Post-transplant Amputation Traumatic Neuroma of the Hilum and Extrahepatic Duct in a Liver Donor

No abstract available.

Synchronous Peripancreatic Lymph Node Gastrinoma and Gastric Neuroendocrine Tumor Type 2

A 34-year-old man was referred to our hospital with gastric polypoid lesions and biopsy-confirmed neuroendocrine tumor (NET). Computed tomography (CT) revealed a 3×3.5×8-cm retroperitoneal mass behind the pancreas, with multiple hepatic metastases. His serum gastrin level was elevated to 1,396 pg/mL. We performed a wedge resection of the stomach, a right hemi-hepatectomy, and a retroperitoneal mass excision. After careful review of the clinical, radiological, histopathological, and immunohistochemical findings, peripancreatic gastrinoma, and synchronous gastric NET were ultimately diagnosed. We reviewed a CT scan that had been performed 6 years previously after surgery for a duodenal perforation. There was no evidence of gastric or hepatic lesions, but the retroperitoneal mass was present at the same site. Had gastrinoma been detected earlier, our patient could have been cured using less invasive treatment. This case demonstrates how important it is to consider Zollinger-Ellison syndrome in patients with a recurrent or aggressive ulcer.

A Case of Superior Mesenteric Artery Aneurysm Mimicking an Abdominal Aortic Aneurysm and Presenting as a Pulsating Abdominal Mass

A 62-year-old male with a smoking history of 30 pack-years presented with a 1-year history of a periumbilical pulsating mass. He had been treated for hypertension for 2 years. Physical examination revealed a huge pulsating mass in the periumbilical abdomen. Femoral and popliteal arterial pulses were palpable. Computed tomography showed arterial dissection in the proximal segment of the superior mesenteric artery, a huge aneurysm (52×50 mm) with mural thrombus and two smaller aneurysms (20×20 mm) in the right ileocolic and ileal branches, along with atherosclerotic changes. Interposition using the great saphenous vein was performed after aneurysmal isolation and ligation of jejunal branches in the sac. Distal flow was reestablished by end-to-end and end-to-side anastomoses of the right ileocolic and ileal branches, respectively. No complications were observed at 1-year follow-up.

The Analysis of Prognostic Factors Affecting Survival in Liver Transplantation: A Single Institution Experience / 대한이식학회지

BACKGROUND: Liver transplantation is considered as the most powerful modality for patients with acute on chronic liver failure and fulminant hepatic failure. The aim of this study is to identify potential prognostic factors that may affect survival after emergent liver transplantation. METHODS: A total of 42 patients who underwent emergent liver transplantation at Gachon University Gil Medical Center from June 2005 to May 2013 were enrolled. The clinical scoring system analyzed for this study were as follows: Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), Model for end-stage liver disease with incorporation of serum sodium (MELD-Na), Acute physiology and chronic health evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA). RESULTS: Preoperative SOFA and APACHE scores were closely related with patient's survival after the operation. Also, the changed value of SOFA while patients waited for their transplantation showed to be significant. In a univariate analysis, serum bilirubin and Glasgow Coma Scale (GCS) showed statistical significance for patient's prognosis. Several factors, such as the use of mechanical ventilator and inotropic agent for treating multiple organ failure were also important. The central nervous system and cardiovascular scores showed an intimate relation with the survival group by a more detailed analysis in SOFA. In a multivariate analysis, SOFA and bilirubin levels affected patient's survival. CONCLUSIONS: In emergent liver transplantation with acute on chronic liver failure and fulminant liver failure, recipient's hepatic function is an important factor along with the donated liver condition l eading to successful operation. Also, it is important to pay attention to the progression of organ failure in predicting the prognosis.

