Complex Hypersensitivity and Irritation Reaction (CHAIR) Phenomenon after Cyanoacrylate Closure of Varicose Vein

Cyanoacrylate glue is a non-thermal, non-tumescent agent used to treat saphenous reflux. It was introduced to overcome heat-related discomfort and complications. Multiple randomized controlled trials using this therapy have demonstrated excellent clinical outcomes at long-term follow-up. However, diffuse injection-site inflammation and systemic urticaria are worrisome complications. In preclinical studies, serial histopathological findings demonstrated acute inflammatory reaction, subacute vasculitis, chronic granulomatous foreign body reaction, fibrotic changes with partial vascular recanalization, and chronic foreign body-type inflammatory response. While the exact nature of this unique complication remains undefined, complex hypersensitivity and irritation reaction phenomena have been suggested based on reported clinical presentations. The incidence of this complication has been reported as ranging from 0.3%-25.4%. Typically, erythematous reactions can occur near treatment sites, with symptoms ranging from mild pruritus and/or erythema that resolves without treatment to recurrent severe inflammation and pruritus requiring nonsteroidal anti-inflammatory drugs, antihistamines, and/ or corticosteroids. Surgical excision has been rarely reported in patients with severe intractable inflammation or treatment-site infections. Although several anecdotal studies reported on using antihistaminics or corticosteroids, no effective strategies have been established to prevent this complication.

Fatal Invasive Pulmonary Aspergillosis after Combined Induction with Rituximab and Antithymocyte Globulin for Kidney Transplantation in a Sensitized Recipient, and Early Rejection Therapy with Plasmapheresis and Low-dose Immunoglobulin / 대한이식학회지

A high degree of sensitization to human leukocyte antigen requires more intensive induction therapy; however, this increases vulnerability to opportunistic infections following kidney transplantation. Although recent studies have suggested that combined induction therapy with antithymocyte globulin and rituximab would be more effective in highly sensitized kidney recipients, we experienced a case of near-fatal invasive pulmonary aspergillosis 2 months after combined induction and early rejection therapy for graft dysfunction. Fortunately, the patient recovered with intensive antifungal treatment and lung lobectomy for a necrotic cavity. Antifungal prophylaxis should be considered in cases undergoing intensive induction therapy.

Who experiences endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy for symptomatic gallstone disease?

PURPOSE: Laparoscopic cholecystectomy (LC) has become a standard treatment of symptomatic gallstone disease. But, some patients suffer from retained common bile duct stones after LC. The aim of this study is to analyze the predicting factors associated with subsequent postoperative endoscopic retrograde cholangiopancreatography (ERCP) after LC. METHODS: We retrospectively reviewed a database of every LC performed between July 2006 and September 2012. We classify 28 patients who underwent ERCP within 6 months after LC for symptomatic gallstone disease as the ERCP group and 56 patients who underwent LC for symptomatic gallstone disease during same period paired by sex, age, underlying disease, operation history, and body mass index as the control group. To identify risk factor performing postoperative ERCP after LC, we compared admission route, preoperative biochemical liver function test, number of gall stones, gallstone size, adhesion around GB, wall thickening of GB, and existence of acute cholecystitis between the 2 groups. RESULTS: Admission route, preoperative AST, ALT, and ALP, stone size, longer operation time, and acute cholecystitis were identified as risk factors of postoperative ERCP in univariate analyses. But, longer operation time (P = 0.004) and acute cholecystitis (P = 0.048) were identified as independent risk factors of postoperative ERCP in multivariate analyses. CONCLUSION: The patient who underwent ERCP after LC for symptomatic gallstone disease are more likely experienced longer operation time and acute cholecystitis than the patient who did not undergo ERCP after LC.

