Regular exercise training increases the number of endothelial progenitor cells and decreases homocysteine levels in healthy peripheral blood.

Endothelial progenitor cells (EPCs) are known to play an important role in the repair of damaged blood vessels. We used an endothelial progenitor cell colony-forming assay (EPC-CFA) to determine whether EPC numbers could be increased in healthy individuals through regular exercise training. The number of functional EPCs obtained from human peripheral blood-derived AC133 stem cells was measured after a 28-day regular exercise training program. The number of total endothelial progenitor cell colony-forming units (EPC-CFU) was significantly increased compared to that in the control group (p=0.02, n=5). In addition, we observed a significant decrease in homocysteine levels followed by an increase in the number of EPC-CFUs (p=0.04, n=5), indicating that the 28-day regular exercise training could increase the number of EPC colonies and decrease homocysteine levels. Moreover, an inverse correlation was observed between small-endothelial progenitor cell colony-forming units (small-EPC-CFUs) and plasma homocysteine levels in healthy men (r=-0.8125, p=0.047). We found that regular exercise training could increase the number of EPC-CFUs and decrease homocysteine levels, thus decreasing the cardiovascular disease risk in men.

Negative pressure wound therapy for inguinal lymphatic complications in critically ill patients.

PURPOSE: In this study, we investigated the therapeutic potential of regulated negative pressure vacuum-assisted wound therapy for inguinal lymphatic complications in critically ill, liver transplant recipients. METHODS: The great saphenous vein was harvested for hepatic vein reconstruction during liver transplantation in 599 living-donor liver transplant recipients. Fourteen of the recipients (2.3%) developed postoperative inguinal lymphatic complications and were treated with negative pressure wound therapy, and they were included in this study. RESULTS: The average total duration of negative pressure wound therapy was 23 days (range, 11 to 42 days). Complete resolution of the lymphatic complications and wound healing were achieved in all 14 patients, 5 of whom were treated in hospital and 9 as outpatients. There was no clinically detectable infection, bleeding or recurrence after an average follow-up of 27 months (range, 7 to 36 months). CONCLUSION: Negative pressure wound therapy is an effective, readily-available treatment option that is less invasive than exploration and ligation of leaking lymphatics and provides good control of drainage and rapid wound closure in critically ill patients.

Embolic stroke after carotid artery ligation during carotid body tumor resection.

This report describes a case of a delayed cerebral embolic infarction, after internal carotid artery (ICA) ligation secondary to carotid body tumor resection. We describe a 34-year-old woman who underwent left ICA ligation during a large carotid body tumor surgery. Immediately after surgery, the patient was neurologically asymptomatic; however, she subsequently developed a cerebral embolic infarction nine hours postoperatively. After beginning antiplatelet therapy, all symptoms ultimately resolved, although over a gradual course. Since the ligation of the ICA can cause thromboembolic infarctions of the cerebrum, we contend that antiplatelet agents be administered to prevent and/or treat embolic strokes.

Surgical treatment of inferior vena cava invasion in patients with renal pelvis transitional cell carcinoma by use of human cadaveric aorta.

We herein report a case of radical nephroureterectomy and replacement of the inferior vena cava (IVC) with ahuman cadaveric aortic graft for a patient with renal pelvis transitional cell carcinoma associated with IVC infiltration. In advanced disease, radical surgery is essential to achieve long-term survival. This case entails the use of another treatment option among the numerous options currently available for the management of patients with advanced renal cancer associated with IVC invasion.

Report of a case of ischemic colitis with bilaterally patent internal iliac arteries after endovascular abdominal aneurysm repair.

