Analysis of Long-Term Survivors after Resection for Hilar Bile Duct Cancer

PURPOSE: Although considerable progress has been made in the management of hilar bile duct cancer, the long-term outlook for most patients remains poor. This study was conducted to analyze the long-term survival (more than 5 years) after resection for hilar bile duct cancer focusing on the clinicopathological factors influencing the outcome, and to develop an optimal strategy to achieve long-term survival after a resection. METHODS: A retrospective review was performed for 68 patients with hilar bile duct cancer who underwent surgical resection between 1988 and 2000. Survival rates and prognostic factors were assessed. Clinical and pathological factors of patients who survived more than 5 years were compared with patients whose survival was less than 5 years. Clinicopathological features characterizing the long-term survivors were also reviewed. RESULTS: Seventeen patients survived longer than 5 years after resection. The actual 5-year survival rate was 25.0%. Perineural invasion and resection margin were identified as independent prognostic factors. When prognostic factors were compared between the long-term and short-term survivors, tumor depth, TNM stage, perineural invasion, and resection margin showed a significant correlation with long- term survival. Long-term survivors had early TNM stages with negative lymph node metastasis and absence of perineural invasion. Six of 17 long-term survivors exhibited a positive resection margin. CONCLUSION: Long-term survivors showed characteristic features of early TNM stages with absence of perineural invasion and negative resection margin. As long-term survival can be expected even in patients with bad prognostic factors, aggressive surgical resection should be attempted for patients with resectable disease.

Hepatic Resection for Right-Sided Intrahepatic Stones

PURPOSE: Hepatic resection is generally considered as the most satisfactory treatment for patients having intrahepatic stones. Yet for cases of right-sided intrahepatic stones, role of hepatic resection is still ambiguous because of the higher operative risks that are entailed when performing surgery at that location. This report presents the results of hepatic resection for the treatment of right-sided intrahepatic stones. METHODS: Seventy-one patients with right-sided intrahepatic stones were operated on during a period of 14 years. The operative procedures executed in the patients were 40 hepatic resections and 31 biliary lithotomies. We analyzed the operative findings and the results of treatment were then compared between the two treatment groups. RESULTS: The intrahepatic bile duct changes associated with stones were cholangitis (n=16), biliary stricture (n=31), biliary dilatation (n=13), and liver atrophy (n=11). Biliary dilatation and liver atrophy were more frequently observed in patients with hepatic resection (p< 0.05). Operative complications occurred in 6.5% of patients after biliary lithotomy and in 25.0% of patients after hepatic resection. There was no operative mortality in both groups. Retained stones were found in 51.6% of patients after biliary lithotomy. There were no retained stones in patients undergoing hepatic resection. After biliary lithotomy, the rate of retained stones was higher for patients having associated bile duct strictures and dilatations (cholangitis; 18.2%, stricture; 64.7%, dilatation; 100%, p< 0.05). Recurrent stones were found to have developed in 10 patients (14.2%), yet the rates for the recurrent stones were not different in both groups. CONCLUSION: Hepatic resection is an effective and safe treatment for right-sided intrahepatic stones. For intrahepatic stones associated with definite bile duct strictures, hepatic resection is the most suitable procedure for the complete removal of stones.

Prognosis of the Pancreatic Carcinoma

PURPOSE: Currently, pancreatic exocrine carcinomas present with low resectability rates and poor survival, even after curative surgery. In this article, the clinicopathological characteristics, and treatment outcomes, of patients are analyzed and discussed. METHODS: Between 1983 and 2000, 106 exocrine pancreatic carcinoma patients were operated on at our institute. The medical records of 95 patients diagnosed with a ductal adenocarcinoma were reviewed, and the postoperative follow up results analyzed. RESULTS: The locations of the tumors were the head, body and diffusely spread in 76 (80.0%), 17 (17.9%) and 2 (2.1%) patients, respectively. Of the 95 patients, 29 underwent surgical resection (resectability rate; 30.6%), 33 palliative bypass procedures and the other 33 an exploration only. The 1-, 3-, and 5-year survival rates in the resection group were 66.7%, 19.8% and 9.9%, respectively. In the non- resection group the 1-year survival rate was 3.3%, with a mean survival period of 5.5 months. The overall 1-, 3- and 5-year survival rates were 23.0%, 6.6%, and 3.3%, respectively. From a multivariate analysis, the location of tumor (P= 0.0067), TNM stage (P=0.0010) and resectability of tumor (P<0.0001) were all significant prognostic factors. CONCLUSION: Pancreatic carcinomas have very low resectability, with a bad prognosis, and long term survival can only be obtained by their early detection and curative resection.

