Malignant Pancreatic Serous Cystic Neoplasm: A Case of Local Recurrence and Liver Metastasis that Occurred During Follow-Up

Serous cystic neoplasms of the pancreas are usually benign, with a low malignant potential. Herein, we report a case of malignant serous cystic neoplasm of the pancreas treated with subtotal pancreatectomy, which progressed to local recurrence and metachronous hepatic metastasis during the regular follow-up period.

Ischemic Colitis due to Fibromuscular Dysplasia Limited to the Inferior Mesenteric Artery: A Case Report

Fibromuscular dysplasia is a nonatheromatous, noninflammatory arterial disorder that results in stenosis and/or aneurysm formation and rarely involves the mesenteric arteries. Herein, we report a case of fibromuscular dysplasia limited to the inferior mesenteric artery, which manifested with arterial aneurysms and ischemic colitis.

Impacts on outcomes and management of preoperative magnetic resonance cholangiopancreatography in patients scheduled for laparoscopic cholecystectomy:for whom it should be considered?

Purpose@#We evaluated the impact of preoperative magnetic resonance cholangiopancreatography (MRCP) on patient outcomes, and found which patients should be considered for MRCP before cholecystectomy. @*Methods@#We performed retrospective analysis of 2,072 patients that underwent cholecystectomy for benign gallbladder disease from January 2014 to June 2017. Patients were grouped as CT only group (n = 737) and MRCP group (n = 1,335), including both CT and MRCP (n = 1,292) or MRCP only (n = 43). The main outcome measure was associated with complications after cholecystectomy, and the secondary outcomes were hospital stay, readmission, and events that could impact patient management due to addition of MRCP. @*Results@#There were no statistical differences in occurrence of intraoperative or postoperative complications or readmission rate between the 2 groups. Hospital stay was about 0.6 days longer in the MRCP group. However, MRCP group was more susceptible to complications due to underlying patient demographics (older age, higher frequency of diabetes, and higher level of the inflammatory markers). MRCP diagnosed common bile duct (CBD) stones in 6.5% of patients (84/1,292) without CBD stones in CT, and bile duct anomalies were identified in 41 patients (3.2%). Elevated γ-GT was the only independent factor for additional detection of CBD stones (adjusted odds ratio [OR], 2.89; P = 0.029) and subsequent biliary procedures (adjusted OR, 3.34; P = 0.018) when additional MRCP was performed. @*Conclusion@#MRCP is valuable for identification of bile duct variation and CBD stones. Preoperative MRCP can be considered, particularly in patients with elevated γ-GT, for proper preoperative management and avoidance of complications.

Malignant Pancreatic Serous Cystic Neoplasm: A Case of Local Recurrence and Liver Metastasis that Occurred During Follow-Up

Serous cystic neoplasms of the pancreas are usually benign, with a low malignant potential. Herein, we report a case of malignant serous cystic neoplasm of the pancreas treated with subtotal pancreatectomy, which progressed to local recurrence and metachronous hepatic metastasis during the regular follow-up period.

Bowel Wall Thickness, Elasticity, Intestinal Permeability, and Inflammatory Cytokines in Patients with Cirrhosis and Ascites / 대한내과학회지

BACKGROUND/AIMS@#Previous studies have reported that endotoxemia is associated with pathogenesis and complications in cirrhosis. Endotoxin stimulates the secretion of inflammatory cytokines, which contributes to the development of complications. In addition, endotoxin easily invades the gut barrier system because of the increased intestinal permeability due to portal hypertensive enteropathy. In this report, we explored changes in cytokine levels and intestinal permeability and measured the thickness and elasticity of the bowel wall using ultrasonography in cirrhotic patients.@*METHODS@#We enrolled 40 patients with cirrhosis classified as Child-Pugh B or C and 20 healthy volunteers. Abdominal ultrasonography examinations were used to evaluate bowel wall parameters in the ascending colon and terminal ileum. Intestinal permeability was measured using dual sugar absorption tests with lactulose and mannitol. Levels of tumor necrosis factor (TNF)-α and IL-10 were determined from blood samples. We compared these outcomes between cirrhotic patients and healthy controls and between Child-Pugh B and C patients. In addition, we explored the correlation between cytokine levels, intestinal permeability ratio, and bowel wall parameters in cirrhotic patients.@*RESULTS@#In cirrhotic patients, the ascending colon wall elasticity decreased (20.4 vs. 10.9 kPa, p = 0.048) and the terminal ileum wall thickness increased (4.2 vs. 1.9 mm, p < 0.001). The intestinal permeability ratio and levels of the cytokines TNF-α and IL-10 increased (0.219 vs. 0.017, p < 0.001; 22.47 vs. 13.48 pg/mL, p < 0.001; and 14.91 vs. 8.57 pg/mL, p = 0.019, respectively) in cirrhotic patients. However, there were no significant differences between Child-Pugh classes and no significant correlations between bowel wall parameters and intestinal permeability or cytokine levels.@*CONCLUSIONS@#Ultrasonography revealed bowel wall thickening and decreases in elasticity; in addition, intestinal permeability and cytokine levels increased in cirrhotic patients compared with healthy controls.