Clinical Analysis and Proper Management of the Patients Visited ER Due to Ingested Foreign Body: Single Center Experience

PURPOSE: The conventional treatment for ingested foreign bodies (IFB) is removal, which is successful in most cases. However, it can be associated with severe complications, such as gastrointestinal tract perforation, and require emergency surgery. The aim of this study is to analyze clinical data relating to IFB and to develop a proper management plan to reduce the incidence of severe complications. METHODS: Between September 2001 and September 2009, 117 patients visited the emergency room complaining of IFB. Among these patients, 29 were diagnosed with bezoar and were excluded from the study. Medical data for the remaining 88 patients was reviewed retrospectively. For statistical analysis, the foreign bodies (FB) were classified into three subgroups according to their shape (round, sharp, and amorphous). RESULTS: The median age of patients with IFB was seven years, and the male-to-female ratio was 1.3:1. Many of these patients were preschool children under the age of seven who had accidentally sw allowed FB (56 cases, 63.6%). The most common symptom presented among the patients was FB sensation (18 cases, 21%). The results of subgroup analysis showed no significant relation between the shape of the FB and the treatm ent m odality. Spontaneous passage was observed in 21 cases (23.9%). Otherwise, endoscopic removal was performed successfully in 61.4% of cases, and 13 patients required emergency operations (14.8%). CONCLUSION: Early diagnosis and a prompt approach are significant in the successful treatment of IFB. Endoscopic or surgical procedures are sometimes required, particularly in cases where complications are suspected.

The Analysis of Prognostic Factors in Patients with Decompensated Liver Cirrhosis Admitted to the Medical Intensive Care Unit / 대한구급학회지

BACKGROUND: Patients with decompensated liver cirrhosis usually resulted in admission to the intensive care unit (ICU) during hospitalization. When admitted to the ICU, the mortality was high. The aim of this study is to identify multiple prognostic factors for mortality and to analyze the significance of prognostic survival model with each scoring system in patients with decompensated liver cirrhosis who was admitted to the ICU. METHODS: From January 2008 to December 2008, 60 consecutive patients with decompensated liver cirrhosis were admitted in the ICU and retrospectively reviewed. Prognostic models used were Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), model for end-stage liver disease with incorporation of serum sodium (MELD-Na), acute physiology and chronic health evaluation (APACHE) II, and sequential organ failure assessment (SOFA). The predictive prognosis was analyzed using the area under the receiver's operating characteristics curve (AUC). RESULTS: The median follow up period was 20 months, and ICU mortality was 17% (n = 10). A total of 24 patients (40%) died during the study period. The average survival of five prognostic models was related with the severity of the disease. All of the five systems showed significant differences in the cumulative survival rate, according to the scores on admission, and the MELD-Na had the highest AUC (0.924). Multivariate analysis showed that bilirubin and albumin were significantly related to mortality. CONCLUSIONS: The CPT, MELD, MELD-Na, APACHE II, and SOFA may predict the prognosis of patients with decompensated liver cirrhosis. The MELD-Na could be a better prognostic predictor than other scoring systems.

Factors influencing hepatocellular carcinoma prognosis after hepatectomy: a single-center experience

BACKGROUND/AIMS: Recurrence after hepatic resection is one of the most important factors impacting the prognosis and survival of patients with hepatocellular carcinoma (HCC). We identified prognostic factors affecting overall survival (OS) and disease-free survival (DFS) in patients with HCC after hepatic resection. METHODS: This study was of a retrospective cohort design, and 126 patients who underwent hepatic resection for HCC at Gachon University Gil Medical Center between January 2005 and December 2010 were enrolled. Various clinical, laboratory, and pathological data were evaluated to determine the prognostic factors affecting OS and DFS. RESULTS: Two- and 4-year OS and 2- and 4-year DFS were 78.1% and 65% and 51.1% and 26.6%, respectively. In a multivariate analysis, preoperative alpha-fetoprotein (> 400 ng/mL), tumor size (> or = 5 cm), multiple tumors (two or more nodules), presence of portal vein invasion, modified Union for International Cancer Control (UICC) stage III/IV, and Barcelona Clinic Liver Cancer (BCLC) stage B/C were independent prognostic factors affecting a shorter OS. In the multivariate analysis, presence of microvascular invasion, modified UICC stage III/IV, and BCLC stage B/C were independent prognostic factors for a shorter DFS. CONCLUSIONS: The presence of vascular invasion was an independent poor prognostic factor for OS and DFS in patients with HCC after hepatic resection. Thus, close postoperative surveillance for early detection of recurrence and additional treatments are urgently needed in patients with vascular invasion after hepatic resection.

