Strangulation of the Floating Gallbladder by the Lesser Omentum

The strangulation of the gallbladder by the omentum is extremely rare. We report a unique case of acute cholecystitis due to the strangulation of a floating gallbladder by the lesser omentum. A 16-year-old male patient presented to a local hospital after the recurrent epigastric pain. The clinical features and image study suggested the gallbladder torsion, and the patient was referred for surgical treatment. Abdominal computed tomography showed no cholecystolithiasis, but the fundus and body of the gallbladder were markedly swollen with wall thickening, whereas the neck of the gallbladder was normal. Based on these findings, the gallbladder torsion was clinically diagnosed and he underwent laparoscopic cholecystectomy. The narrowed part of the gallbladder was tightly strangulated by the lesser omentum. So, strangulation of a floating gallbladder by the lesser omentum was finally diagnosed. We believe this case to be the third case of reported literatures in English.

Strangulation of the Floating Gallbladder by the Lesser Omentum

The strangulation of the gallbladder by the omentum is extremely rare. We report a unique case of acute cholecystitis due to the strangulation of a floating gallbladder by the lesser omentum. A 16-year-old male patient presented to a local hospital after the recurrent epigastric pain. The clinical features and image study suggested the gallbladder torsion, and the patient was referred for surgical treatment. Abdominal computed tomography showed no cholecystolithiasis, but the fundus and body of the gallbladder were markedly swollen with wall thickening, whereas the neck of the gallbladder was normal. Based on these findings, the gallbladder torsion was clinically diagnosed and he underwent laparoscopic cholecystectomy. The narrowed part of the gallbladder was tightly strangulated by the lesser omentum. So, strangulation of a floating gallbladder by the lesser omentum was finally diagnosed. We believe this case to be the third case of reported literatures in English.

Non-typical Symptomatic Appendico-Vesical Fistula

Appendico-vesical fistula is rare and occurs secondary to acute or missed acute appendicitis. It was first described in 1898. Since then, over 110 cases have been reported in the literature. We report a case of a 46-year-old male with a non-typical symptomatic appendico-vesical fistula.

Adrenal Tuberculosis Mimicking a Malignant Tumor with Primary Adrenal Insufficiency

Adrenal tuberculosis is a relatively infrequent cause of primary adrenocortical insufficiency in developed countries. Isolated adrenal tuberculosis, especially with enlargement of adrenal glands, can cause diagnostic problems and requires differentiation from primary or secondary neoplasms. A 40-year-old woman presented to Soonchunhyang University Gumi Hospital with altered consciousness. She showed biochemical evidence of adrenal insufficiency without signs of tuberculosis. Abdominal computed tomography (CT) scan showed a calcified mass 3.3×2.3 cm in size and peripheral enhancement of the left adrenal gland. A laparoscopic adrenalectomy was performed for a diagnosis of left adrenal malignant tumor. The diagnosis of adrenal tuberculosis was confirmed by a final histological examination.

Common bile duct dilatation after cholecystectomy: a one-year prospective study / 대한외과학회지

PURPOSE: Bile duct dilatation after cholecystectomy continues to be a matter of controversy. We aimed determine the magnitude of common bile duct (CBD) dilatation after cholecystectomy followed up to 1 year. METHODS: Sixty-four cases (age, 47.3 +/- 11.7 years; men, 28; women, 36) enrolled in this study. They received laparoscopic cholecystectomy in Chungbuk National University Hospital for symptomatic cholelithiasis or gallbladder polyps with normal bile duct, less than 7 mm. The CBD diameter was measured by one radiologist using ultrasonography at the maximum point after full length evaluation of extrahepatic bile duct. Forty-five and thirty-one cases were followed at 6 months and 1 year, respectively. RESULTS: The CBD was dilated slightly from 4.1 mm at baseline to 5.1 mm at 6 months and 6.1 mm at 12 months after cholecystectomy. The number of cases of CBD dilatation of more than 7 mm at 6 months and at 12 months after cholecystectomy were 11 (24.4%) and 9 (29.0%), respectively. Seven cases at 6 months and 5 cases at 12 months showed bile duct dilation of more than 3 mm compared to baseline. There were no cases having bile duct dilation of more than 10 mm. CONCLUSION: Postcholecystectomy dilatation of the bile duct occured slightly in most cases. But some cases showed more than 3 mm dilatation over baseline. Asymptomatic bile duct dilatation of up to 10 mm can be considered as normal range in patients after cholecystectomy.