Bowel Wall Thickness, Elasticity, Intestinal Permeability, and Inflammatory Cytokines in Patients with Cirrhosis and Ascites / 대한내과학회지

BACKGROUND/AIMS: Previous studies have reported that endotoxemia is associated with pathogenesis and complications in cirrhosis. Endotoxin stimulates the secretion of inflammatory cytokines, which contributes to the development of complications. In addition, endotoxin easily invades the gut barrier system because of the increased intestinal permeability due to portal hypertensive enteropathy. In this report, we explored changes in cytokine levels and intestinal permeability and measured the thickness and elasticity of the bowel wall using ultrasonography in cirrhotic patients.METHODS: We enrolled 40 patients with cirrhosis classified as Child-Pugh B or C and 20 healthy volunteers. Abdominal ultrasonography examinations were used to evaluate bowel wall parameters in the ascending colon and terminal ileum. Intestinal permeability was measured using dual sugar absorption tests with lactulose and mannitol. Levels of tumor necrosis factor (TNF)-α and IL-10 were determined from blood samples. We compared these outcomes between cirrhotic patients and healthy controls and between Child-Pugh B and C patients. In addition, we explored the correlation between cytokine levels, intestinal permeability ratio, and bowel wall parameters in cirrhotic patients.RESULTS: In cirrhotic patients, the ascending colon wall elasticity decreased (20.4 vs. 10.9 kPa, p = 0.048) and the terminal ileum wall thickness increased (4.2 vs. 1.9 mm, p < 0.001). The intestinal permeability ratio and levels of the cytokines TNF-α and IL-10 increased (0.219 vs. 0.017, p < 0.001; 22.47 vs. 13.48 pg/mL, p < 0.001; and 14.91 vs. 8.57 pg/mL, p = 0.019, respectively) in cirrhotic patients. However, there were no significant differences between Child-Pugh classes and no significant correlations between bowel wall parameters and intestinal permeability or cytokine levels.CONCLUSIONS: Ultrasonography revealed bowel wall thickening and decreases in elasticity; in addition, intestinal permeability and cytokine levels increased in cirrhotic patients compared with healthy controls.

Resection plane-dependent error in computed tomography volumetry of the right hepatic lobe in living liver donors

BACKGROUND/AIMS: Computed tomography (CT) hepatic volumetry is currently accepted as the most reliable method for preoperative estimation of graft weight in living donor liver transplantation (LDLT). However, several factors can cause inaccuracies in CT volumetry compared to real graft weight. The purpose of this study was to determine the frequency and degree of resection plane-dependent error in CT volumetry of the right hepatic lobe in LDLT. METHODS: Forty-six living liver donors underwent CT before donor surgery and on postoperative day 7. Prospective CT volumetry (VP) was measured via the assumptive hepatectomy plane. Retrospective liver volume (VR) was measured using the actual plane by comparing preoperative and postoperative CT. Compared with intraoperatively measured weight (W), errors in percentage (%) VP and VR were evaluated. Plane-dependent error in VP was defined as the absolute difference between VP and VR. % plane-dependent error was defined as follows: |VP–VR|/W∙100. RESULTS: Mean VP, VR, and W were 761.9 mL, 755.0 mL, and 696.9 g. Mean and % errors in VP were 73.3 mL and 10.7%. Mean error and % error in VR were 64.4 mL and 9.3%. Mean plane-dependent error in VP was 32.4 mL. Mean % plane-dependent error was 4.7%. Plane-dependent error in VP exceeded 10% of W in approximately 10% of the subjects in our study. CONCLUSIONS: There was approximately 5% plane-dependent error in liver VP on CT volumetry. Plane-dependent error in VP exceeded 10% of W in approximately 10% of LDLT donors in our study. This error should be considered, especially when CT volumetry is performed by a less experienced operator who is not well acquainted with the donor hepatectomy plane.

