Predictive factors for invasive intraductal papillary mucinous neoplasm of the pancreas

BACKGROUNDS/AIMS: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has malignant potential. Predicting invasive IPMN has proven difficult and controversial. We tried to identify predictive factors for invasive IPMN. METHODS: Thirty six patients underwent resection for IPMN from February 2001 to July 2011. Clinicopathological features including demographic, imaging, microscopic, and serological findings were retrospectively reviewed. Receiver operating characteristic (ROC) curve analysis was used to analyze sensitivity and specificity of all possible cut-off values for the diameter of the main pancreatic duct and mass size predicting invasive IPMN. Student t-test, chi-square test, and logistic regression were used for univariate and multivariate analysis. RESULTS: The mean age was 63.5+/-8.4 years. Males were more commonly affected (58.3% vs 41.7%). Pancreaticoduodenectomy was performed in 55.6% of patients, distal pancreatectomy in 36.1%, and central pancreatic resection in 8.3%. Non-invasive IPMNs were present in 80.6% (n=29), whereas invasive IPMNs were present in 19.4% (n=7). In univariate analysis, tumor location (p=0.036), Kuroda classification (p=0.048), mural nodule (p=0.016), and main duct dilatation (> or =8 mm) (p=0.006) were statistically significant variables. ROC curve analysis showed that a value of 8 mm for the main duct dilatation and a value of 35 mm for the size of the mass lesion have 80% sensitivity and 75% specificity and 100% sensitivity and 82.6% specificity, respectively. However, in multivariate analysis, main ductal dilatation (> or =8 mm) was identified to be the only independent factor for invasive IPMN (p=0.049). CONCLUSIONS: Main duct dilatation appears to be a useful indicator for predicting invasive IPMN.

Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

Comparison of Surgical Outcomes and Long-term Survival between Limited and Major Hepatic Resection for Hepatocellular Carcinoma Less than 5 cm

PURPOSE: Though major hepatic resections including hemihepatectomy, trisectionectomy, and central bisectionectomy are most commonly employed for small (<5 cm) hepatocellular carcinoma (HCC), limited hepatic resection is indicated in some HCC patients with impaired liver function, poor physical condition, or tumors peripherally located. We compared the clinicopathological features and long-term survival between the patients who underwent major resection and limited resection. METHODS: From January 1998 to May 2007, 223 patients who underwent hepatic resection for small HCC were enrolled. 123 patients underwent limited resection and 100 patients underwent major resection. Clinocopathologic features, overall, and disease-free survival were compared between both groups. RESULTS: The limited resection group had lower mean serum albumin levels (3.86+/-0.41 vs. 4.11+/-3.61, P<0.0001) and higher mean ICG R15 (12.66+/-0.87 vs. 7.51+/-4.33, P<0.0001). Patients with esophageal varix and liver cirrhosis were more common in the limited resection group (34.1% and 73.1% versus 9% and 45% respectively). Morbidity and mortality were not different in both groups. Overall 1-, 3-, 5-year survivals in both limited resection and major resection groups were 89.4%, 77.3%, 43.8% and 87.8%, 76.5%, 62.1% respectively (P=0.161) and 1-, 3-, 5-year disease free survivals were 80.2%, 50.2%, 38.6% and 79.9%, 63.2%, 50.4% respectively (P=0.10). CONCLUSION: Despite indifference of overall and disease-free 5-year survival rates between limited and major resection groups, careful follow up is essential to detect late recurrence in the limited resection group, since limited resection tends to have more frequent recurrence, especially 2 years after surgery.

Is Laparoscopic Cholecystectomy Safe in Octogenarians?