Survival benefits of surgical resection in recurrent cholangiocarcinoma / 대한외과학회지

PURPOSE: Attempt to identify the beneficial effects associated with surgical procedures on survival outcome of patients with recurrent cholangiocarcinoma. METHODS: 921 patients diagnosed with cholangiocarcinoma underwent surgical resection with curative intent in a single institute during the last 15 years. Patients with recurrent disease were divided into two groups according to whether surgical procedures were performed for the treatment of recurrence. Clinicopathologic variables, ranges of survival based on sites of recurrence, and types of treatment were analyzed retrospectively. RESULTS: The median follow-up period was 21.8 months and 316 (34.3%) patients had recurrence. 27 (group A) patients with recurrent disease were treated surgically and 289 patients (group B) were not treated. Liver resection, metastasectomy, pancreaticoduodenectomy, partial pancreatectomy, and regional lymph node dissection were performed on the patients in group A. The overall survival rate was statistically higher in group A (P = 0.001). Among the surgical procedures, resection of locoregional recurrences (except liver) in abdominal cavity (4.0 to 101.8 months vs. 0.6 to 71.6 months) and metastasectomy of abdominal or chest wall (3.5 to 18.9 months vs. 1.9 to 2.2 months) showed remarkable differences with respect to the range of survival. CONCLUSION: Better survival outcomes can be expected by performing surgical resection of locoregional recurrences (except liver) in abdominal cavity and abdominal or chest wall metastatic lesions in recurrent cholangiocarcinoma.

Adenocarcinoma of the ampulla of Vater: predictors of survival and recurrence after curative radical resection

BACKGROUNDS/AIMS: Because of low incidence rates, there have been few reports on the patterns of and risk factors for recurrence after curative resection of the ampulla of Vater (AoV) cancer. The aim of this study was to characterize patterns of recurrence and to evaluate risk factors affecting survival rates and recurrence after curative resection. METHODS: Medical records of 181 patients who had undergone pancreaticoduodenectomy with curative intent for AoV adenocarcinoma between December 1994 and March 2010 at Samsung Medical Center were retrospectively reviewed. Factors influencing on overall survival rate, recurrence rates, and recurrence patterns were analyzed. RESULTS: Lymph node metastases and high preoperative serum carcinoembryonic antigen (CEA) level >5 ng/ml were identified as independent factors affecting overall survival (p=0.006, p5 ng/ml, and total bilirubin level >1.5 mg/dl were identified as independent prognostic factors of recurrence after curative resection (p=0.008, p<0.001, p=0.003, respectively). CONCLUSIONS: AoV adenocarcinoma has a better prognosis than other periampullary carcinomas, but still has a high recurrence rate, especially during the first three years after curative radical resection. Therefore, careful follow-up is needed during the first 3 years, especially for the higher risk group. Further study of adjuvant therapy to decrease recurrence after curative resection is now warranted.

Clinical Analysis of Single-Port Laparoscopic Cholecystectomies: Early Experience

PURPOSE: Single-port laparoscopic cholecystectomy (SPLC) is a technique under development in the field of minimally-invasive surgery. We have considered the feasibility of SPLC based on the advantages or restrictions compared with multi-port procedures. METHODS: Two hundred seventeen patients with benign gallbladder disease who underwent SPLC or multi-port laparoscopic cholecystectomy (MPLC) during the most recent 10 months were retrospectively reviewed. RESULTS: Patients were divided into two or three groups based on the operative period and disease. The mean age and ASA scale were different between the three groups. The intra-operative bile leakage and post-operative hospital stay were significantly less in the SPLC group; however, the blood loss and operative time was greater in the SPLC group. When patients with empyema of the gallbladder were excluded and all patients were reassigned into two groups based on the operative method, the incidence of bile leakage and post-operative hospital stay were similar between the two groups. The mean blood loss and operative time were higher in the patients who underwent SPLC. The mean numeric rating scale (NRS) and requirement for opioid analgesics were similar in the two groups. CONCLUSION: With the exception of increased intra-operative hemorrhage and a longer operative time, the risks associated with SPLC were not greater than MPLC. With adequate analgesics, advances in laparoscopic instruments, and surgical experience, SPLC is expected to gain acceptance amongst physicians.