Impact of high-grade obstruction on outcomes in patients with appendiceal inflammatory masses managed by nonoperative treatment

PURPOSE: To retrospectively assess the impact of high-grade obstructions identified on initial CT on outcomes of patients with appendiceal inflammatory masses managed by nonoperative treatment. METHODS: Institutional Review Boards approved this retrospective study and informed consent was waived. Included were 52 consecutive patients diagnosed with appendiceal inflammatory masses by CT scan and managed by nonoperative treatment. The main outcome measure was treatment failure and secondary outcomes were complications and initial and total hospital stay. Patient demographics, inflammatory markers, and CT findings for presence of an appendiceal inflammatory mass and high-grade obstruction were assessed. Patients with and without high-grade obstruction were compared for patient characteristics and outcomes using Fisher exact test and Student t-test. RESULTS: Among 52 patients, 14 (27%) had high-grade obstruction on CT examination at presentation. No significant differences were observed in patient characteristics (P > 0.05), treatment failure (P = 0.33), complications (P = 0.29), or initial (P = 0.73) or total (P = 0.72) hospitalization between patients with and without high-grade obstruction. CONCLUSION: For patients who were managed by nonoperative treatment for appendiceal inflammatory masses, the presence of high-grade obstruction identified on initial CT scan did not significantly affect outcomes of treatment failure, complications, and initial and total hospitalization.

Single-Shot Echo-Planar Diffusion-Weighted MR Imaging at 3T and 1.5T for Differentiation of Benign Vertebral Fracture Edema and Tumor Infiltration

OBJECTIVE: To compare the apparent diffusion coefficient (ADC) value using single-shot echo-planar imaging sequences at 3T and 1.5T for differentiation of benign fracture edema and tumor infiltration of the vertebral body. MATERIALS AND METHODS: A total of 46 spinal examinations were included in the 1.5T MRI group, and a total of 40 spinal examinations were included in the 3T MRI group. The ADC values of the lesion were measured and calculated. The diagnostic performance of the conventional MR image containing sagittal T2-weighted fat saturated image and each diffusion weighted image (DWI) with an ADC value with different b values were evaluated. RESULTS: The mean ADC value of the benign lesions was higher than that of the malignant lesions on 1.5T and 3T (p 0.05). The diagnostic accuracies were higher when either of the DWIs (b values of 400 and 1000) was added to routine MR image for 1.5T and 3T. Statistical differences between 1.5T and 3T or between b values of 400 and 1000 were not seen. CONCLUSION: The ADC values of the benign lesions were significantly higher than those of the malignant lesions on 1.5T and 3T. There was no statistically significant difference in the diagnostic performances when either of the DWIs (b values of 400 and 1000) was added to the routine MR image for 1.5T and 3T.

Impact of hypothyroidism on the development of non-alcoholic fatty liver disease: A 4-year retrospective cohort study

BACKGROUND/AIMS: Hypothyroidism is reported to contribute to the development of nonalcoholic fatty liver disease (NAFLD). We compared the risk of the development of NAFLD among three groups with different thyroid hormonal statuses (control, subclinical hypothyroidism, and overt hypothyroidism) in a 4-year retrospective cohort of Korean subjects. METHODS: Apparently healthy Korean subjects without NAFLD and aged 20-65 years were recruited (n=18,544) at health checkups performed in 2008. Annual health checkups were applied to the cohort for 4 consecutive years until December 2012. Based on their initial serum-free thyroxine (fT4) and thyroid-stimulating hormone (TSH) levels, they were classified into control, subclinical hypothyroidism (TSH >4.2 mIU/L, normal fT4), and overt hypothyroidism (TSH >4.2 mIU/L, fT4 <0.97 ng/dL) groups. NAFLD was diagnosed on the basis of ultrasonography findings. RESULTS: NAFLD developed in 2,348 of the 18,544 subjects, representing an overall incidence of 12.7%: 12.8%, 11.0%, 12.7% in the control, subclinical hypothyroidism, and overt hypothyroidism groups, respectively. The incidence of NAFLD did not differ significantly with the baseline thyroid hormonal status, even after multivariate adjustment (subclinical hypothyroidism group: hazard ratio [HR]=0.965, 95% confidence interval [CI]=0.814-1.143, P=0.67; overt hypothyroidism group: HR=1.255, 95% CI=0.830-1.899, P=0.28). CONCLUSIONS: Our results suggest that the subclinical and overt types of hypothyroidism are not related to an increased incidence of NAFLD.