PURPOSE: Biliary tract disease is one of the most common causes of acute abdominal pain in elderly patients, but there is still some debate over treatment. The aim of this study is to determine the safety and surgical outcomes of laparoscopic cholecystectomy (LC) for benign gallbladder disease in octogenarian patients. METHODS: We selected 42 patients of 80 years or older who underwent LC or open-converted cholecystectomy (OC) from February 1992 to November 2006. We evaluated clinicopathological features, treatment modalities, and surgical outcomes retrospectively. RESULTS: The patients included 17 males and 25 females. The mean age of the patients was 83.3 and 83.7, respectively. Right upper quadrant pain was the most common symptom, present in 85.7% of the patients. Gallstones were present in 85.7%. ASA class II and III comprised 92.9% of the patients. Comorbidities included hypertension, cardiac disease, pulmonary disease, and diabetes mellitus. Preoperatively biliary drainage was performed in 12 cases (endoscopic drainage in 8, percutaneous drainage in 4 cases). Preoperative cholecystostomy was performed in 5 cases. Emergency operations were more frequent than elective surgery (25 vs. 17). Mean hospital stay of LC patients was 5 days, whereas that of OC patients was 13 days. Open conversion rate was 16.7%. No surgical mortality was present and postoperative morbidity included acute myocardial infarction in one patient and wound infection in one patient. CONCLUSION: LC in octogenarian patients was safe. However, since the incidence of comorbidities is high in these patients, great care should be taken to evaluate and manage the comorbidities before surgery.

The Risk Factors for Intrahepatic Early Recurrence after Resection for Hepatocellular Carcinoma

PURPOSE: The purpose of this study is to comprehend the prognosis and risk factors for the early recurrence after resection for hepatocellular carcinoma (HCC). METHODS: Between 1997 and 2005, 237 patients underwent curative resection for HCC at Kyungpook National University Hospital. The patients were followed up regularly to detect any recurrences of HCC by performing imaging studies and AFP. Early recurrence was defined as recurrence that occurred within one year after resection. The patients were divided into the early recurrence group and the others, which included both patients without recurrence and with recurrence that occurred later than 1 year after resection. The clinicopathologic factors of both group were compared to identify the prognosis and the risk factors by performing univariate and multivariate analyses. RESULTS: Seventy three patients (30.8%, 73/238) had early recurrence after resection and 164 patients (69.2%, 164/238) didn`t have recurrence in the first year. The survival rate was significantly better in the without early recurrence group than that in the early recurrence group (96.3% vs 60.3% and 85.1% vs 23.4%, 62.8% vs 7.3% 1, 3, 5 years). The risk factors for early recurrence in the HCC patients were a tumor size greater than 5 cm (P=0.011; odds ratio=2.304) and vascular invasion (P=<0.001; odds ratio=6.342). CONCLUSION: Since a large tumor size and vascular invasion are the risk factors for early recurrence, the patients who have these risk factors should be followed up with caution and possible postoperative adjuvant therapeutic trials should be considered.

Analysis of the Surgical Outcome and Quality of Life after Pancreaticoduodenectomy for Nonneoplastic Disease

PURPOSE: Pancreaticoduodenectomy for mass-like lesions that are suspicious of malignancy sometimes reveals only nonneoplastic disease, especially in those cases where adequate tissues for biopsy are unavailable. In this study, we evaluated the outcomes and quality of life (QOL) after pancreaticoduodenectomy for treating nonneoplastic disease. METHODS: The clinical data of 28 patients who underwent pancreaticoduodenectomy for nonneoplatic disease and trauma from Jan. 1992 to Feb. 2006 were reviewed retrospectively. The QOL was evaluated using the FACT-Hep questionnaire. The patients who underwent laparoscopic cholecystectomy for benign gallbladder disease were utilized as the control group. RESULTS: 13.8% (28/203) of all the pancreaticoduodenectomized patients had nonneoplatic disease and trauma. Male patients were predominant (25/28) and all the trauma patients were male. The mean age was 48 (23~72) years old. The indications for surgery included lesions suspicious for malignancy (16 cases), pancreaticoduodenal artery aneurysm (1 case), and pancreatoduodenal injury (11 cases). The histologic findings of the nonneoplastic lesions revealed benign inflammation of the bile duct (6 cases), chronic pancreatitis (8 cases), pancreatic pseudocyst (1 case), and fibrosis of the Ampulla of Vater (1 case). No surgical mortality occurred. However, the trauma patients group had higher morbidity (72.7% Vs 23.5%, respectively, P=0.01) and a longer hospital stay (68.0 days Vs 32.6 days, respectively, P=0.02) after surgery compared to the nonneoplastic disease patient group. The QOL of the patient who underwent pancreaticoduodenectomy for nonneoplatic disease was not different from that of the control group. CONCLUSION: Since pancreaticoduodenectomy for nonneoplastic disease was safe and the QOL of the patients was acceptable, it should be performed more often when malignancies can not be excluded from the differential diagnosis.