Post-transplant lymphoproliferative disorder presented as small bowel intussusception in adult liver transplant patient / 대한외과학회지

Intestinal obstruction after liver transplant is a rare complication, with diverse clinical manifestations. Intestinal adhesion is the most common cause. However, internal hernia, abdominal wall hernia, and neoplasm are also reported. Intussusception is another rare cause of intestinal obstruction, which has been reported primarily in pediatric patients. Herein, we report a case of intestinal obstruction from intussusception in an adult liver transplant patient associated with post-transplant lymphoproliferative disorder.

Simultaneous Laparoscopic Cholecystectomy and Endovascular Abdominal Aortic Aneurysm Repair / 대한혈관외과학회지

Concomitant cholelithiasis and abdominal aortic aneurysm (AAA) is not uncommon. Cholecystectomy at the time of aneurysm repair was delayed in patients with asymptomatic cholelithiasis due to the possibility of the graft infection. If a patient is subjected to a high risk of aneurysmal rupture and symptomatic cholelithiasis, the combined cholecystectomy and aneurysm repair should be performed. With the advent of the minimally invasive surgery, minimal invasive approach is widely adopted in patients with cholelithiasis and AAA. We reported one patient who had symptomatic cholelithiasis and AAA, successfully treated with the laparoscopic cholecystectomy and endovascular AAA repair.

Splenectomy affects the balance between hepatic growth factor and transforming growth factor-beta and its effect on liver regeneration is dependent on the amount of liver resection in rats / 대한외과학회지

PURPOSE: Small-for-size syndrome (SFSS) is a major problem in liver surgery, and splenectomy has been used to prevent SFSS. However, it is unknown whether splenectomy has the same effect on liver regeneration in both standard and marginal hepatectomy. The aim of this study is to see a difference in effect of splenectomy on liver regeneration according to the amount of liver resection. METHODS: Thirty male Sprague-Dawley rats (220 to 260 g) were divided into the following five groups: control (n = 6), 70% hepatectomy (n = 6), 70% hepatectomy with splenectomy (n = 6), 90% hepatectomy (n = 6), and 90% hepatectomy with splenectomy (n = 6). The animals were euthanized 24 hours after surgery and liver specimens were obtained. To assess liver regeneration, we performed immunohistochemistry of liver tissue using 5-bromo-2-deoxyuridine (BrdU) labeling and Western blot analysis of hepatic growth factor (HGF) and transforming growth factor-beta (TGF-beta) in the liver tissue. RESULTS: The splenectomized subgroup had a higher BrdU-positive cell count in the 90% hepatectomy group, but not in the 70% hepatectomy group (P < 0.001). Splenectomy significantly decreased TGF-beta expression (P = 0.005) and increased the HGF to TGF-beta ratio (P = 0.002) in the 90% hepatectomy group, but not in the 70% hepatectomy group. CONCLUSION: The positive effect of splenectomy on liver regeneration was greater in the group with the larger liver resection. This phenomenon may be related to the relative balance between HGF and TGF-beta in the liver.

Clinical review of laparoscopic cholecystectomy in acute cholecystitis

BACKGROUNDS/AIMS: Laparoscopic cholecystectomy is the best treatment choice for acute cholecystitis. However, its higher conversion rate and postoperative morbidities remain controversial. The purpose of this retrospective study is to evaluate the clinical significance of laparoscopic cholecystectomy that is performed at our institution in patients with acute cholecystitis. METHODS: Between January 2003 and December 2009, a retrospective study was carried out for 190 cases of acute cholecystitis undergoing laparoscopic cholecystectomy at our institution. They were divided into 2 groups, based on the time of operation from the onset of the symptom and other previous abdominal operation history. These groups were compared in the conversion rate and perioperative clinical outcomes, such as sex, age, accompanied disease, operation time, complications, postoperative hospital stay, total hospital stay and total costs. RESULTS: We compared the two groups based on the timing of laparoscopic cholecystectomy and history of previous abdominal operation. There were no significant differences in the open conversion rate, postoperative complications and postoperative hospital stay, total hospital stay and total costs. The sex ratio, female in the previous abdominal operation group, was larger than the non-previous abdominal operation group (70.2% vs. 43.2%, p=0.003, OR=0.32 [95% CI, 0.15-0.70]). Early operation group was larger than delayed operation group, at previous abdominal operation history (26.1% vs. 13.3%, p=0.026, OR=0.43 [95% CI, 0.20-0.91]) and closed suction drain use (79.3% vs. 66.3%, p=0.044, OR=0.51 [95% CI, 0.27-0.99]). CONCLUSIONS: Although this study was limited, early laparoscopic cholecystectomy for acute cholecystitis with previous abdominal operation history seems to be safe and feasible for patients, having a benefit of decrease in total hospital stay.