Enucleation of Pancreatic Endocrine Tumor Following Pancreatic Duct Stenting: A Case Report

Pancreatic fistula is the most frequent complication after pancreatic resection regardless of the extent of the resection. A 68-year-old woman with B-viral hepatitis was referred with an incidentally detected pancreatic head mass that was diagnosed 4 months previously when performing following up of her liver cirrhosis. She had no specific symptoms, but she had a 1.2 cm sized solitary mass that was suspected to be a pancreatic endocrine tumor and it was located very close to the main pancreatic duct in the pancreas uncinate process on the imaging workup. Preoperative endoscopic pancreatic stenting was prepared to guide the enucleation of the mass while identifying the pancreatic duct using intraoperative ultrasonography. Precise intraoperative estimation of the mass and the pancreatic duct was possible and the enucleation was successful without injury to the duct. We recommend this operative approach and especially when planning local pancreatic resection for tumors in the pancreatic head or uncinate process, as these tumors make the pancreatic duct injury vulnerable to injury.

Non-Functioning Somatostatinoma of the Duodenum in Patient with Von Recklinghausen's Disease

Somatostatinoma is a rare endocrine tumor that comprises around 1% of all gastroenteropancreatic endocrine neoplasm. The estimated annual incidence is 1 in 40 million. This tumor may be associated with von Recklinghausen's disease. We present here a rare case of a 51-year-old female patient with a duodenal nonfunctioning somatostatinoma combined with von Recklinghausen's disease. Whipple' procedure was performed. The postoperative course was uneventful and the histopathologic findings were consistent with malignant nonfunctioning somatostatinoma with lymph node metastases. The patient is alive, healthy and without tumor recurrence 10 months after surgery.

Non-Functioning Somatostatinoma of the Duodenum in Patient with Von Recklinghausen's Disease

Somatostatinoma is a rare endocrine tumor that comprises around 1% of all gastroenteropancreatic endocrine neoplasm. The estimated annual incidence is 1 in 40 million. This tumor may be associated with von Recklinghausen's disease. We present here a rare case of a 51-year-old female patient with a duodenal nonfunctioning somatostatinoma combined with von Recklinghausen's disease. Whipple' procedure was performed. The postoperative course was uneventful and the histopathologic findings were consistent with malignant nonfunctioning somatostatinoma with lymph node metastases. The patient is alive, healthy and without tumor recurrence 10 months after surgery.

Effect of Pediatric Endoscopic Sinus Surgery with Antrochoanal Polyps on Sinus Growth / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Pediatric endoscopic sinus surgery (ESS) has become widely used for the treatment of chronic or recurrent rhinosinusitis that is unresponsive to medical management. But the effect of pediatric ESS on facial growth or sinus growth are controversial and not well understood. The object of the present study was to determine whether pediatric ESS causes the volumetric restriction of the sinuses. SUBJECTS AND METHOD: Fifteen cases of patients who underwent unilateral endoscopic sinus surgery for antrochoanal polyp were reviewed retrospectively. Postoperative maxillary and ethmoid sinus volumes were measured by computed tomography at 73.5 (51-101) months after surgery, and these were compared with non-operated sinus volumes. RESULTS: The mean volume of the operated and non-operated maxillary sinuses were 18.9+/-6.4 ml and 21.7+/-5.3 ml. and the mean volume of the operated and non-operated ethmoid sinuses were 4.1+/-1.2 ml and 3.7+/-1.2 ml. There was no significant difference in sinus growth between operated and non-operated sinuses. CONCLUSION: There was no evidence that pediatric ESS affected maxillary and ethmoid sinus growth.

A Case of Ectopic Cervical Thymus Presenting as a Submandibular Mass / 대한이비인후과학회지

Ectopic cervical thymus is an extremely uncommon etiology of neck mass in infants. We report a case of ectopic thymus in five months old male baby, presenting as a submandibular mass. Ultrasonography and CT scan revealed a 5.2 x 1.6 x 1.5 cm-sized solid mass in the left suprahyoid neck between parotid and submandibular gland, which was regarded as malignant lesion though it was soft, non-tender on examination. For differential diagnosis of malignant lymphoma and soft tissue sarcoma, an incisional biopsy was performed to confirm ectopic cervical thymus. He is under our observation without having gone through surgical excision because the thymus will involute spontaneously and he has no symptoms.