Surgical Indications for Polypoid Lesions of the Gallbladder

PURPOSE: Polyps and polypoid lesions of the gallbladder are now increasingly detected. However the nature of disease is hard to define before operation and the indications for surgical intervention remain controversial. We attempted to differentiate between benign polyps and neoplastic lesions by comparing their clinical data and pathological findings. METHODS: The study comprised 128 consecutive patients who underwent resection for polypoid lesions of the gallbladder. The lesions were classified into five groups histologically, and the clinico-pathological characteristics were compared among the groups. RESULTS: We found cholesterol polyps in 42 patients, inflammatory polyps in 13, adenomyomatoses in 14, adenomas in 15, and carcinomas in 44. The mean age of the patients with carcinoma, all of whom were over 40 years, was significantly higher than that of the other groups (P<0.05). Carcinoma patients showed a female preponderance. The incidences of gallstones and presenting symptoms were not different between the benign and malignant diseases. The mean diameters of cholesterol polyps and inflammatory polyps were less than 5 mm, those of adenomyomatoses and adenomas were around 1 cm, and that of carcinoma was over 2 cm (P<0.05). Most of the benign polyps were pedunculated, but sessile lesions were more frequent in the malignant polyps (P<0.05). Neoplastic polyps tended to be single. CONCLUSION: It is suggested that polypoid lesions of the gallbladder should be removed surgically when the lesion exceeds 1 cm in diameter, is single in number, or is sessile. The possibility for malignancy should be considered if the patient is female, and over 40 years of age.

Surgical Treatment and Prognosis for 268 Patients with Biliary Tract Cancers

PURPOSE: Carcinomas of the biliary tract are considerably rare conditions. In spite of recent progress in diagnosis and treatment, resectability remains low, and the prognosis is still discouraging. This review summarizes our 12-year experience with biliary tract cancers, with particular focus on the survival rates after operation and the prognostic factors that affected the survival of patients. METHODS: Between 1987 and 1998, 268 patients with biliary tract cancers were operated on at our institution. The clinical and the pathologic data were collected, and a survival analysis was performed. RESULTS: The tumor was located in the gallbladder in 90 patients, in the proximal bile duct in 74 patients, in the distal bile duct in 54 patients, and in the ampulla of Vater in 50 patients. One hundred ninety-seven patients underwent a radical resection (resection rate: 73.5%). A curative resection was achieved in 140 patients (curative resection rate: 71.1%). The overall operative mortality after resection was 3.0%. The cumulative survival rates at five years after resection were 61.1% for carcinomas of the gallbladder, 25.8% for proximal bile duct cancers, 28.9% for distal bile duct cancers, and 48.7% for ampulla of Vater cancers. The one-year survival rates for the non-resection group were 18.2% and 26.6% for gallbladder cancers and proximal bile duct cancers, respectively. The mean survival periods for unresectable distal bile duct cancers and ampullary cancers were 4.7 months and 8.3 months, respectively. Positive lymph-node metastasis was a statistically significant, poor prognostic factor. CONCLUSION: Long-term survivals can be expected by a radical surgery for patients with biliary tract cancers. Increasing the resection rate by performing an extended procedure is essential for the improvement of treatment outcomes.

