expression are significant events in hepatocarcinogenesis, and further studies are needed to evaluate the relationship between the methylation of the MGMT promoter and HCC carcinogenesis.

Serum Vascular Endothelial Growth Factor (VEGF) and Microvessel Tumor Invasion in Hepatocellular Carcinomas

PURPOSE: Vascular endothelial growth factor (VEGF) is a potent angiogenic factor in a number of cancers. The aim of this study was to evaluate the clinical significance of the serum level of VEGF in hepatocellular carcinoma (HCC) patients. METHODS: Serum VEGF was measured by an enzyme linked immunosorbent assay (ELISA) method. The correlation between serum VEGF level and clinico-pathological data of HCC patients were evaluated. RESULTS: The serum VEGF levels significantly increased with increasing tumor size and platelets count. The mean serum VEGF level in HCC patients with microvessel tumor invasion was higher than in those without microvessel tumor invasion. CONCLUSION: A high serum VEGF level may be an indicator of tumor progression and an important predictor of microvessel tumor invasion.

Analysis of Effect of Coagulation Management Based on the Changes of Thromboelastographic Variables during Orthotopic Liver Transplantation / 대한마취과학회지

Introduction: Thromboelastography (TEG) provides an overall assessment of the platelet-coagulation protein cascade interaction. The information generated from the TEG is rapidly obtained and made useful to guide replacement therapy. The purpose of this study was to evaluate the efficacy of the TEG as its guided blood replacement therapy and pharmacological therapy during liver transplantation. METHODS: This study was carried out in 13 consecutive patients who were subjected to TEG-guided replacement therapy during liver transplantation. A prepared mixture of blood products used for continuous replacement therapy was a fluid composed of red blood cells(2 units), fresh frozen plasma (2 units), and normal saline(500 ml). The pharmacological therapy was performed by comparing TEG of untreated blood and blood treated with antifibrinolytic and heparin neutralizing agent. Based on the findings of TEG, platelet concentrates were given. The TEG samples were obtained at various intervals. Additional TEG tracing was obtained as needed to see the effect of therapeutic intervention. RESULTS: In all patients the reaction time was kept in an acceptable range in the preanhepatic stage by administration of the mixture of blood products. Heparin-induced anticoagulation was observed in 3 cases in the anhepatic stage and in 11 cases upon reperfusion. Fibrinolysis was seen in all but one patients: 8% in the preanhepatic stage, 41% in the anhepatic stage, 69% at reperfusion, and 2% in the postanhepatic stage. Early and aggressive treatment with epsilon-aminocaproic acid effectively inhibited fibrinolysis without complications. Ten patients needed platelet transfusion in the postanhepatic stage with significant improvement in the TEG. CONCLUSIONS: The results of this study suggest that TEG monitoring and TEG-guided replacement and pharmacological therapy are clinically effective in maintaining blood coagulability.

Peripheral Cholangicoarcinoma

Peripheral cholangiocarcinoma (PCC) is defined as a malignancy of intrahepatic bile duct presenting as a focal liver mass, specifically, those located peripheral to the 2nd-order branchings of the bile duct. During the study period of 11 years from Jan. 1985 through Dec. 1995, a total of 12 patients underwent liver resection for PCC at the Department of Surgery, Inje University Paik Hospital, Seoul. This figure accounts for 8.3% of primary liver cancer. There were 9 men and 3 women with a ratio of 3:1, the mean age was 53.3 years with a range of 39 to 67 years. Twenty-five per cent of the patients had concomitant intrahepatic stone (IHS). HBsAg was positive in one case (8.3%) who had chronic hepatitis. No patient had liver cirrhosis. The accurate preoperative diagnosis of PCC in 3 cases was difficult because of the association with IHS. These 3 patients underwent surgery under the diagnosis of chronic cholangitis rather than PCC. CEA and CA 19-9 were elevated in 70% and 50% of the patients, respectively. In most cases concomitant measurement of CEA and AFP facilitated the differentiation between PCC and hepatocellular carcinoma. As to the tumor characteristics, 83% of the patients had tumors greater than 5 cm in diameter, indicating the advanced stage of the tumor at the time of resection. The site of origin of tumor mass was distributed more or less evenly between the hepatic lobes. The patients with mass-forming, expanding type of tumors made up 58% of the cases, infiltrating type 25%, and the remainder being the combination of both. A significant number of patients, 27%, had nodal metastasis. Two thirds of the patients underwent major hepatic resections. Segmentectomies here include the resection of lateral segment done as a treatment for IHS, which later proved to be cancer on histologic examination. There was no operative death among the 12 patients. The overall median survival time was 12 months. The overall survival rates at 1, 3, and 5 years were 42.4%, 42.4%, and 42.4%, respectively. Only the radicality of the resection was the statistically significant risk factor for survival by univariate analysis. The 5-year survival rate was 100% in 6 patients who had curative resection (no lymph node invasion, no peritoneal seeding, clear resection margin). The prognosis of patients with advanced PCC is unfavorable unless the tumor is entirely removed. In view of the association of IHS in a significant portion of the cases, the possible coexistence of the carcinoma should always be borne in mind when dealing with patients with IHS.