Acute Hepatic Failure Associated with Stevens-Johnson Syndrome Induced by Carbamazepine Treatment in a Patient with Transverse Myelitis

Carbamazepine-induced liver injury is less common, but the consequences of the side effects can be very serious leading to death or a need for liver transplantation. We report a case of a 60-year-old female transverse myelitis patient with fulminant hepatic failure and Stevens-Johnson syndrome induced by carbamazepine who successfully underwent deceased donor liver transplantation. The patient, a 60-year-old female, was admitted to our service due to acute liver insufficiency and a drowsy mental state attributable to carbamazepine. She had been treated with carbamazepine to control transverse myelitis. Fifty days after the use of carbamazepine, she developed jaundice, erythematous papules and bullae, and decreased consciousness. The diagnosis of Stevens-Johnson syndrome was considered. She underwent deceased donor liver transplantation. She was discharged with normal graft functions 5 months after transplantation. Thus, liver transplantation can be a feasible therapy for patients with carbamazepine-induced hepatic failure associated with Stevens-Johnson syndrome.

Auxiliary partial orthotopic liver transplantation for adult onset type II citrullinemia / 대한외과학회지

Adult-onset type II citrullinemia (CTLN2) is a disorder caused by an inborn error of metabolism affecting the liver. CTLN2 is an autosomal recessive disorder characterized by recurrent encephalopathy with hyperammonemia due to highly elevated plasma levels of citrulline and ammonia, caused by a deficiency of argininosuccinate synthetase in the liver. A small number of patients have undergone liver transplantation with favorable results. In Korea, the limitations of the deceased donor pool have made living donor liver transplantation a common alternative treatment option. We report the case of a patient with type II citrullinemia who was treated successfully with auxiliary partial orthotopic liver transplantation (APOLT) from a living donor. This is the first description of an APOLT for a patient with adult onset type II citrullinemia in Korea.

Aggressive hilar inflammatory myofibroblastic tumor with hilar bile duct carcinoma in situ / 대한외과학회지

Inflammatory myofibroblastic tumor (IMT) of the biliary tree is extremely rare and is generally a benign condition, though malignant change is possible. Making a differential diagnosis between this lesion and other malignant conditions is very difficult on preoperative imaging studies. Hence, the final diagnosis of IMT may be made during or after operation depending on the pathologic examination. We treated a 63-year-old woman who received right hepatectomy with caudate lobectomy under the suspicion of hilar cholangiocarcinoma. Frozen biopsy during the operation showed carcinoma in situ and there were stromal cells in the bile duct's resection margins. The postoperative hospital course was uneventful except for minor bile leakage. At postoperative month 4, she developed jaundice, ascites and pleural effusion. Computed tomography images showed a mass-like lesion in the porta hepatis with portal vein thrombosis and a right chest wall mass. Excisional biopsy was done and the pathology report was malignant spindle cell tumor suggestive of an aggressive form of IMT. Her condition rapidly deteriorated regardless of the best supportive care and she expired at postoperative month 5. Further investigation is necessary to clarify the reasons for recurrence and infiltration of this disease.