Gallbladder Carcinomas found after a Laparoscopic Cholecystectomy

PURPOSE: An laparoscopic cholecystectomy (LC) is being increasingly performed for benign gallbladder disease. Accordingly, gallbladder carcinomas have been increasingly reported in patients after undergoing an LC. This study aims to reveal the clinicopathological features and prognosis of gallbladder carcinomas found after an LC. METHODS: Between April 1994 and March 2007, 2714 patients underwent an LC and 1.5% of the patients were diagnosed histologically as having a gallbladder carcinoma. We retrospectively evaluated the clinicopathological features and long-term survival of the patients. RESULTS: There were 19 male patients and 21 female patients, with a mean age of 60.7 degrees+/-12.3 years. The indications for LC included acute calculous cholecystitis, chronic calculous cholecystitis and polypoid lesions of the gallbladder (PLGs). An LC only was performed in 26 patients (13 pT1a, 7 pT1b and 6 pT2 cases) while additional surgery including gallbladder bed resection and lymph node dissection was performed in 14 patients (2 pT1a, 2 pT1b, 8 pT2 and 2 pT3 cases). The patients with a carcinoma associated with PLGs were younger, had more incidence of pT1a and had well differentiated carcinomas and a better 5-year survival rate as compared to patients with a non-polypoid carcinoma. Whereas no recurrences or deaths occurred for the 24 pT1 patients, two of the 14 pT2 patients had a recurrence. Both pT3 patients had a recurrence despite additional surgery. In patients with pT2 or more, additional surgery did not improve survival (p = 0.82). CONCLUSION: The polypoid morphology of gallbladder carcinoma, but not additional surgery, favorably affects survival of gallbladder carcinoma patients following an LC. However, a further multi-institutional study may be needed to determine the benefit of additional surgery.

A Retroperitoneal Foregut Duplication Cyst: A Case Report

Retroperitoneal foregut duplication cyst is an extremely rare congenital malformation. Pathologically, this lesion contains both gastric mucosa and respiratory type mucosa; radiologically, it is often challenging to differentiate it from the other cystic neoplasms that present a similar appearance. We report here on a case of retroperitoneal foregut duplication cyst that was lined by both gastric and pseudostratified ciliated columnar epithelium, and it was also accompanied by a pancreatic pseudocyst. Initially, it presented with peripancreatic and intrapancreatic cystic masses in an asymptomatic 30-year-old man, and this man has since undergone surgical resection.

Surgical Outcomes and Risk Factors for Gallbladder Carcinoma of Polypoid Lesions of Gallbladder