Primary Sarcomas of the Liver

Primary hepatic sarcomas are uncommon, representing less than 1% of the primary malignant lesions of the liver. Three patients underwent resection for primary hepatic sarcoma at the Department of Surgery, Inje University Paik Hospital, Seoul: a 6 year-old girl with malignant mesenchmoma, a 74 year-old man with malignant fibrous histiocytoma and a 53 year-old man with rhabdomyosarcoma. Abdominal mass, fever with chills, and abdominal pain were the presenting symptoms, respectively. The patient with rhabdomyosarcoma was positive for HBsAg and had chronic active hepatitis. AFP level was elevated in this patient. CA 19-9 level was elevated in the patient with malignant fibrous histiocytoma. CEA levels were normal in all cases. All these tumors were hypodense on computed tomography. Malignant mesenchymoma was hypovascular and rhabdomyosarcoma was hypervascular on angiography. Immunohistochemical stains of the tumors were positive for vimentin but negative for epithelial markers, differentiating these lesions from other hepatic tumors. Electron microscopic examination was helpful in the diagnosis of the specific type of primary hepatic sarcoma. None had postoperative adjuvant chemotherapy or radiotherapy. The patient with malignant mesenchymoma, who underwent right hepatic trisegmentectomy, was disease free at 32 months. The patient with malignant fibrous histiocytoma, who underwent non-curative excision, died of the tumor at 2 months. The patient with rhabdomyosarcoma, who underwent posterior segmentectomy, was alive at 4 months. Resection of primary hepatic sarcoma should be executed if feasible, with potential survival measured in years, in view of the lack of other effective treatment modalities.

Surgical Treatment of Stage IV Hepatocellular Carcinoma

This study was conducted to clarify the strategy of surgical treatment for stage IV hepatocellular carcinoma (HCC), for which no effective treatment modality is present so far. There were 29 patients (20.3%) with stage IV HCC among 143 HCC patients who underwent partial liver resection during the period from Jan. 1985 through Jul. 1996 at our department. The mean age was 53 years with a range of 18 to 76 years. There were 23 men and 6 women with a ratio of 4:1. Positive rates for HBsAg and HCV Ab were 55.2% and 12.5%, respectively. Ninety per cent of the patients were complicated by chronic liver disease. Abdominal pain and/or mass were the predominating symptoms in about 60% of the patients. Serum AFP level was elevated above 20 ng/ml in 72.4% of the cases. Twenty-three patients harbored stage IV-A disease and 6 patients IV-B disease. The main surgical procedures used in the cases were trisegmentectomy in 3, lobectomy in 12, segmentectomy in 12, subsegmentectomy in 1 and wedge resection in 1. Additionally wedge resection of the liver was performed in 6 cases and ethanol injection in 9 cases. Among 11 cases with tumor thrombus in large portal veins, successful tumor thrombectomy was conducted in 7 of them. Out of 22 patients with stage IV-A HCC, complete tumor removal was possible in 8 and ethanol injection into the residual tumor was executed in another 6. The mean operation time was 282 minutes and the mean transfusion 4 pints. Four patients (13.8%) suffered from postoperative complications, 2 of whom succumbed to liver failure 2 months postoperatively. The cumulative survival rates at 1, 2, and 3 years after surgery were 33.5%, 15.7%, and 10.5%, respectively, with a median survival time of 10 months. The longest survivor is alive 58 months after surgery. Significant prognostic factors were gross portal vein thrmobosis, invasion into adjacent tissues, tumor rupture, and the development of complications. In particular, the survival of patients with stage IV-A HCC who underwent complete tumor removal was not statistically different from that of those who had an absolute noncurative operation plus intraoperative ethanol injection into the residual tumors. For stage IV-A HCC surgical treatment is considered to be effective when all the tumors can be removed or when the residual tumors can be treated by intraoperative ethanol injection.

Intraoperative ultrasonographic imaging of the left and middle hepatic veins

No abstract available.

Orthotopic Liver Transplantation in Dogs by Veno - venous bypass using Centrifugal Pump / 대한마취과학회지

The Orthotopic liver transplantation for the terminal liver diseases has been performed frequently since the introduction of new immuno-suppressive agent (cyclosporin A), technical advances in surgical skill, uae of biopump during anhephatic stage, rapid infusion system for transfusion and thromboelastography for coagulopathies were used. In Korea, only one case of orthotopic liver transplantation succeeded in 1988, but the animal experiments have been going on for many years in many institutes. Orthotopic liver transplantation in dogs using centrifugal pump (Bio-pump) were experienced and the results were analysed; 1) There were no differences in hemodynamic parameters during anhepatic stage with assistance of Biopump compared with preanhephatic stage. 2) The mean flow rate of Biopump during anhepatic stage was 0.75+/-0.09L/min, and maximun and minimum flow rate were 1.5L/min. and 0.4L/min, respectively. 3) Mean artery pressure, cardiac output and systemic vascular resistance after reperfusion of transplanted liver were significantly reduced compared with the values of before reperfusion; meanwhile, mean pulmonary artery pressure, pulmonary capillary wedge pressure and pulmonary vascular resistance were not significantly different. 4) After reperfusion of transplanted liver serum potassium level was significantly increased to 6. 07+/-1.8 mEq/L and the amount of base was significantly decrease to-12.9+/-5.9 mEq/L. By using Bio-pump the degree of hemodynamic changes could be reduced during the clamping of inferior vena cava and hepatic vein.