Common Bile Duct Angiosarcoma / 대한췌담도학회지

Angiosarcoma is a very rare form of neoplasm derived from soft tissue. It is reported even more rarely in hepatobiliary system. Because of its nonspecific symptoms and difficulty in diagnosis, angiosarcoma is often presented in a progressed state and often results in poor prognosis. To our best knowledge, there has been no report regarding angiosarcoma in common bile duct worldwide. We report a case of 77-year-old-woman presented with right upper abdominal pain diagnosed as angiosarcoma in common bile duct.

Gastric Bleeding Arisen in a Patient with Situs Inversus Totalis and Large Accessory Spleen

Situs inversus totalis is a rare congenital disorder, which is total transposition of thoracic and abdominal organs. Its incidence is 1 in 10,000~50,000 live births. This might be associated with multiple abnormalities such as accessory spleen, asplenia, intestinal malrotation and so on. For this reason, in cases of operation in patients with situs inversus totalis, we need to scrutinize the presence of accompanied anomalies. Moreover, if Dieulafoy gastric bleeding has occurred, vascular anomalies can be accompanied. This 31-year-old male patient with situs inverses totalis was admitted to our hospital for management of UGI (upper gastrointestinal) bleeding. Gastroendoscopy revealed Dieulafoy disease in the upper body of the stomach as the cause of UGI bleeding. Several attempts with endovascular embolization and hemoclips were applied but failed. We performed a suture & ligation of the Dieulafoy lesion as well as total resection of accessory spleen with devascularization of prominently developed vessels around the upper stomach. We report this case with a review of the literature.

Leiomyosarcoma of the Inferior Vena Cava Mimicking Right Adrenal Tumor

The most frequent tumor arising from retroperitoneum is sarcoma. Most sarcomas of retroperitoneal origin have no symptoms and comprise 15% of all sarcomas. However, they can grow so great as to cause pain, which implies the possibility of invasion to adjacent organs. Moreover, if its location is between right adrenal gland and inferior vena cava (IVC) ambiguity of its origin can arise. Leiomyosarcoma of IVC is so rare that it can be seen to mimic right adrenal tumor. This 56-year-old female patient with back pain since approximately 4 months prior was transferred to our hospital via local clinic. We performed radical resection of tumor including segmental resection of IVC. Final diagnosis was leiomyosarcoma of IVC. We report this case with a review of literature.

Surgical Clip Moved into the Extrahepatic Bile Duct after Laparoscopic Hepatectomy / 대한내시경복강경외과학회지

In the case of using surgical clips for division of the cystic duct during laparoscopiccholecystectomy, surgical clip migration into the common bile duct is known to be an extremely rare complication. However, its mechanism is currently unclear. The incidence of performing laparoscopic hepatectomy has significantly increased in the laparoscopic center of hospitals. Accordingly, the complications associated with using clips in laparoscopic cholecystectomy have increase as well. A 49 year-old female patient underwent laparoscopic left hepatectomy due to left intrahepatic duct stones with cholangitis. We report here on a case of a clip that migrated into the common bile duct and the duct had bile stones. We also review the relevant literature.

Synchronous Double Primary Cancer of the Stomach and Duodenum

The concern about multiple primary cancers has been raised in recent years, but their cause has yet to be elucidated clearly. It has been speculated that many factors may contribute, such as family history, genetic factors, chemotherapy, and radiotherapy.(1) The incidence of multiple primary cancers is estimated to be 13%. However, synchronous multiple primary cancers of the stomach and duodenum are uncommon due to the rarity of duodenal cancer. Duodenal cancer poses diagnostic difficulties because of its rarity, non- specific signs and symptoms, and the fact that duodenum is usually ignored during upper gastrointestinal endoscopy. This 71-year-old female patient was diagnosed with double primary cancer of the stomach and duodenum, which was found by abdominal computed tomography preoperatively, and she underwent a Whipple procedure. The histological diagnosis revealed poorly-differentiated adenocarcinoma in the stomach and moderately-differentiated adenocarcinoma in the duodenum. Here we report a case of synchronous double primary cancer of the stomach and duodenum with a review of the literature.