Treatment of Hepatocellular Carcinoma with Drug-eluting Beads Chemoembolization and Liver Transplantation / 대한소화기학회지

No abstract available.

Hepatic Arterial Complications after Liver Transplantation: A Single-Center Experience / 대한이식학회지

BACKGROUND: We wanted to explore performing hepatic arterial reconstruction in living donor liver transplantation (LDLT) using right lobe liver grafts and cadaveric liver transplantation (CLT) in a single center. METHODS: Thirty five LDLTs were performed from April 2005 to August 2009. The back wall support suture without twisting was used in most cases. A single RHA was anastomosed to the RHA in 24 patients, to the proper HA in 2 patients, to the RAHA in 4 patients, to the LHA in 2 patients and to an aberrant RHA arising from the SMA in 3 patients. The diameter of the donor RHA was between 1.5 mm and 3.0 mm (mean: 2.5 mm). In the 34 patients who underwent CLT, most of the arterial anastomoses were usually performed using two cuffs at the recipient HA and the GDA bifurcation and a branching point on the donor CHA with running and intermittent stay suture. RESULTS: The total incidence of HA complication was 4.34% (3/69): 1 HAT (2.85%) occurred in a case of LDLT and 2 HAS (5.88%) occurred in a case of CLT. HAT occurred in 1 recipient on the 1st day following LDLT and 2 HAS occurred in CLT recipients at one and two months, respectively, following LDLT. CONCLUSIONS: HA complications occurred as a mild type of late complication and these complications might not be fatal in CLT. A low incidence of HAT can be achieved with using non-twisting method-guided microsurgical techniques for creating hepatic arterial anastomosis in LDLT. When early HAT occurs, early surgical reconstruction is mandatory for preventing the loss of the graft. Back wall sutures with only single needle suture might be a feasible method for HA microsurgical reconstruction.

Splenic Abscess: A Single Institution Study and Review of the Literature

PURPOSE: The aim of this study was to review our experience with splenic abscesses, with respect to the relevant aspects of splenic abscesses and treatment outcomes. MATERIALS AND METHODS: We reviewed the cases of 18 patients who had splenic abscesses and who were treated at our hospital from November 1993 to December 2008. RESULTS: The most common symptom at presentation was abdominal pain in 12 patients (66.7%). The median duration from symptom onset until establishment of a diagnosis was 22 days. Streptococcus viridians was the most common pathogen (27.8%), follow by Klebsiella pneumoniae (22.2%). The mortality rate during the inpatient period and the previous 90 days was 16.6%. Three of four patients with Klebsiella pneumoniae showed a single abscess pocket. Four patients (22.2%) underwent percutaneous drainage, eight (44.5%) recieved antibiotic treatment only and six (33.3%) underwent splenectomy. CONCLUSION: There is no gold standard for treating splenic abscesses. Treatment should be customized for each patient.

Clinical Feature of Iatrogenic Fistulas between Prosthetic Graft and Native Vein in CRF Patients