PURPOSE: Most polypoid lesions of the gallbladder (PLGs) are benign, and laparoscopic cholecystectomy is the treatment of choice unless the suspicion of malignancy is high. PLGs were reviewed to identify risk factors for neoplastic polypoid lesions. METHODS: Between March 1992 and February 2005, 205 cases of PLGs, including 67 neoplastic and 138 nonneoplastic PLGs, were evaluated. Risk factors for neoplastic PLGs and gallbladder carcinomas were analyzed using multiple regression analysis. A receiver operating characteristics (ROC) curve was used to obtain a cut-off value of the tumor size and age of patients for predicting neoplastic PLGs and gallbladder carcinomas. RESULTS: The mean age of the patients, and the size, number and type of polyp were statistically different between 67 neoplastic (47 adenomas, 20 adenocarcinomas) and 138 nonneoplastic PLGs (104 cholesterol polyps, 22 hyperplastic polyps, 11 adenomyomas, and 1 xanthogranulomatous polyp). A multiple regression analysis showed that the size, number and type of polyp were significant risk factors for neoplastic PLGs. Of the 67 neoplastic PLGs, the age of the patient, and the size and type of polyp were significant risk factors of carcinomas. The sizes of tumors for predicting neoplastic PLGs and carcinomas were 0.85 and 1.1 cm, respectively, while the age for predicting a carcinoma was 55 years. In 5 carcinoma patients, an additional curative resection was performed. No recurrence or carcinoma related death were observed in the laparoscopic cholecystectomy (LC) only (15 cases) and additional surgery groups (5 cases). CONCLUSION: Risk factors of a carcinoma in PLGs include the age of the patients, and the size and sessile type of the PLG. The ROC curve showed that the appropriate size of the tumor and the age of the patient for predicting gallbladder cancer in PLGs were 1.1 cm and 55 years, respectively. Additional curative surgery immediately after an LC seems to increase the survival of gallbladder carcinoma patients, but its role should be determined through long term follow-up.

Comparison between Laparoscopic Unroofing and Open Surgery for Nonparasitic Hepatic Cyst

PURPOSE: Nonparasitic hepatic cyst is being increasingly found due to the frequent application of diagnostic imaging. The treatment for nonparasitic hepatic cysts varies according to the nature of the lesion. Many authors have recently reported the benefit of performing laparoscopic unroofing for nonparasitic hepatic cyst. In this study, we reviewed the indications and the results of open surgery and laparoscopic unroofing for nonparasitic hepatic cyst. METHODS: From May 1992 until May 2005, 28 patients underwent an operation for nonparasitic hepatic cyst in our hospital. 12 patients had open surgery and 16 patients had laparoscopic unroofing. The indications and outcomes for open surgery and laparoscopic unroofing were compared. RESULTS: 25 patients were female and 3 patients were male, and the mean age was 59.7 (range: 35~80) years. Non- specific abdominal pain was the most common symptom in 74.4% (20/28) of the patients. The indications for open surgery included suspicious neoplastic cyst (3), hemorrhagic cyst (1), infected cysts (2), a huge cyst involving one lobe (1), cysts in segment 7 (2), and simple cysts that had been operated on before 1996 (2). Three suspicious neoplastic hepatic cysts turned out to be simple cysts on the pathology report. Laparoscopic unroofing was performed for 15 simple nonparasitic hepatic cysts and for one infected cyst. The mean hospital stay was 4.7 days (mean stay: 2~11) for the laparoscopic surgery patients compared to 16.2 days (mean tay: 7~38) for the open surgery patients (p< 0.0005). No morbidity or mortality was present in both groups. CONCLUSION: Laparoscopic unroofing for nonparasitic hepatic cyst is less invasive and it required a shorter hospital stay. Thus, laparoscopic unroofing is favored for the nonparasitic hepatic cyst unless it is complicated by neoplastic cysts.

The Surgeon's Expertise-Outcome Relationship in Gastric Cancer Surgery / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The surgical caseload or duration of practice of a surgeon may influence the outcomes of gastric cancer surgery. This study aimed to clarify the surgical quality provided by specialized gastric cancer surgeons. MATERIALS AND METHODS: The postoperative courses of 1, 877 patients who underwent surgery for gastric cancer were retrospectively reviewed. For classification of the surgeon's expertise, the number of yearly resections performed by, and consecutive years of practice of, the surgeons were used. The outcome measures used were the 30-day mortality and long-term survival. RESULTS: Surgical mortalities of patients who underwent surgery by a specialized surgeon and those by a general surgeon revealed no statistically significant difference. A significant difference in the five-year survival rates was found with surgeons with at least two consecutive years of practice compared to those with less than two years, when 50 or more cases had been conducted per year (63.9% and 59.7%; p=0.0380). In cases of four-years of consecutive practice, the five-year survival rate was significantly improved, even if only 10 cases were performed annually (64.9% and 58.3%; p=0.0023), although the best survival rate was found with surgeons that had performed 50 or more surgeries per year. CONCLUSION: Improved survival rates, with acceptable surgical mortality, can be achieved for gastric cancer when the surgery is performed by a specialized surgeon. A specialized gastric cancer surgeon can be defined as one who has operated on more than 50 new cases per year, with 2 or more consecutive years of surgical practice.