Radical Surgery for Carcinoma of the Gallbladder

BACKGROUND: Carcinomas of the gallbladder have a poor prognosis, and the only chance for cure lies in early detection and complete surgical resection. The objective of this study was to determine the outcomes of surgical treatment for gallbladder carcinomas, with special reference to the histopathologic characteristics. METHODS: Seventy patients with gallbladder carcinomas were operated on during a period of seven years. Of those 42 patients underwent a resection for cure and were included in this study. The clinicopathologic data were collected, and the survival was measured. RESULTS: The resection rate was 60.0%. Operative morbidity and mortality were 14.3% and 4.8%, respectively. The 3-year survival rate after resection was 61.1%. The survival rate was significantly higher in patients with negative lymph-node metastasis and in those with a curative resection. Regional lymph-node metastasis, venous invasion, lymphatic permeation, and perineural infiltration increased with the depth of tumor invasion. In cases limited to the mucosa, no lymph-node metastasis or other extensions were observed. In patients with stage I gallbladder carcinomas, the outcome was good after a simple cholecystectomy alone. In stage II to IV, the survival rate for patients with a radical resection was higher than that for those with a simple cholecystectomy. CONCLUSIONS: Improved survival in gallbladder carcinomas can be achieved by a radical resection, including various types of liver resections and regional lymphadenectomies. Patients with tumors limited to the mucosa can be treated for cure by a simple cholecystectomy. In more advanced stages, a radical resection should be performed.

The Root of Korean Modern Surgery, Paik Inje and the Growth of Paik Inje Tree

The President of Inje University Paik Inje was born in Chungju, Korea in 1899. He graduated Kyungsung Junior Medical College with the best degree. He became a chairman of the Department of Surgery of it. He studied abroad two times in Germany and upgraded the levels of surgery in Korea. He resigned the position in his school and opened his private clinic, Paik Surgical Clinic in 1941. His clinic was flourished due to his excellent surgical skill and modern medical knowledge. After the liberation from Japanese Annexation in 1945, he dedicated much to the establishment of Korean medical societies. He served as a first and second president of Seoul Branch of Korea Medical Association, and also did as a first, second, and third president of The Korean Surgical Society. He donated his whole property to 'the Foundation of Paik Hospital', which was the first nonprofit foundation in Korea. Even though he was kidnapped by the army of North Korea during Korean War in 1950, Paik Surgical Clinic's growth was remarkable due to the contributions of his juniors. The Foundation of Paik Hospital became the Inje Medical College in 1979, and later became Inje University in 1989. The foundation have three hospitals now, Seoul Paik Hospital, Pusan Paik Hospital, and Sangye Hospital. The total number of beds of those is two thousands, and will be 2,600 when Ilsan Paik Hospital will be opened this year. Paik Inje and his juniors made contributions in the development of surgery in Korea. Paik Inje introduced the decompression method for the patients of mechanical intestinal obstruction in 1937 for the first time in the world three years before Wangensteen's report of decompression. The private blood bank was introduced in Paik Hospital in 1954 for the first time in Korea. Pelvic exenteration, intramedullary nail fixation, choledocho-duodenostomy, esophagoplasty were first introduced in Paik Hospital for the first time in Korea by me and collegues. I reported 328 intussusception cases, the most cases at that time. The Swenson operation for the Hirshsprung's disease was first done by me about 1960. Paik Inje was a forerunner of modern medicine and surgery of Korea. He and his juniors, we may call it the Paik Inje Tree, contributed much to the development of surgery of Korea.