PURPOSE: Failure of hemodialysis access is the main medical problem in chronic renal failure patients. This resulted from complications such as thrombosis, infection, pseudoaneurysm, steal syndrome and so on. This study was undertaken in an attempt to describe the clinical characteristics and significances of dialysis failure due to iatrogenic fistula between prosthetic graft and native vein at puncture site. METHODS: During 5 years between Feb. 2005 and Feb. 2009, five Iatrogenic fistulas were identified in a retrospective review of 133 patients performed 220 times fistulography due to dialysis failure in PTFE (polytetrafluoroethylene) graft. RESULTS: Overall incidence is 3.8 % in PTFE graft cases. Mean age is 50 (28~75) years, male to female ratio 2:3. Median 1st patency period is 20 months (6~36). All iatrogenic fistula is usually located in not venous but arterial limb of forearm loop, combined with the stenosis in venous limb and anastomosis site. More than 70% venous anastmotic stenosis in 4 cases (80%) and diffuse stenosis of venous limb in 3 cases (60%), revised concomitantly either by patch angioplasty or ballooning. Medial follow-up period is 8 months (5~12), graft occlusion occurred in one case. CONCLUSION: All iatrogenic fistula usually occurs in not venous but arterial limb of forearm loop graft. Most iatrogenic fistula is combined with the stenosis in venous limb and anastomosis sites, must be revised concomitantly either by patch angioplasty or ballooning. Close assessment to superficial vein and graft is needed for early detection. Fistulography is the most useful diagnostic tool. Careful cannulation method is required to prevent the occurrence of iatrogenic fistula in chronic renal failure patients.

Acute Abdominal Aortic Dissection after Blunt Trauma: Report of 2 Cases

Abdominal vascular injury after blunt trauma does not occur very frequently. Penetrating trauma is the most common cause (90%) of abdominal vascular injury. A 57-year-old male presented with abdominal pain and color change of the right lower leg after blunt trauma. The physical examination showed rigid tenderness in the entire abdomen and no pulse in the right femoral artery. Computed Tomography (CT) demonstrated the acute aortic dissection, which extended from the infrarenal aorta to the iliac artery and there was embolic occlusion below the right common iliac artery. He underwent endarterectomy after thrombectomy, fasciotomy and small bowel segmental resection. A 65-year-old male presented with abdominal pain after an auto-bicycle crash. On the physical examination, there was tenderness and rebound tenderness noted on the entire abdomen. The CT done outside our hospital demonstrated an intramural hematoma around the descending aorta. He underwent small bowel and sigmoid segmental resection and S-colostomy. On day 1 after operation, he complained of sudden abdominal pain. He then developed the signs of acute liver and renal failure. His condition deteriorated rapidly with conservative management, and he died on day 2.

Saphena Varix Mimicking Femoral Hernia

Saphena varix is very rare disease that characterized by isolated distention of the saphenous vein below the sapheno-femoral junction. Saphena varix must be differentiated from other medical problems that can cause a groin mass. A 49-year-old man presented with a palpable mass on the right upper thigh and he'd had the mass for 6 months. There was no history of trauma, and the mass was especially noticeable when he was standing. On the physical examination, a 5 cm-sized soft, nontender, compressible mass was detected at the right upper medial thigh near the femoral foramen. Doppler sonography showed a saccular venous dilatation of the great saphenous vein just below the saphenofemoral junction. On computed tomography, there were superficially dilated veins in the right thigh and calf, a focal saccular aneurysm at the proximal segment of the right greater saphenous vein and no evidence of deep vein thrombosis. Aneurymal excision and stripping of the greater saphenous vein were performed. No complication was observed at the 2 week follow-up.

Surgical Technique of Biliary Reconstruction in Adult-to-Adult Living Donor Liver Transplantation: Survey of 9 Major Centers in Korea