Nonoperative Treatment for Grade IV Liver Injury / 한국간담췌외과학회지

PURPOSE: Though the nonoperative management of liver injury (NOMLI) has frequently been employed for traumatic liver injuries, the indications for NOMLI for grade IV liver injuries are still controversial. To determine the usefulness of the NOMLI in grade IV liver injuries, the clinical features of an operative management (n=26) and a NOMLI group (n=20) were compared. METHODS: For the 10 years up until Feb. 2004, 46 grade IV liver injury cases, according to the AAST liver injury scale, at the Kyung Pook National University Hospital, were selected for this study. The clinical features, grade of liver injury and outcomes of treatments were reviewed retrospectively. RESULTS: Of the 46 cases 40 (87%) and 6 (13%) were male and female, respectively. The mean ages of the male and female cases were 37.6 (15.2 and 34.5 (16.7 years, respectively. The causes of liver trauma were vehicle accident (71.7%, 33/46), industry accident (26.1%, 12/46) and violence (2.2%, 1/46). The accompanying abdominal injury was not present in the NOMLI group compared to 30.8% (8/26) in the operative management group. NOMLI was more than 2 times more frequently indicated after Feb. 1999. The mortality in operative management group was 11.5% (3/26) compared with none in the NOMLI group. 20% (4/20) of NOMLI group failed due to delayed bleeding and eventually had to undergo operations and the 80% (16/20) of NOMLI group was successful. The morbidity in successful NOMLI group was bile collection (6.25%, 1/16) and empyema (6.25%, 1/16). CONCLUSION: Nonoperative management for grade IV liver injury in hemodynamically stable patients without accompanying abdominal injury was successful. However, continuous monitoring and immediate operative management should be prepared for the delayed bleeding.

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.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.

Transduodenal Ampullectomy in Ampullary Neoplasm

PURPOSE: Periampullary malignant tumors become symptomatic at an early stage because of their particular location. For this reason, radical resection is possible in the majority of cases. Periampullary tumors can be removed either by a local resection, as performed by Halsted in 1899, or by a radical pancreaticoduodenectomy, as performed by Whipple et al. in 1935. Both techniques have been used, and their respective places in the treatment of benign or malignant periampullary tumors has been the subject of constant debate. Therefore, we reviewed the cases of four patients who had undergone a transduodenal ampullectomy for an ampullary tumor which was confined to the ampulla of Vater. METHODS: The clinical records of 4 patients who undergone a transduodenal ampullectomy were reviewed. All patients were diagnosed as having an ampullary mass based on gastroduodenoscopy, endoscopic retrograde cholangiopancreatography, or both. Clinical presentation, comparison of pathologic findings of preoperative endoscopic biopsy, operative frozen section, final pathologic examination, complications, follow-up period, and recurrence were reviewed. RESULTS: The two men and the two women studied had a median age of 59.3 (range, 49 to 64 years). Among the four patients who underwent a transduodenal ampullectomy, an adenocarcinoma was found at final pathologic examination in two patients with preoperative diagnoses of a villotubular adenoma and a villous adenoma, respectively. The other two cases were diagnosed as tubular adenomas at final pathologic examination as they had been at the preoperative diagnosis. No evidence of disease was observed in any of the four patients on follow-up at 29 months, 30 months36 months, and 4 months. None of these patients had major complications in the immediate postoperative period, transient hyperamylasemia without clinical significance developed in two patients. CONCLUSION: The transduodenal ampullectomy is a valuable tool in the treatment of ampullary lesions. The result of local excision of the Vater for ampullary tumors appears satisfactory, and this procedure may be particularly indicated for benign tumors, as well as for older or high-risk patients whose malignant lesions are confined to the ampulla of Vater. However, the selection of this procedure required judicious decision making and precise technique and should involve an experienced team of pathologists and surgeons. As a result, for patients in whom it is indicated, a transduodenal ampullectomy is an alternative to the pancreaticoduodenectomy and has good long-term results.