Cyclooxygenase (COX)-1, Cyclooxygenase (COX)-2 and E-cadherin Expression in Colorectal Cancer Patients with Hepatic Metastasis

PURPOSE: Recent studies have shown that cyclooxygenase (COX)-2 may be involved in colorectal carcinogenesis. In this study, we evaluate the differences of COX-2 expression in patients with synchronous and metachronous hepatic metastasis of colorectal cancer. In addition, the expression of COX-1 and E-cadherin were also evaluated. METHODS: Paraffin embedded blocks were obtained from 41 patients who underwent surgery for colorectal cancer with hepatic metastasis. Samples from primary colorectal cancer, synchronous and metachronous hepatic lesions were stained by immunohistochemistry for monoclonal antibody against COX-1, COX-2, and E-cadherin. RESULTS: In colonic COX-1 expression, there was no significant difference in the degree of COX-1 expression between primary colorectal cancer with synchronous hepatic metastasis and that of metachronous hepatic metastasis (P=0.507). In colonic COX-2 and E-cadherin expression, the degree of COX-2 expression was not different between the two groups. But, the patient survival rate in the positive group of COX-1 and COX-2 expression was lower than in the negative group, respectively (P=0.023, P=0.006). CONCLUSION: The degree of colonic COX-1 and COX-2 expression has an impact on prognosis in synchronous and metachronous hepatic metastasis. Further large-scale study is necessary to determine the meaning of COX-2 expression in colorectal cancer.

Laparoscopic Cholecystectomy in Patients with a History of Upper Abdominal Surgery / 대한내시경복강경외과학회지

PURPOSE: Laparoscopic cholecystectomy is currently the treatment of choice for gallbladder disease. Previous abdominal surgery was considered as a relative contraindication for laparoscopic cholecystectomy due to the presence of intraabdominal adhesion and the difficulty in visualization. Several recent studies have suggested that previous abdominal surgery is no longer a contraindication for laparoscopic surgery by virtue of the accumulation of surgeons' experience and the evolution of laparoscopic instruments. In this study, we evaluated the impact of previous upper abdominal surgery on laparoscopic cholecystectomy. METHODS: The data of 706 consecutive patients who underwent laparoscopic cholecystectomy from September 2004 to December 2007 was retrospectively analyzed. Thirty-three patients had undergone pervious upper abdominal surgery and 673 patients had not. We compared the operative time, the type of trocar that was used, the postoperative complications, the frequency of open conversion and the length of the postoperative hospital stay between the two groups RESULTS: The operative time was longer (141.8+/-88.7 min vs. 74.1+/-37.4 min, p<0.001) and larger trocars were used more often (p<0.001) in the previous upper abdominal surgery group. There was no significant difference in the open conversion rate, the major postoperative complication rate and the length of the postoperative hospital stay. CONCLUSION: Laparoscopic cholecystectomy might be an optimal treatment for patients with a history of previous upper abdominal surgery. Previous upper abdominal surgery is not a contraindication for laparoscopic cholecystectomy when it is performed by experienced laparoscopic surgeons.

Short-term Oncologic Outcome of Curative Resection for Obstructive Colorectal Cancer Followed by Stent Insertion: Comparative Study with Non-abstructive Colorectal Cancer

PURPOSE: Recently, a self-expandable metallic stent has allowed an elective single-stage resection avoiding the risk of emergency operation and stoma formation in patients with obstructive colorectal cancer (CRC). But, forceful expansion of stent may increase the possibility of tumor cell exfoliation and dissemination through bowel lumen, lymphatic and blood vessels. Aim of study is to evaluate the short-term outcome of curative resection for obstructive colorectal cancer followed by stent in terms of oncologic safety. METHODS: Twenty-seven patients who underwent curative resection for obstructive CRC followed by stent insertion were included in 'stent group' and control group included 87 patients who underwent surgery for non-obstructive CRC. The clinicopathologic characteristics and prognosis were compared between two groups. RESULTS: There was no significant difference in clinicopathologic characteristics between two groups. No difference was found in postoperative complications between two groups. Overall survival rate of two groups showed no statistically significant differences (P=0.1254). Stage-matched survival rates (stage II & III) were also showed no differences between two groups. CONCLUSION: Stent insertion itself does not compromise the survival of patients with obstructive CRC. Oncologic safety of stent insertion for obstructive CRC is acceptable. A further large-scaled prospective study and long-term follow-up is necessary to evaluate the oncologic safety of stent insertion in obstructive CRC.