Immunohistochemical Expression of p53, Bcl-2, and Ki-67 Proteins in Traditional Serrated Adenomas of Colon / 대한소화기학회지

BACKGROUND/AIMS: Serrated adenomas of the colon show mixed characteristics of both hyperplastic and adenomatous polyps. Serrated adenomas are known to progress via the serrated pathway than the adenoma-carcinoma pathway. The aim of this study was to evaluate the characteristics of traditional serrated adenomas compared to hyperplastic polyps and tubular adenomas by using immunohistochemical staining for p53, Bcl-2, and Ki-67. METHODS: Age, sex, location, size and the immunoexpression of p53, Bcl-2, and Ki-67 were retrospectively analyzed in 20 traditional serrated adenomas, 20 hyperplastic polyps, and 20 tubular adenomas from January 2007 to December 2012 at The Catholic University of Korea, Yeouido St. Mary's Hospital. RESULTS: There was no difference in Bcl-2 and p53 expression between traditional serrated adenomas and hyperplastic polyps. Ki-67 Expression of traditional serrated adenomas was higher than that of hyperplastic polyps (p=0.001). Ki-67 and p53 expression was similar between traditional serrated and tubular adenomas. Bcl-2 expression of traditional serrated adenomas was lower than that of tubular adenomas (p=0.001). Regarding the expression of p53, Bcl-2, and Ki-67 in traditional serrated adenomas, there were no statistical differences among age, sex, location, and size. CONCLUSIONS: Our study suggested that Ki-67 may be helpful in distinguishing traditional serrated adenomas from hyperplastic polyps, and p53 expression may be ineffective in distinguishing between traditional serrated and tubular adenomas. From Bcl-2 expression, it is suggested that the tumorigenesis of traditional serrated adenomas is lower than that of tubular adenomas.

Immunohistochemical Expression of p53, Bcl-2, and Ki-67 Proteins in Traditional Serrated Adenomas of Colon / 대한소화기학회지

BACKGROUND/AIMS: Serrated adenomas of the colon show mixed characteristics of both hyperplastic and adenomatous polyps. Serrated adenomas are known to progress via the serrated pathway than the adenoma-carcinoma pathway. The aim of this study was to evaluate the characteristics of traditional serrated adenomas compared to hyperplastic polyps and tubular adenomas by using immunohistochemical staining for p53, Bcl-2, and Ki-67. METHODS: Age, sex, location, size and the immunoexpression of p53, Bcl-2, and Ki-67 were retrospectively analyzed in 20 traditional serrated adenomas, 20 hyperplastic polyps, and 20 tubular adenomas from January 2007 to December 2012 at The Catholic University of Korea, Yeouido St. Mary's Hospital. RESULTS: There was no difference in Bcl-2 and p53 expression between traditional serrated adenomas and hyperplastic polyps. Ki-67 Expression of traditional serrated adenomas was higher than that of hyperplastic polyps (p=0.001). Ki-67 and p53 expression was similar between traditional serrated and tubular adenomas. Bcl-2 expression of traditional serrated adenomas was lower than that of tubular adenomas (p=0.001). Regarding the expression of p53, Bcl-2, and Ki-67 in traditional serrated adenomas, there were no statistical differences among age, sex, location, and size. CONCLUSIONS: Our study suggested that Ki-67 may be helpful in distinguishing traditional serrated adenomas from hyperplastic polyps, and p53 expression may be ineffective in distinguishing between traditional serrated and tubular adenomas. From Bcl-2 expression, it is suggested that the tumorigenesis of traditional serrated adenomas is lower than that of tubular adenomas.