Clinical analysis of surgical management for cystic neoplasms of pancreas / 한국간담췌외과학회지

BACKGROUND: Cystic neoplasms of pancreas comprise pathologically heterogeneous groups of tumors with many shared clinical features. Although relatively uncommon, they have a very important place in the surgical pathology of the pancreas because of their high cure rate and their potential confusion with far more common pancreatic pseudocysts. METHODS: We analysed clinical features of 23 patients with pancreatic cystic neoplasm that we treated within 8-years` period (13 women, 10 men, mean age; 47.2 years old) The cystic neoplasms of pancreas comprise 5 serous cystadenoma, 3 benign mucinous cystic tumor, 3 borderline malignancy of mucinous cystic tumor and 4 mucinous cystadenocarcinoma, 4 papillary cystic tumor, 1 cystic teratoma, 1 cystic mesothelioma, 1 lymphoepithelial cyst. 1 mucinous ductal ectasia. RESULTS: Mean tumor size was 6.8cm(3 to 15cm). 73.9 percent had abdominal pain and 26.1 percent had abdominal mass. Computed tomography, ultrasonography and MRI were useful in detecting cystic mass in all cases but was not reliable to distinguish serous from mucinous tumor, benign from malignant. For the treatment of the tumor, 17 distal pancreatectomy with splenectomy, 1 distal pancreatectomy with spleen preserving, 1 proximal pancreatic resection, 2 local excision of pancreas and 1 PPPD were performed. During the period of follow up (mean: 29 months) after surgical resection, 1 recurrence occurred in the patient who underwent local excision for mucinous cystic tumor showing borderline malignancy on histologic finding. All the patients are alive except 2 patients who were lost to follow-up. CONCLUSION: Pancreatic cystic neoplasms are rare and their prognosis are acceptable when they are treated early and properly. So early detection and surgical treatment is the mainstay of management of cystic neoplasm of pancreas.

Laparoscopic Splenectomy for Chronic Idiopathic Thrombocytopenic Purpura

PURPOSE: In chronic idiopathic thrombocytopenic purpura (ITP), primary treatment is steroid therapy. However treatment with steroids effects a complete response in less than 30% of the patients whereas a splenectomy is successful in more than 60% of the patients who undergo it. The minimal access afforded by a laparoscopic splenectomy (LS) is considered highly desirable for these patients. The purpose of this study was to compare the clinical benefits of a LS with those of conventional open surgery (OS) for patients with ITP. METHODS: The results of 12 subsequent laparoscopic splenectomies performed from December 1996 to May 1998 were compared with those of 10 open splenectomies performed from September 1987 to May 1995. The indications of a splenectomy were medical intractability, recurrent ITP and/or complications of steroids. The operative time, the time to resumption of oral intake, the postoperative hospital stay, the platelet count, the postoperative response rate, the incidence of accessory spleen, and the period of complication after preoperative steroid administration were statistically analyzed (t-test, chi-square test). Also, the timing of the splenectomy was compared. RESULTS: The operative time was longer in the LS patients (LS 221 min, OS 127 min, p=0.0033), but the length of stay (LS 9.3+/-3.87 days, OS 4.6+/-1.92 days, p=0.0033) and duration of ileus (LS 2.9+/-0.32 days, OS 1.9+/-0.90 days, p=0.0002) were shorter in the LS group. There were no significant differences in platelet count, postopertative response rate, and incidence of accessory spleen between the two groups. Accessory spleens were found in 4 patients (18%). The conversion rate was 17% (only 2 initial cases). The splenectomy had been chosen as a second-line treatment in 91.7% and 60% of the LS and OS patients, respectively, and as a third-line treatment in 8.3% and 40% of those patients, but these result have no statistical significance. The time interval between diagnosis and operation also was not significantly different, between the two groups. CONCLUSION: A LS is safe and effective for the management of ITP and allowsrapid recovery. A LS should be the early treatment of choice for patients, who do not response to primary steroid therapy or who have recurrent or complicated ITP. When such patients are managed early surgical laparoscopic treatment, the side effects of steroid may be minimized.