During endovascular aneurysm repair (EVAR), interruption of the internal iliac arteries (IIAs) or the inferior mesenteric artery by stents or embolization is thought to cause colon ischemia. To minimize this risk, attempts have been made to preserve the IIAs using iliac branch devices or IIA revascularization. Here we present our experience of colon ischemia after EVAR in a patient with bilaterally patent IIAs without evidence of embolism. A 70-year-old man had abdominal pain and a ruptured abdominal aortic aneurysm was found. We performed EVAR with custom-made tube grafts preserving the bilateral IIAs. On postoperative day 2, the patient complained of abdominal pain, a sigmoidoscopy was performed revealing colon ischemia. On laparotomy, transmural infarction of the sigmoid colon was found and resected. Because IIA preservation cannot guarantee protection against colon ischemia, surgeons should maintain a high level of suspicion and use surveillance liberally after EVAR for early diagnosis of colon ischemia, even if both IIAs are preserved.

More than 7-year survival of a patient following repeat hepatectomy for total 20 colon cancer liver metastases.

A 54-year-old man was transferred with sigmoid colon cancer combined with multiple bilobar liver metastases. Nine metastases were in the left lobe and 5 metastases were in the right lobe. After low anterior resection, all 9 lesions in the left lobe were completely removed by wedge resections. Because the remnant liver volume after multiple wedge resection of the left lobe was not sufficient to perform a right hepatectomy simultaneously, we planned a two-stage hepatectomy. Right portal vein embolization was performed one week after the first liver operation. A right hepatectomy was safely performed 22 days after the first hepatectomy. A recurrent mass developed in the segment III 18 months after the right hepatectomy. Radiofrequency ablation (RFA) was performed to remove that lesion. Five other metastases developed 18 months after RFA whereby multiple wedge resections were performed. The patient has survived for more than 7 years after the first liver operation.

Outcomes of salvage procedures for occluded autogenous radiocephalic arteriovenous fistula.

The outcomes of surgical and endovascular treatments for thrombosed access fistulas are variable and provide no definitive indications for treatment choice. We purposed to review our experience in treating thrombosed radiocephalic arteriovenous fistulas (AVFs) and to evaluate the outcome of procedures, including proximal neo-anastomosis (NEO), replacement of the stenosed segment with a polytetrafluoroethylene graft (GI), patch angioplasty (PA), and endovascular procedures (such as percutaneous transluminal angioplasty [PTA]). A total of 117 occluded radiocephalic AVFs were treated by surgery or an endovascular procedure from January 2002 to December 2007. We evaluated the rates of initial success, re-thrombosis, the post-interventional five-year patency rate, and temporary catheter requirement. Forty-five patients (38.5%) underwent NEO, 32 patients (27.4%) GI, 10 patients (8.5%) PA, and 30 patients (25.6%) PTA. The overall initial procedural success rate was 98.3% (surgery 98.9% and PTA 96.7%), and the post-interventional patency rates at five years were 92.2% (97.1% for NEO, 82.7% for GI, 90.0% for PA, and 96.7% for PTA). Twenty-four patients (20.5%) required a temporary catheter during healing of the functioning segment after treatment: four patients for NEO, 18 patients for GI, two patients for PA, and no patients for PTA (P < 0.001). Both surgery and endovascular treatment gave high rates of initial success and low re-thrombosis rates as salvage treatments for occlusion of radiocephalic AVFs, if treatments were selected according to the length, and location of the stenosis to be corrected. When stenosis of a long segment is suspected, endovascular treatment should be attempted first in order to maintain the functional segment and thereby avoid use of a temporary catheter.

In situ polytetrafluoroethylene graft bypass for primary infected aneurysm of the infrarenal abdominal aorta.