Cytoplasmic Expression of HuR is Related to Cyclooxygenase-2 Expression in Colon Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: HuR, human family embryonic-lethal abnormal vision-like protein, can bind to mRNA and stabilizes the nucleic acid in the cytoplasm, resulting in more efficient translation. HuR is predominantly present in the nucleus and shuttles between the nucleus and cytoplasm. HuR stabilizes cyclooxygenase-2 (Cox-2) mRNA in several cancers, including breast, stomach, lung and brain cancer. MATERIALS AND METHODS: We investigated the expression and cellular location of HuR, as well as evaluated Cox-2 expression in 79 colorectal cancer patients with the use of immunohistochemical methods. The biological implications of HuR localization and Cox-2 expression in colorectal carcinoma were evaluated. RESULTS: Nuclear HuR expression was observed in 59 (74.7%) tumors and cytoplasmic HuR expression was seen in 25 (31.6%) tumors. Cox-2 immunoreactivity was noted in 42 (53%) tumors. The expression of cytoplasmic HuR was significantly associated with Cox-2 expression (p=0.004). Cytoplasmic expression of HuR showed a correlation with lymphatic invasion (p=0.025) and the presence of a lymph node metastasis (p=0.027). The presence of nuclear HuR showed no correlation with Cox-2 expression or any other of the clinicopathological parameters that were examined. CONCLUSION: These results suggest that cytoplasmic translocation of HuR is associated with Cox-2 expression for some colorectal carcinomas.

Comparison of Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair and Tension-Free Herniorrhaphy Using Perfix(R): Short-Term Follow-Up Results

PURPOSE: Tension-free open repair for inguinal hernia is a safe and popular operation with a high success rate, but laparoscopic techniques are fairly recent. Comparing the tension-free herniorrhaphy using mesh and plug (Perfix(R)) with laparoscopic totally extraperitoneal (TEP) hernia repair is the aim of this study. METHODS: We compared two groups of patients in which 39 patients with inguinal hernias were treated by tension-free repair using Perfix(R) (group P) and 39 patients were treated by laparoscopic TEP repair (group T). Information about operation time, length of hospital stay, use of analgesics (pain), recurrence, complications, cosmetic satisfaction, medical costs, and time until return to work were evaluated retrospectively. RESULTS: Mean operation time, postoperative hospital stay, and the time until return to work were 101+/-33 min, 1.9+/-1.0 days, 11+/-8 days in group T, 86+/-28 min, 2.0+/-0.8 days, 12+/-10 days in group P. Postoperative complications, medical costs and the cosmetic satisfaction were 20.5%, 821,048 won, 94% (32/24) in group T, 7.7%, 692,149 won, 79% (19/24) in group P. There was difference between the two groups but not significant statistically. Group P used more analgesics than group T, significantly (P<0.05). There was only 1 recurrence in group T. CONCLUSION: Although we need more experience in patients with inguinal hernias, laparoscopic TEP repair may be a secure and feasible procedure compared to tension-free repair using Perfix(R).

A Common Bile Duct Web Presenting with Obstructive Jaundice without Common Bile Duct Stone

There are many causes of extrahepatic biliary obstruction. The most common causes are gallstones and malignant or benign strictures. Web of the common bile duct is a rare disease, and it may produce obstructive jaundice. On cholangiography, a common bile duct web typically appears as a shelf--like radiolucent ring. It is frequently associated with bile duct stone, and it is occasionally related to bile duct trauma or primary sclerosing cholangitis. We report here on a case of a web of the common bile duct without choledocholithiasis in a 27-year-old man. The patient was treated by Roux-en-Y choledochojejunostomy above the level of the web.