Primary Hepatic Tuberculoma Associated with Intrahepatic Duct Stones and Abscess

Tuberculosis is a systemic disease that can occur anywhere in body. Its incidence is various according to the organ or location, and TB in an organ where the general incidence is rare causes so many unexpected symptoms and complications that physicians can sometimes be baffled when attempting to make a diagnosis. If this rare occurrence of TB in an unusual location results in non-specific symptoms, then it is important not to overlook the possibility of tuberculosis. Hepatic tuberculosis is mainly a secondary type of disease that has disseminated from the lungs or other organs. Because a primary TB focus in the liver is rare, in the case in which the lung or other organs have no tuberculosis, it is extremely difficult to arrive at the proper diagnosis of primary hepatic tuberculosis. The authers experienced a case of primary tuberculous granuloma that was associated with intrahepatic duct stones and abscess. This patient was first diagnosed as suffering with intrahepatic duct stones and abscess only. We discovered the associated tuberculous granuloma of the liver by histologic examination after hepatectomy. We report on this case with a review of the relevant literature.

Clinical Analysis between the Endoscopic Thyroidectomy and the Open Thyroidectomy during the Same Period

PURPOSE: We peformed endoscopic thyroidectomy and open thyroidectomy during the same period. In this study, we analyzed the result (merits and demerits) between endoscopic procedure and open procedure. METHODS: From Aug. 2003 to Aug. 2004, each procedure was performed in 92 patients. Conventional open thyroidectomy was underwent in 50 patients and endoscopic thyroidectomy was underwent in 42 patients. We performed the endoscopic thyroidectomy using breast approach. The 2 incisions, which could use 12 mm ports were placed on the areolar area of the breast as a circumferential fashion. The remaining 1 incision, which could use 5 mm port was placed on the right subclavicular area, 3~4 cm below right clavicle. We used 25 degree, a rigid laparoscope with 5 mm Hg of CO2 insufflation pressure. We also compared the results of mean ages and sex ratio, pathologic diagnosis, extent of operation, mean hospital day, mean operation time between open surgery group and endoscopic thyroidectomy group. RESULTS: We found that the mean age in the endoscopic group was younger, inversely the operation time was longer than in the open surgery group significantly (P0.05). The endoscopic group in the aspect of cosmetic was satisfactory. CONCLUSION: We could perform the endoscopic thyroidectomy safely and feasibly. The endoscopic surgery was cosmetically satisfactory. We expect it can increase the extent of surgery.

Double Primary Cancer of the Gallbladder and the Ampulla of Vater in Association with Adenoma-Carcinoma Sequence

An adenoma is a rare benign tumor arising in the extra-hepatic biliary duct. Adenocarcinomatous changes are often observed in the background of an adenoma. Double or triple cancer with an adenoma and adenocarcinoma in the biliary tract can be the crucial evidence of the adenoma-carcinoma sequence. We first performed laparoscopic surgery on a 63-year old male patient complaining of pain in the right upper quadrant of the abdomen and jaundice a week earlier, which was initially diagnosed by a radiologist as a sessile polyp of the gallbladder along with stones in the gallbladder and the common bile duct. A mass was found in the distal common bile duct and ampullary area during intraoperative choledochoscopy. The frozen sections taken during surgery indicated a cancer or dysplasia in the gallbladder and the distal common bile duct. The patient underwent a pylorus-preserving pancrea-toduodenectomy. The final diagnosis was a double primary can-cer originating in the gallbladder and the ampulla of Vater with an adnocarcinoma in an adenoma. We report this case with review of the relevant literature.