PURPOSE: Despite refinements in the surgical techniques for adult-to-adult living donor liver transplantation (ALDLT), biliary complications still remain the Achilles' heel of ALDLT. Moreover, there is no consensus for the ideal technique of biliary reconstruction to reduce the rate of complications to an acceptable range. We strove to collate the available data of the current surgical techniques for biliary reconstruction in ALDLT in Korea. METHODS: A questionnaire concerning the surgical techniques for biliary reconstruction was sent to 9 surgeons who performed biliary anastomosis in the major LDLT centers of Korea (the response rate was 100%). RESULTS: MR cholangiography (n=7) and/or intra-operative cholangiography (n=5) were routinely performed to evaluate the donor biliary anatomy. All the participants (n=9) preferred duct-to-duct anastomosis to hepatico-jejunostomy. Anastomosis was usually made on the whole layer (n=7 epithelium, n=2) of recipient's common hepatic duct under loupe magnification (n=8); only one center reconstructed the anastomosis on the 2nd order hepatic duct under view of a surgical microscope. There were various techniques for biliary reconstruction as follows: suture material (absorbable: n=5, non-absorbable: n=4), suture method (continuous: n=4, interrupted: n=3, mixed: n=3) and the use of a biliary stent (routine: n=3, sometimes: n=5, rare: n=1). Ductoplasty was performed on the back table (n=7) for the cases with a very close distance (<5 mm) between the bile ducts' openings, but each duct was separately anastomosed to the recipients' bile duct (n=8) or a roux-en-Y limb (n=1) was done in cases with a distance more than 10 mm. CONCLUSION: In 9 LDLT centers of Koreas, duct-to-duct was preferred; however, there was no unique consensus, among the major centers, for the biliary reconstruction techniques that might reduce complications.

The Effect of Delayed Surgery in Adult Patients with Acute Appendicitis

PURPOSE: There are many reports that delayed operation of appendicitis in children is safe, but it is controversial whether the same principle can be applicable in adult patients. The aim of this study was to evaluate the relationship between the interval from onset of symptoms to operation and the pathologic degree of appendicitis. METHODS: In this retrospective study, 783 adult patients (16 years old or more) diagnosed with appendicitis pathologically between 2004 and 2007 were included. The time from onset of symptoms to hospital arrival (patient interval) and time from hospital arrival to operation (hospital interval) were investigated. Pathologic and gross state of the appendicitis was graded as G1 (suppurative), G2 (gangrenous), G3 (ruptured), G4 (periappendiceal abscess). RESULTS: The median time from symptom onset to operation (total interval) was 35 hours. The percentage of G1, G2, G3, and G4 was 86.3%, 11.4%, 2.4%, and 0% when total interval was <24 hours, 61.3%, 21.3%, 15.8%, and 1.6% when between 24 and 72 hours, and 23.8%, 13.9%, 36.9%, and 25.4% when the interval was over 72 hours. The advanced grade of appendicitis correlated with increased hospital stay (P<0.0001). CONCLUSION: This study suggests that delayed appendectomy in acute appendicitis in adults is a risk factor for advanced grades, and that the sooner the operation is undertaken, the better the outcome is.

Multiple Aneurysms of the Radial Artery: a Case Report

True aneurysm of the radial artery is very rare, and the false aneurysms are more common. True aneurysms of the radial artery are usually secondary to trauma or iatrogenic injury. A 71-year-old male presented with a several year history of a left forearm-pulsating mass. He suffered from a brain infarct and had received acupuncture for his hemiplegia for the previous year. The physical examination revealed two pulsating masses on the left forearm. The left ulnar and radial arteries were palpable. The laboratory values were normal. Computerized tomography showed two 40x25 and 37x20 mm-sized saccular true aneuryms containing mural thrombosis in the left proximal radial artery with atherosclerotic change. The aneurysms were resected with reconstruction by using the cephalic vein. Distal flow was reestablished by using end-to-end anastomosis. No complications have been observed during the 4 weeks of follow-up.

Liver Transplantation for Alcoholic Liver Disease: An Analysis on the Posttransplant Course and Alcoholic Relapse / 대한이식학회지

PURPOSE: Alcoholic liver disease (ALD) has been one of the most common causes of cirrhosis in Western countries, and its incidence has been increasing recently in Korea. In this study, we investigated the clinical course and outcome of liver transplantation in ALD patients with special attention to specific risk of alcohol relapse. METHODS: We retrospectively reviewed the clinical course, complication and survival of 18 ALD patients out of 807 liver transplants in Asan medical center from August 1992 to December 2003. Relapse of alcohol intake was investigated. The changes of liver function test were analyzed to clarify its relation with alcoholic relapse. RESULTS: Of these 18 patients, 2 (11%) died and 4 (22%) experienced alcoholic relapse. Alcoholic relapsers showed significant deterioration of serum AST, ALT and total bilirubin levels in acute stage comparing with non-relapsers, but such functional deteriorations resolved after recovery period of abstinence. Recipient age at the time of liver transplantation and abstinence not more than 6 months prior to transplantation were proven as significant risk factorsfor alcoholic relapse. CONCLUSION: ALD recipient revealed favorable outcome and survival following liver transplantation. To reduce the possibility of posttransplant alcoholic relapse, pretransplant abstinence more than 6 months is highly recommended. In addition, recipient of younger age should receive adequate education and strict surveillance for abstinence.