Factors Influencing Mortality in Geriatric Trauma

BACKGROUND: The goal of this study is to identify the factors that predict mortality in elderly trauma patients. METHOD: We reviewed retrospectively the medical record of 144 cases of geriatric trauma admitted to Kyungpook National University Hospital firm January 1998 to December 1998. We evaluated the general characteristics, mechanisms of injury, Revised Trauma Score(RTS), Injury Severity Score(ISS), Probability of survival(Ps) by TRISS(Trauma and Injury Severity Score) method, amount of blood transfused, preexisting disease, complications, length of stay, and mortality. RESULTS: 1. The mean age was 75.39+/-7.89 years old, and male to female ratio was 0.89 : 1. 2. The mechanisms of injury were primarily frills(56.3%) followed by bicycle or motorcycle(13.9%), and pedestrian injuries(13.2%) and motor vehicle accidents(6.9%). 3. The mean Glasgow Coma Scale(GCS), RTS and ISS ate 13.3+/-3.5, 7.2+/-1.4 and 14.2 +/-11.6 respectively. 4. The actual mortality rate was 18.1% (26/144). But by TRISS method, predicted mortality rate was 9.3%(12.5/144), excess mortality rate was 108% and Z score was 3.99 indicating that actual number of death exceed predicted number of death. 5. Between the survivors and nonsurvivors, the insults were significantly different as follows ; systolic blood pressure(141.9+/-28.3 vs. 116.8+/-48.7 mmHg), GCS(14.3+/-2.0 vs. 9.0 +/-5.1), RTS(7.8+/-0.7 vs 5.4+/-2.3), ISS(11.3+/-5.6 vs 27.2+/-20.2), Ps by TRISS(0.97+/-0.06 vs 0.65+/-0.37), preexisting diseases(50.8 vs 69.8%). CONCLUSION: Geriatric patients are more likely to die after trauma than other age groups. The cause of higher actual mortality rate compared to predicted mortality rate was considered as the higher incidence of delayed death due to sepsis or multiple organ failure. In order to reduce the mortality, even with relatively stable initial vile sign, invasive hemodynamic monitoring and intensive treatment are recommended and also, prevention and treatment of nosocomial infection are very important.

Pseudo-obstruction of the Portal Vein in Hepatic Transplantation and Liver Resection: Case Reports / 한국간담췌외과학회지

Confirmation of patency of the portal vein by either ultrasound or angiography is important for evaluating patients considered for living-related liver transplant(LRLT) and liver resection(LR). Portal vein thrombosis(PVT) in LRLT necessitates planning for a technically difficult operation because consideration must be given to obtaining an alternative for splanchnic inflow. When performing LR for hepatocellular carcinoma(HCC), portal vein tumor thrombus was usually thought of as a poor prognositic factor for tumor recurrence. Recently, we experienced two cases of pseudo-obstruction of the portal vein, one in LRLT and the other in LR. In the case of LRLT, a 16-month-old female patient was diagnosed as congenital biliary atresia. PVT had been preoperatively suggested, but the vein was actually open. The patient was successfully transplanted using the left lateral segment of the donor with ordinary portal vein anastomosis and the postoperative course was uneventful except for mild acute rejection episodes. In the case of LR, a 60-year-old male patient presented with incidental symptoms. Preoperative ultrasonography, computed tomography, and angiography showed a 9x8cm-sized mass in the right lobe of the liver with obstruction of the right portal vein, which suggested tumor thrombus. However, the operation disclosed the patency of the portal vein and a right lobectomy was subsequently done. Because of the scanty blood flow of the portal vein due to arterio-portal shunt, PVT was preoperatively suggested. Our experience indicates that more sophisticated image studies are needed for evaluating portal vein patency in the patient who needs hepatic transplant as well as liver resection, and that the surgeon should not hesitate to procede to operative procedures even though conventional studies suggest PVT.