The Safety and Feasibility of Laparoscopic Exploration of Common Bile Duct and Choledochoscope in the Magagement of Patients with Choledocholithiasis

PURPOSE: Traditionally, the main treatment for common bile duct (CBD) stones and gallstones is ERCP combined with a laparoscopic cholecystectomy (LC). However, this procedure is generally performed in 2 stages, which makes the patients uncomfortable and unsatisfied. It also can result in the need for several procedures if it fails, and sometimes the surgery is warranted. Recently in the laparoscopic era, the laparoscopic skill has been developed quite rapidly. In the case of CBD stones, there are many reports involving laparoscopic procedures. We reviewed the safety and feasibility of removing CBD stones using a laparoscope and choledochoscope. METHOD: This retrospective study reviewed 40 cases who underwent a laparoscopic cholecystectomy and choledocholithotomy for bile duct stones between Feb. 2002 and Aug. 2004. RESULTS: Of the 40 patients who underwent the laparoscopic procedure, 25 were combined with gallstones, and 12 underwent the transcystic duct approach. The average operation time and average hospital stay was 141.2 mins and 11.3 days, respectively, and the average age was 69.4 year old. There was 1 case of a major complication, where bile leakage occurred for more than 14 days due to a shincter stenosis. This case was improved by an endoscopic sphincterotomy. Of them, 30 underwent a primary closure and 8 underwent T-tube drainage, 2 underwent a biliary stent. CONCLUSION: The laparoscopic cholecystectomy and choledocholithotomy using a choledochoscope are quite safe and feasible, can reduce the patient's anxiety, and increase their level of satisfaction.

Hepatocellular Carcinoma with Jaundice Caused by the Obstruction of Hepatic Hilum

The most causes of an icteric hepatoma are a late stage hepatocellular carcinoma or intrahepatic cholangiocarcinoma. A hepatocellular carcinoma, causing an obstrucution of the bile duct, rarely results in jaundice. With a late stage hepatocellular carcinoma, the accurate diagnosis and treatment may be difficult. Herein, we report a case of a hepatocellular carcinoma and obstructive jaundice, due to hilar tumor emboli, with a review of the literature.

A Case of Hepatocellular-cholangiocarcinoma Invading the Gallbladder / 대한간학회지

Metastasis of hepatocellular carcinoma occurs at a relatively late stage of the disease. Hematogenous and lymphatic metastases are the most common routes for dissemination of tumor cells. Hepatocellular carcinoma also extends into the adjacent portal vein and bile ducts. Since there is no peritoneum between the body of the gallbladder and the liver fossa, gallbladder cancer can easily cross the boundary. Gallbladder invasion of hepatocellular carcinoma, however, is quite rare. We report a case of hepatocellular- cholangiocarcinoma in a non-cirrhotic liver that invaded the gallbladder mimicking the gallbladder carcinoma complicated by cholecystitis and liver abscess.

A case of large cell neuroendocrine carcinoma of gallbladder presenting with pyogenic liver abscess / 대한내과학회지

Pyogenic liver abscess is a rare but highly lethal disease. The diagnosis and treatment of pyogenic liver abscess has been evolving owing to specific antibiotic therapy, ultrasonography, abdominal computed tomography with improved percutaneous and operative techniques. However, pyogenic liver abscess may present as a rapidly fatal outcome. These unfavorable results are mainly attributed to the increasing numbers of patients with malignant disease and biliary tract disease. Carcinoma of the gallbladder has remained an uniformly fatal neoplasm characterized by early metastasis and rapid fatal course. In early stage, the symptom is nonspecific and often mimics benign biliary tract disease. We experienced a case of the gallbladder carcinoma presenting with pyogenic liver abscess in a 78-year-old female patient. Surgical drainage and cholecystectomy were done. The microscopic finding of resected gallbladder revealed large cell neuroendocrine carcinoma of gallbladder.