Histoculture Drug Response Assay in Colorectal Cancer Specimen

PURPOSE: For decades, systemic medical treatment for colorectal cancer has been limited almost entirely to 5- fluorouracil (5-FU). In cases of advanced colorectal cancer, the response rate to standard 5-FU regimen was lower than 20%. Recently, new drugs that have another action mechanism have been introduced-irinotecan, oxaliplatin, raltitrexed, capecitabine, etc. Clinicians have to choose the appropriate drug for advanced cases. Until recently, choice of chemotherapeutic agents was based on the experience of clinicians, or on retrospective or prospective clinical trial reports. In this study, we performed HDRA (histoculture drug response assay) to assess the effectiveness of chemotherapeutic agents in colorectal cancer. METHODS: Tumor specimens of 33 colorectal cancers were collected in 15 ml tubes containing PBS buffer. Tissues were minced using an autoclaved knife and histocultured on collagen sponge gel matrix, followed by treatment with 5-FU, 5-FU & leucovorin, oxaliplatin, oxaliplatin & 5-FU, irinotecan, or irinotecan & 5-FU. After 48 hours, cell viability was assessed by MTT assay. The inhibition rate of each drug was calculated for relative survival. Cases of drug responsibility below 30% were regarded as drug resistant cases. RESULTS: Thirty cases were tested. Three cases had synchronous lesion. Thirty-three tissues were evaluated using HDRA. Seventeen cases (53.3%) were rectal cancer. The initial 6 cases were tested using a single agent the other 27 cases were tested using combined agents. The regimen showing the best responses was oxaliplatin with 5-FU (8/26 cases, 30.8%). Seven cases were regarded as chemoresistant cases because they showed low IR below 30% for all agents. Synchronous lesions showed similar drug responses. CONCLUSION: HDRA is relatively simple and easily applicable to in vitro study to determine the appropriate chemotherapeutic agents. Further study is necessary to assess the effectiveness including tumor recurrence and survival.

Primary Small Cell Carcinoma of the Parotid Gland / 대한이비인후과학회지

Small cell neuroendocrine carcinomas mainly occur in the lung. Four percent of small cell carcinomas arise in extrapulmonary sites. In the head and neck region, small cell carcinomas arise most commonly in the larynx and very rarely in the parotid gland. Although the prognosis for patients with small cell carcinoma of the salivary glands is better than for those with small cell carcinoma of the lung or larynx, it is a high grade malignancy that is treated aggressively. We have recently experienced a case of primary small cell neuroendocrine carcinoma of parotid gland with extensive neck metastases. The histopathologic findings showed undifferentiated small cells with hyperchromatic nuclei, numerous mitoses, ductal differentiations and squamous changes. The positive findings for CD56 and neuron specific enolase staining determined this carcinoma to be a neuroendocrine subtype, and the patient received chemoradiation after surgery. We present this case with a review of literatures.

The Effect of Intratympanic Dexamethasone on Tinnitus in Inner Ear Diseases / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Intratympanic steroid serves as a good therapeutic alternative for various inner ear diseases presenting with vertigo, hearing loss, and tinnitus. This study reports the effect of intratympanically injected dexamethasone (ITDEXA) on tinnitus in various cochlear pathologies. SUBJECTS AND METHOD: 19 patients with cochlear tinnitus (7 sudden sensorineural hearing loss (SSNHL), 5 noise induced hearing loss, 4 Meniere's disease and 3 acoustic trauma) were subjected to the IT-DEXA. The injection was performed with a spinal needle through the posterior superior quadrant of the tympanic membrane for 2 to 5 consecutive days. RESULTS: The overall improvement rate was 31.6%. Tinnitus was improved in 4 patients with SSNHL and 2 patients with Meniere's disease. Tinnitus was not improved in noise induced hearing loss or acoustic trauma. CONCLUSION: IT-DEXA is a therapeutic modality for tinnitus in SSNHL and Meniere's disease.

A Case of Duodenal Mucormycosis in a Immunocompetent Patient / 대한소화기내시경학회지

Mucormycosis is a rare and fulminating opportunistic fungal infection that occurs almost in immunocom-promised patients. It is also a highly virulent and rapidly progressive disease with poor prognosis. Its incidence has been increasing in recent years. We have experienced a case of solitary duodenal mucormycosis in a 45 year-old male patient. Mucormycosis was diagnosed by pathology & culture and he was treated with amphotericin B and discharged with clinical improvement. We report this case with a literature review.

Evaluating the Usefulness of the ICT Tuberculosis Test Kit for the Diagnosis of Tuberculosis / 결핵