BACKGROUND: Reinfection is a major issue of surgical treatment for patients with infected abdominal aortic aneurysm (AAA). The present report describes outcomes after use of our procedure for treating patients with infected aneurysm of the infrarenal abdominal aorta. The procedure involved an in situ polytetrafluoroethylene (PTFE) graft bypass and omental wrapping of the graft. The procedure was used regardless of the presence of Gram-stain-positive pus or tissue or the type of pathogen identified. METHODS: We retrospectively reviewed nine consecutive patients with primary infected aneurysms of the infrarenal abdominal aorta treated from June 2001 to August 2006 at the Asan Medical Center, Seoul, Korea. Diagnosis was based on preoperative abdominopelvic CT scans. Treatment involved removal of all infected tissue, including infected aorta tissue, in situ PTFE graft reconstruction, and wrapping of the graft with retrocolically transposed great omentum. Sensitive antibiotics were administered before and after the operation. RESULTS: In all cases, aneurysms were the result of aortitis and aortic wall perforation, and presented as aortic pseudoaneurysms with rupture. The pathogens identified were Salmonella non-typhi (n = 4), Klebsiella pneumoniae (n = 2), Streptococcus pneumoniae (n = 1), Citrobacter freundii (n = 1), and Brucella abortus (n = 1). There was no infection-related morbidity or mortality during a median follow-up period of 49 months. CONCLUSIONS: Surgical treatment comprising complete removal of all infected tissue, in situ PTFE graft reconstruction, and omental wrapping of the graft was effective in treating infected AAA. Key adjunct procedures were a precise preoperative diagnosis using abdominopelvic CT scans, and pre- and postoperative sensitive antibiotic treatment.

Surgical treatment of inferior vena cava tumor thrombus in patients with renal cell carcinoma.

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. Cephalic extension of the thrombus is closely related to perioperative morbidity. We purposed to design a safe and successful surgical strategy through a review of our surgical experience and treatment results in 35 patients (male:female=28:7, mean age=56 yr [32-77]) who underwent IVC thrombectomy with radical nephrectomy between January 1997 and December 2006. The limit of tumor extension was level I in 10 patients (28.6%), level II in 17 (48.6%), and level III and IV in 4 patients each (11.4%). Liver mobilization with hepatic vascular exclusion was performed in 12 patients and cardiopulmonary bypass in 7. Thirty-two primary closures, 2 patch closures, and 1 graft interposition were performed. One patient underwent simultaneous pulmonary embolectomy because of an operative pulmonary embolism. There was no operative mortality, and the overall survival at 5-yr was 50.8%. Complete thrombus removal without tumor fragmentation under long venotomy on fully exposed involved IVC is recommended for successful result in a bloodless operative field. The applicability of liver mobilization, hepatic vascular exclusion, and cardiopulmonary bypass, can be determined by the level of thrombus.

Prognostic impact of sarcomatous change of hepatocellular carcinoma in patients undergoing liver resection and liver transplantation.

Sarcomatous change has been rarely observed in hepatocellular carcinoma (HCC), but it is usually associated with very aggressive tumor behavior and widespread metastasis. To assess the impact of sarcomatous changes, we analyzed the outcomes of 15 patients with sarcomatous HCC after resection (n = 11) or liver transplantation (LT) (n = 4). No imaging findings characteristic of sarcomatous changes were observed. According to modified pathological tumor-node metastasis staging, the HCC lesions were classified as stage II in five patients, stage III in six, stage IVa2 in two, and stage IVb in one. The Milan criteria were met in 7 of 15 patients, including 3 of 4 in the LT group. R0 resection was achieved in 9 of 11 resected patients, and their 3-year overall and disease-free survival rates were both 18.2%. In the LT group, 3-year overall and disease-free survival rates were 37.5 and 25%, respectively. In patients within the Milan criteria, 2-year overall survival rate was 25% after resection and 33% after LT, showing no prognostic difference. Extrahepatic metastasis as initial recurrence was detected in 80% after resection and 66.7% after LT. In conclusion, we found that the prognosis of patients with sarcomatous HCC was very unfavorable after either resection or LT and that, except for liver biopsy, no diagnostic method could distinguish between sarcomatous and ordinary HCC. Vigorous postoperative systemic surveillance may be helpful for timely detection and treatment of localized metastases.

Surgical treatment of primary neuroendocrine tumors of the liver.