Appendiceal Mucocele

Appendiceal mucocele is a cystic dilatation of the appendiceal lumen with mucus, which may be caused by either benign or malignant diseases. In this report, five cases of appendiceal mucocele are reported, three of which had a preoperative diagnosis of mucocele, whereas the others were found incidentally during the operation under the diagnosis of intussusception and periappendiceal abscess. All five patients underwent surgical resections, including one ileocecal resection and four right hemicolectomies. Histopathology revealed a mucinous cystadenoma in four cases, and a mucinous cystadenocarcinoma in one. There was no disease-related death during 18 months of follow-up.

Clinical Review of Appendiceal Tumors (Retrospective Study of 3,744 Appendectomies or Right Hemicolectomies)

PURPOSE: This study was undertaken to describe the clinicopathologic characteristics and evaluate the appropriate management of appendiceal tumors. METHODS: During 5 years between Sep. 2000 and Sep. 2005, 28 appendiceal tumors were identified in a retrospective review of 3,744 cases of appendectomy or right hemicolectomy pathology. RESULTS: Carcinoids were found incidentally as appendicitis. Mucinous cystadenomas were common in women older than 50 aged; half of the cases presented with appendicitis and the other half presented with non-specific abdominal symptoms such as palpable mass, intestinal obstruction and intussusception. Carcinomas were common in the older patients (mean age: 62.8 years) and this presented as periappendiceal abscess. Right hemicolectomy was undertaken when there was evidence of tumor spread beyond the resection margin, and carcinoma and tumors were located in the appendiceal base. Recurrence and metastasis were identified only in the carcinoma cases. CONCLUSION: Most appendiceal tumors presented with appendicitis and periappendiceal abscess. One stage curative resection was possible in more than 76% of the patients, and the prepoperative diagnosis rate was less than 35%. The preoperative diagnosis did not have much impact on the clinical course, and the postoperative pathology was important in determining the additional treatment. Close follow-up is needed for the early detection of recurrence, and all the carcinomas that were advanced as serosal involvement, peritoneal seeding and liver metastasis.

Laparoscopic Removal of an Ingested Needle, which was Penerated to the Lesser Omentum of the Stomach

The perforation and migration of ingested sharp metallic bodies is a rare event. A perforation of the gastrointestinal tract is difficult to accurately and quickly diagnose when there is no peritonitis or abscess formation. Patients often present with no symptoms. The discovery of a foreign body on a radiological examination of the abdomen may be made incidentally. Moreover, a history of ingestion is usually difficult to obtain. Foreign bodies after perforation have been reported to migrate to any intra-abdominal site and to extra-abdominal sites in rare cases. We report one case of young man with ingested needle in which perforated silently and migrated to the lesser omentum. A 23-year-old man presented with an incidental foreign body. He has no definite ingestion history or psychiatric disorder, but was a heavily drinker. An abdominal plain X-ray showed a needle in the upper abdominal area. Computed tomography revealed the foreign body to be located beneath the liver and in the lesser omentum. The patient underwent a laparoscopic examination performed in the supine position. After creating a pneumoperitoneum by CO2 gas insufflation at 12 mmHg, 3 trochars (two 5-mm and 12-mm) were introduced at each subcostal and supraumbilical area. Surgical management using laparoscopic extraction was successful. The patient was discharged in good health on the 3rd day after the procedure. Laparoscopy can be used to remove ingested foreign bodies when surgery is indicated.