BACKGROUND: Early diagnosis of tuberculosis is critical, especially in Korea, an area where tuberculosis is endemic. Because antibody responses to some membrane proteins of Mycobacterium tuberculosis are not comparable, and the policy of BCG vaccination and the prevalence of tuberculosis are different from country to country, the usefulness of the serological diagnostic tests is questionable in Korea, even though they have been confirmed to be useful in other countries. In the specific context of Korea, we tried to evaluate the validity of the ICT Tuberculosis Test (ICT), a membrane-based antibody kit that purports to detect the 5 M. tuberculosis complex-specific antigens including 38-kDa protein. METHOD: 68 patients with tuberculosis were tested: 37 had no history of previous tuberculosis, and 31 were reactivated cases. The control group comprised 77 subjects: 25 healthy adults, 35 hospital workers with frequent contact with tuberculosis patients, and 17 in-patients with non-tuberculous respiratory diseases. RESULTS: The diagnostic sensitivities of the ICT were 87% and 73% in patients with versus without previous history of tuberculosis, respectively. The sensitivities of smear-positive and smear-negative patient groups were 81% and 73%, respectively. Both of the two patients with extrapulmonary tuberculosis tested positive through the ICT. The specificities of the ICT were 88%, 94%, and 94% in healthy adults, hospital workers, and non-tuberculous patients, respectively, with an overall specificity of 92%. Conclusion: It is suggested that when combined with traditional techniques, the ICT is an useful tool for the diagnosis of pulmonary tuberculosis. The procedure is simple, easy to perform, rapid, and needs no equipment. It shows 73% sensitivity and 92% specificity for the diagnosis of tuberculosis.

Evaluating the Usefulness of the ICT Tuberculosis Test Kit for the Diagnosis of Tuberculosis / 결핵

BACKGROUND: Early diagnosis of tuberculosis is critical, especially in Korea, an area where tuberculosis is endemic. Because antibody responses to some membrane proteins of Mycobacterium tuberculosis are not comparable, and the policy of BCG vaccination and the prevalence of tuberculosis are different from country to country, the usefulness of the serological diagnostic tests is questionable in Korea, even though they have been confirmed to be useful in other countries. In the specific context of Korea, we tried to evaluate the validity of the ICT Tuberculosis Test (ICT), a membrane-based antibody kit that purports to detect the 5 M. tuberculosis complex-specific antigens including 38-kDa protein. METHOD: 68 patients with tuberculosis were tested: 37 had no history of previous tuberculosis, and 31 were reactivated cases. The control group comprised 77 subjects: 25 healthy adults, 35 hospital workers with frequent contact with tuberculosis patients, and 17 in-patients with non-tuberculous respiratory diseases. RESULTS: The diagnostic sensitivities of the ICT were 87% and 73% in patients with versus without previous history of tuberculosis, respectively. The sensitivities of smear-positive and smear-negative patient groups were 81% and 73%, respectively. Both of the two patients with extrapulmonary tuberculosis tested positive through the ICT. The specificities of the ICT were 88%, 94%, and 94% in healthy adults, hospital workers, and non-tuberculous patients, respectively, with an overall specificity of 92%. Conclusion: It is suggested that when combined with traditional techniques, the ICT is an useful tool for the diagnosis of pulmonary tuberculosis. The procedure is simple, easy to perform, rapid, and needs no equipment. It shows 73% sensitivity and 92% specificity for the diagnosis of tuberculosis.

Expression of bFGF and CD-31 in Laryngeal Squamous Cell Carcinoma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Tumor angiogenesis is an essential process required for growth and metastasis of cancer. Basic fibroblast growth factor (bFGF) is one of angiogenetic factors, and platelet endothelial cell adhesion molecule (CD-31) is the commonly used marker to identify the vessel. It is unclear that the degree of angiogenesis and expression of bFGF are related to the growth and metastasis in laryngeal squamous cell carcinoma. We examined the expression of bFGF and degree of angiogenesis in laryngeal squamous cell carcinoma and compared them to normal larynx. Relationship between bFGF and angiogenesis to growth and nodal metastasis in laryngeal squamous cell carcinoma was also evaluated. MATERIAL AND METHODS: Immunohistochemical study for bFGF and CD-31 were performed to detect the angiogenetic factor and degree of angiogenesis in 24 squamous cell carcinoma of larynx and 6 normal laryngeal tissue. Relationship of bFGF expression and degree of angiogenesis in laryngeal squamous cell carcinoma were compared to that in normal larynx. We evaluated relationship of expression of bFGF and degree of angiogenesis to primary stage and nodal stage in laryngeal squamous cell carcinoma. RESULTS: These expression of bFGF and degree of angiogenesis in laryngeal squamous cell carcinoma were significantly higher than in the normal control (p<0.05). The degree of angiogensis were significantly correlated with bFGF expression (p<0.05): the bFGF expression and degree of angiogenesis were not correlated to the nodal stage, but to the primary stage in laryngeal squamous cell carcinoma (p<0.05). CONCLUSION: These results indicate that bFGF and angiogenesis may play an important role in the growth of larygeal squamous cell carcinoma.