Treatment Strategy Based on Multimodal Management Outcome of Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF) / 신경중재치료의학

PURPOSE: Angiographic finding including venous drainage pattern should be correlated to the presenting symptom pattern (SxP) in CSDAVF. We present outcome of CSDAVF management and suggest a strategy according to SxP and type of treatment based on our experience. MATERIALS AND METHODS: We evaluated SxP, angiographic type (proliferative, restrictive or late restrictive), mode of treatment (embolization, Gamma Knife Radiation (GKR) or conservative management), mode of embolization (transarterial or transvenous), and final clinical status (cure, improvement, aggravation or no change). Ninety consecutive patients were included from a prospective database. The mean follow-up was 17 months. We compared the outcomes according to SxP, angiographic type, mode of treatment, and embolization using the chi-square or Fisher's exact test. RESULTS: Ninety patients with 34 proliferative, 40 restrictive, and 16 late restrictive types of CSDAVF were treated by embolization (n = 63), GKR (n = 7), and conservative management (n = 20). Cure or improvement was 91% after embolization, 88% after conservative management, and 72% after GKR. Following embolization, 100% of 24 proliferative types, 87% of 30 restrictive types, and 90% of 10 late restrictive types were cured or improved. Cure or improvement after transvenous embolization was 98% (43/44) compared with 88% (15/17) after transarterial embolization (p = 0.003). CONCLUSION: Various factors of SxP, angiographic type, and mode of treatment should be considered in order to obtain a more favorable outcome for patients with CSDAVF. Embolization via venous approach tended to result in a more complete cure than that via arterial approach.

Chondroblastoma of the Lumbar Spine: A Case Report and Review of the Literature

We report a case of chondroblastoma arising in the lumbar spine in a 25-year-old man who presented with low back pain of 5 years duration. Plain radiography and computed tomography revealed a well-defined osteolytic mass surrounded by marginal sclerosis in the third lumbar vertebra. The mass encroached on the left neural foramen on magnetic resonance imaging. Histologically, the tumor consisted of round to oval cells with eosinophilic cytoplasm and randomly scattered osteoclastic type giant cells. There were characteristic chicken-wire calcification and aneurysmal bone cyst-like changes. Chondroblastomas of the lumbar spine are extremely rare, and only nine cases have been reported. Spinal chondroblastoma should be distinguished from other benign bone tumors, because it tends to show aggressive biological behavior with high recurrence and mortality rates.

Severe Atherosclerotic Cerebral Steno-occlusion in Koreans: Factors Related to Intracranial versus Extracranial Involvement / 신경중재치료의학

PURPOSE: To evaluate the factors related to severe intracranical atherosclerotic stenosis (intracranial vs. extracranial) as diagnosed by conventional angiography in Korean patients. MATERIALS AND METHODS: We retrospectively analyzed the angiographic results and clinical data of 127 consecutive patients with an angiographically confirmed stenosis greater than 70%. Nine factors, i.e. age, gender, hypertension, diabetes mellitus, hyperlipidemia, smoking and alcohol habit, previous stroke and ischemic heart disease were included as presumed explanatory variables to discriminate different types of atherosclerotic stenosis (extracranial versus intracranial stenosis). Multiple logistic regression analysis was used to estimate independent effects of the predictive variables on cerebral occlusive disease. RESULTS: Among 127 patients, 62 patients had intracranial stenosis and 65 patients had extracranial stenosis. Compared to extracranial stenosis, mean age was lower (p < 0.001), female-to-male ratio was higher (p = 0.001) and the number of patients with diabetes mellitus was less (p = 0.019) in group of severe intracranial stenosis significantly. There were no differences in hypertension, smoke and alcohol, hyperlipidemia, ischemic heart disease and previous stroke between two groups. CONCLUSION: In Korean patients, severe atherosclerotic intracranial stenosis has younger, female and diabetes-free preference than severe atherosclerotic extracranial stenosis.

Solitary Fibrous Tumor of the Pancreas: Imaging Findings

We report here a case of a pathologically proven solitary fibrous tumor of the pancreas. A 54-year-old man was referred to our hospital for further evaluation of a pancreatic mass that was found incidentally. CT, MR imaging, and endoscopic ultrasonography showed a well-defined, enhancing mass with cystic portions of the pancreas body. MR cholangiopancreatography showed no pancreatic duct dilatation. A solitary fibrous tumor of the pancreas is a very rare lesion.