A case of gastric variceal bleeding associated with pancreatic endocrine tumor in the pancreas tail / 대한내과학회지

Isolated obstruction of the splenic vein leads to segmental portal hypertension, which is mainly originated from pancreatic disease, such as chronic pancreatitis, pancreatic pseudocyst, pancreatic cancer. The clinical manifestation are devoid of ascites and encephalopathy, but presented with gastric variceal bleeding. We experienced 27-year-old male patient who complained of hematochezia and melena. After work-up with CT and angiography, we performed operation with the impression of pancreatic tumor associated with splenic vein occlusion. It resulted nonfunctioning pancreatic endocrine tumor. Often called islet cell tumor, pancreatic endocrine tumor has various names according to secreted hormones, such as insulinoma, Zollinger-Ellison syndrome and glucagonoma. It was classified as nonfunctioning tumor if there were any evidence of hormone secretion by radioimmunoassay and immunohistochemistry. Surgical excision and adjuvant medical therapy is the mainstay of therapy. We performed tumor resection and splenectomy for control of gastric variceal bleeding due to splenic vein occlusion.

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.

Localization of an Insulinoma by CT-Angiography

Insulinomas are the most common type of islet cell tumor. Generally, these tumors are benign (90%), intrapancreatic, solitary, and small (measuring less than 2 cm), and they occur throughout the head, body, and tail of the pancreas with equal frequency. The methods for diagnosing an insulinoma involve whipples triad and biochemical test by a monitored 72-hour test. The diagnosis is obtained by blood for glucose and insulin, C-peptide samples taken every 4 to 6 hours during the test, particularly when symptoms develop, and calculation of the insulin to glucose ratio. Preoperative radiographic localization of islet cell tumors in patients with insulinomas is important to remove the tumor adequately. A 43-year-old man with dizziness, sweating, and loss of consciousness twice in a period of 2 years was hospitalized with clinical suspicion of an insulinoma. The findings of computed tomography,and transabdominal and endoscopic ultrasonography were all negative. Transhepatic venous sampling for a pancreatic hormone assay showed a sudden increase in the insulin level in the proximity of the head of the pancreas, however, this was not localized correctly. We report a case where insulin was found in the tail of the pancreas, as confirmed by CT-angiography , and we present a review of literature.

Synchronous Biliary Tract Cancers in a Patient with von Recklinghausen Disease

Von Recklinghausen's disease (VRD) is known to be associated with various neoplasms of both neural crest and nonneural crest origin. Approximately 25% of all patients with VRD have documented gastrointestinal involvement. However, most of these tumors are benign neurofibromas. Less commonly, leiomyomas, sarcomas, ganglioneuromas and carcinoids have been reported. We report two cases of synchronous biliary cancer (gallbladder & ampulla of Vater) in patients with von Recklinghausen Disease with jejunal stromal tumors. One case (F/39) was diagnosed as an adenocarcinoma of Vater's ampulla and adenoma of the gallbladder. She underwent a pancreaticoduodenectomy. Another patient (M/55) was diagnosed as an adenocarcinoma of the Vater's ampulla and squamous cell carcinoma of the gallbladder. He underwent a right lobectomy of the liver and a pancreaticoduodenectomy (HPD).

Pancreatic Mucinous Ductal Ectasia A clinical study of four patients

Four cases of mucinous ductal ectasia of the pancreas are presented, along with a review of the literature. Mucinous ductal ectasia is a clinicopathologic entity characterized by dilation and filling of the main pancreatic duct or its side branches with thick, viscid mucus, leading to recurrent acute pancreatitis or symptoms that mimic chronic pancreatitis. Three of the patients were male (M:F=3:1) and the patients were 54~74 years old. The symptoms of two patients were abdominal pain and they had a frequent admission history due to pancreatitis. One patient had jaundice, and one patient presented no symptoms. In all of the patients, the tumor was located in the read of the pancrease and the size of tumor was about 3 cm. A total pancreatectomy was performed, and three pancreatico-duodenectomy were performed. The pathologic report revealed that two cases were malignant and two cases were borderline malignant. The tumor marker did not correlate with the presence of malignancy. Because mucinous ductal ectasia is recognized as a premalignant disease, the treatment of choice is pancreatic resection.