Primary neuroendocrine tumor (NET) of the liver is a very rare neoplasm, requiring strict exclusion of possible extrahepatic primary sites for its diagnosis. We have analyzed our clinical experience of eight patients with hepatic primary NET. From January 1997 to December 2006, eight patients with a mean age of 50.4 +/- 9.5 years underwent liver resection for primary hepatic NET. Seven patients underwent preoperative liver biopsies, which correctly diagnosed NET in four. Of the eight patients, six underwent R0 and two underwent R1 resection. Diagnosis of hepatic primary NET was confirmed immunohistochemically and by the absence of extrahepatic primary sites. All tumors were single lesions, of mean size 8.6 +/- 5.7 cm, and all showed positive staining for synaptophysin and chromogranin. During a mean follow-up of 34.0 +/- 39.7 months, three patients died of multiple liver metastases after tumor recurrence, whereas the other five remain alive to date, making the 5-year recurrence rate 40% and the 5-year survival rate 56.3%. Univariate analysis showed that Ki67 proliferative index was a risk factor for tumor recurrence. In conclusion, although primary hepatic NET is very rare, it should be distinguished from other liver neoplasms. The mainstay of treatment is curative liver resection.

Effect of a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis in pancreaticoduodenectomy: a single surgeon's experiences.

BACKGROUND/AIMS: The aim of the present study is to ascertain the effect of a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis in pancreaticoduodenectomy through a single surgeon's experiences. METHODOLOGY: From March 1, 2002 to March 31, 2005, among 512 patients who had pancreaticoduodenectomy at Asan Medical Center, 56 patients who had a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis were selected consecutively for prospective study. RESULTS: There were 44 pylorus-preserving pancreaticoduodenectomy, 10 pancreaticoduodenectomy, 2 hepatopancreaticoduodenectomy. No pancreatic leakage was reported. All three wound infections recovered after conservative treatment, and a gastric ulcer bleeding was resolved by suture-ligation through laparotomy. There was no mortality after surgery. CONCLUSIONS: Although it is a report with low surgical volume, a single layer continuous suture between pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis in pancreaticoduodenectomy is thought to be a good method to prevent the complications of pancreatic leakage using a tight close attachment of pancreas and jejunum.

Retroduodenal resection of ampullary carcinoid tumor in a patient with cavernous transformation of the portal vein.

Although pancreatoduodenectomy is the standard treatment for periampullary neoplasms, limited pancreas-preserving resections are sometimes performed. This report describes a carcinoid tumor of the ampulla of Vater for which pancreatoduodenectomy was not feasible because of diffuse cavernous transformation of the portal vein (PV) secondary to main PV obliteration of unknown cause. We performed retroduodenal resection of the ampullary carcinoid with total preservation of the pancreas. The duodenal wall defect was primarily repaired, and the pancreatic and bile ducts were separately reconstructed using Roux-en-Y pancreaticojejunostomy and choledochojejunostomy. The patient recovered uneventfully and is currently progressing well at 10 months postoperatively, with no tumor recurrence or complications. The surgical procedures are described, and the literature pertaining to this limited surgery is reviewed.

Neurologic complications in adult living donor liver transplant recipients.

BACKGROUND: Neurologic complications (NC) after liver transplantation are not uncommon, with serious complications such as central pontine myelinolysis (CPM), often causing disability. OBJECTIVE: We investigated the incidence and features of NC following liver transplantation in adult recipients. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 319 adult patients who underwent liver transplantation between January 2004 and May 2005 at the Asan Medical Center. RESULTS: Neurologic complications developed in 49 of 319 patients (15.4%). Although most of these complications were minor, including tremor and foot drop, three patients developed CPM, and one each developed posterior leukoencephalopathy, cerebral hemorrhage, and cerebral infarction. One-yr survival rates were 95.9% in patients without NC and 83.7% in patients with NC (p = 0.004). Hospital stay was prolonged in patients with NC. Graft-to-recipient body weight ratio (GRWR) did not affect occurrence of NC. CONCLUSIONS: Neurologic complications were not uncommon in liver transplant recipients. These complications contributed to prolongation of hospital stay, increased in-hospital mortality, and decreased graft and patient survival. Every effort should be made to prevent NC, as well as to detect and treat them as soon as possible.

Preoperative evaluation of biliary anatomy of donor in living donor liver transplantation by conventional nonenhanced magnetic resonance cholangiography.