A Clinical Analysis on the Pancreaticoduodenectomy / 한국간담췌외과학회지

BACKGROUND/AIMS: During the past several decades pancreaticoduodenectomy has carried a tremendous operative risk. Recently, however, mortality has decreased markedly to around 5%. The aim of this study was to determine the indication, clinical course and complications for the procedure. We also assessed the risk factors of operative morbidity and mortality. METHODS: During the period from June 1979 to July 1998, 155 patients underwent pancreaticoduodenectomy at our institution. The clinical records and pathologic reports were reviewed retrospectively. RESULTS: There were 102 men and 53 women. Mean age was 55.5 years. Indications for the procedure were periampullary carcinoma in 121 patients(78.1%), other malignant tumors in 13 patients(8.2%), and benign diseases including trauma in 21 patients(13.5%). A standard pancreaticoduodenectomy was performed in 113 patients. The remaining 42 patients underwent pylorus preserving pancreaticoduodenectomy. Operative morbidity occurred in 46 patients (29.7%). Pancreatic fistula was the most common complication (11.0%). There were nine operative deaths(5.8%). For the patients with pancreatic fistula, the mortality rate was 41.1%. Patient's age, serum albumin, serum bilirubin, hemoglobin, and leucocyte count had no significant influences on the result of operation. Type of procedure, operation time, amount of transfusion, or use of octreotide were not determining factors for operative mortality. CONCLUSIONS: Pancreaticoduodenectomy was performed in 155 patients with a mortality of 5.8% and a morbidity of 29.7%. The main cause of operative death was pancreatic fistula. There were no specific contributing factors leading to operative morbidity and mortality. It is suggested that technical precision and gentleness are of great importance for patients undergoing pancreaticoduodenectomy

The Experience and Evaluation of Problem-Based Learning in Inje University College of Medicine / 한국의학교육

While renovating our traditional medical curriculum to integrated curricular system in 1996, we planned to introduce a course of problem-based learning (PBL) on tutorial basis after finishing 14 courses of the integrated medical curriculum for two years. One tutorial group was composed of one tutor and eight students, and 105 students of the second grade were divided into thirteen small tutorial groups. The period of PBL course was two weeks from December 1 to 14 in 1997. There were three interrelated steps for design of PBL course: course preparation, implementation, and evaluation which were conducted by PBL subcommittee consisted of nineteen teachers. Students were exposed to four clinical case modules, and they met in small tutorial room three times per week for two weeks. The PBL programme was evaluated by questionnaire survey method at the end of PBL course. We obtained satisfactory and positive results from reply of faculty and students. Since many teachers participated in planning, implementing, and evaluation of PBL, we could accumulate lots of knowledge and skills regarding the PBL, and it was a good opportunity to train expertise for PBL, test the feasibility changing to PBL curriculum. At this moment, our present integrated medical curriculum will be gradually converted to PBL system totally, and our experience will provide a good aid for other medical schools appling traditional medical curriculum to introduce PBL in their medical education.

Assessment of Validity of RT-PCR and EIA for The Detection of Hepatitis C Virus Infection / 예방의학회지

This study was conducted to estimate the validity of reverse transcriptase-polymerase chain reaction(RT-PCR) compared to enzyme immunoassay(EIA) for the detection of hepatitis C virus (HCV) infection. ElA for antibody to HCV(anti-HCV) and RT-PCR for HCV was executed on the subjects from Pusan and kyungnam area with questionnaire survey to collect some relating factors of HCV infection As the result from 617 cases, the prevalence of flcv infection was 1.5% by ElA and 3.7% by RT-PCR(p<0.05), and the age standardized rate was 1.7% and 3.4% by ElA and RT-PCR, respectively. The prevalence of hepatitis B surface antigen(HBsAg) was 6.8% by enzyme linked immunosorbent assay(ELlSA) and the age standardized rate was 7.7%. It was the higher in male group comparing to female group(p<0.01). Both of the prevalence of HCV and HBsAg were higher in elevated asparate aminotransferase(AST) and alanine aminotransferase (ALT) group than in normal AST and ALT group(p<0.01). There was no specific risk factor of HCV infection. Though the degree of agreement of EIA and RT-PCR by gamma statistics was 97.2%, it showed a significant difference between the two methods(p<0.01). For the detection of HCV infection, positive predictive value of ElA was 66.7 % and negative predictive value of EIA was 97.2%. This study suggests that negative result to anti-HCV by ElA didn't mean the free state of HCV infection, therefore it would be helpful that further monitoring for HCV infection by RT-PCR in the case of elevated AST and ALT and/or clinically suspected.

120 liver resections:a four year experience

No abstract available.