Detailed preoperative evaluation of the biliary anatomy of the donor in living donor liver transplantation (LDLT) can minimize postoperative morbidity in the recipient and maximize safety for the donor. We prospectively evaluated the diagnostic accuracy and clinical usefulness of nonenhanced conventional magnetic resonance cholangiography (MRC) for depicting the biliary anatomy of LDLT donors. MRC and intraoperative cholangiography (IOC) examinations of 111 donors were performed between August 2005 and February 2006. We observed the classical branching pattern of the biliary system in 67 subjects (60.4%), with the remaining 44 subjects (39.6%) showing anatomical variations. MRC showed accurate anatomy of the biliary system, using IOC as the reference standard, in 98 (88.3%) subjects. MRC had a sensitivity in differentiating normal from variant anatomy of 95.5%, specificity of 95.2%, a positive predictive value of 96.8% and a negative predictive value of 93.3%. The agreement between MRC and IOC findings, as evaluated by kappa-value (0.865) was statistically significant (P<0.001). In conclusion, the diagnostic accuracy of conventional nonenhanced MRC is sufficient for this method to be used for the preoperative evaluation of biliary anatomy in LDLT donor candidates.

Ligation of left renal vein for large spontaneous splenorenal shunt to prevent portal flow steal in adult living donor liver transplantation.

Persistance of a large spontaneous splenorenal shunt (SRS) may result in graft failure in adult living donor liver transplantation (LDLT) because it reduces the effective portal perfusion to the partial liver graft by diversion of hepatotrophic portal flow into this hepatofugal pathway. We performed a prospective study to evaluate the efficacy of ligation of left renal vein (LRV) to prevent portal flow steal and the safety of this procedure to the renal function in adult LDLT patients with SRS. Between October 2001 and January 2005, 44 cirrhotic patients with large SRS underwent LDLT with ligation of LRV. Each patient received pre- and postoperative computed tomography and Doppler USG to assess the changes of collaterals and portal flow, as well as serial renal and liver function tests. Portal flow after ligation of LRV was statistically and significantly increased when compared with pre-operative value (P = 0.001). Whereas four patients (9.1%) demonstrated sustained, elevated serum creatinine levels after operation, the renal function tests returned to normal in 40 patients. All patients recovered with satisfactory regeneration of the partial liver graft and there was no procedure-related permanent renal dysfunction. In conclusion, ligation of LRV to prevent a 'portal steal phenomenon' seems to be a safe and effective graft salvage procedure for large spontaneous SRS (>10-mm diameter) in adult LDLT.

[Surgical treatment of sclerosing hepatocellular carcinoma].

BACKGROUND/AIMS: Sclerosing hepatocellular carcinoma (HCC) is an unusual subtype of HCC that is characterized by an embedded dense fibrous stroma in the tubular neoplastic structures. We aimed to assess the surgical approaches and outcomes of sclerosing HCC. METHODS: We retrospectively analyzed the clinicopathologic features of 6 patients with sclerosing HCC who underwent surgical treatment at Asan Medical Center between July 1989 and December 2005. RESULTS: Six HCC patients with sclerosing HCC were diagnosed out of the total 1390 HCC patients (0.43%) during the study period. The mean age was 58 years and 4 patients were male. Weight loss and abdominal pain were the most common symptoms. The serum calcium and phosphorus levels were normal in all the patients. All of them were hepatitis B surface antigen-positive, but none was positive for hepatitis C. All the lesions were solitary. The tumor size ranged from 45 to 150 mm in diameter (median size: 81 mm). We performed right trisegmentectomy (n=1), central bisegmentectomy (n=1), right anterior segmentectomy (n=1), ex-vivo resection and autotransplantation (n=1) and right posterior segmentectomy (n=2). The median overall survival and disease free-survival periods were 24 months and 9.5 months, respectively. CONCLUSIONS: The incidence of sclerosing HCC was very low. Sclerosing HCC was often not correctly diagnosed before an operation, but performing resection prolonged the patients' survival and their prognosis was not worse than that for ordinary HCC. Our experience implicates that aggressive surgical treatment for sclerosing HCC is beneficial for patient survival.