Benign Schwannoma Compressing the Common Bile Duct in the Porta Hepatis

Schwannoma or neurilemmoma is an uncommon neoplasm, and it is derived from the peripheral nerve sheath. These tumors most frequently occur in the head, neck and flexor surfaces of the upper and lower extremities, while the porta hepatis and retroperitoneum are rarely implicated. We report here on a case of benign schwannoma in the porta hepatis with compression of the common bile duct, and this was successfully treated by surgical excision. The patient was a 63-year-old woman who had a slow growing upper abdominal mass for 3 years. The abdominal CT scan showed a 12 cm-sized cystic mass with a solid portion, and this was accompanied with intrahepatic bile duct dilatation. Abdominal exploration revealed a yellowish, cystic, encapsulated mass attached to the inferior vena cava, portal vein, the common bile duct and the liver. There has been no evidence of recurrence during 36 months of follow-up.

A case of duodenal gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GISTs) are rare tumers of the alimentary tract, and these tumors arise from primitive mesenchymal cells. Duodenal GISTs comprise 4-5% of all GISTs. In this article, we report on a case of duodenal GIST in 35-year-old male who presented with a fistulo in ano and anal bleeding. Abdominal computed tomography and magnetic resonance imaging revealed a huge tumor, about 11x7 cm in size, of the duodenum. Duodenoscopy revealed a protruded mass with central deep ulceration on the third portion of the duodenum. Endoscopic biopsies showed subepithelial spindle cell proliferation of the tumor, and this was consistent with GIST. Pylorus-preserving pancreaticoduodenectomy was then performed. He subsequently underwent the sphincter-preserving modified loose Seton surgical technique. The patient did not have any problems postoperatively and he remained symptom-free at 6 months after surgery.

Totally Extraperitoneal Laparoscopic Repair of Obturator Hernia withPartial Intestinal Obstruction

Obturator hernia is a rare variety of pelvic hernia. The diagnosis frequently is delayed and may be accompanied by dehydration, acute abdominal distress and small bowel strangulation. We report a case of totally extraperitoneal repair of obturator hernia with partial intestinal obstruction. An eighty-two-year old female with intermittent abdominal pain was diagnosed with obturator hernia with partial intestinal obstruction. We did total extraperitoneal laparoscopic repair of the obturator hernia with polypropylene mesh. Total extraperitoneal laparoscopic repair for obturator hernia is a safe and effective treatment.

Laparoscopic Cholecystectomy in Patients with a Left-sided Gallbladder

Laparoscopic cholecystectomy has been widely performed as the gold standard for patients suffering with symptomatic gallstone disease. However, conversion to open cholecystectomy is a dilemma when the surgeon encounters a variant biliary anomaly. A gallbladder lying to the left of the round ligament represents a rare congenital anomaly, which is termed as a left-sided gallbladder. The true left-sided gallbladder, situated on the inferior aspect of the left lobe of the liver, is extremely rare and this represents a truly ectopic gallbladder that may developmentally arise as a second gallbladder from the left hepatic duct. This is accompanied by the disappearance of the normal gallbladder on the right side. We report here on 2 cases of left-sided gallbladder that were successfully treated with laparoscopic cholecystectomy at Hallym Medical Center. In both cases, the true left-sided gallbladders were identified intraoperatively. The round ligament was indeed located in its normal position, and the gallbladder was located to the left of the round ligament, which is a type of malposition known as sinistroposition. The operation was carried out in the usual manner with the trocars placed their usual location. Although operations can be carried out with using the standard port sites, a better arrangement for laparoscopic cholecystectomy consists of more medial positioning of the gallbladder-retracting port and placement of the right hand operating port to the left side of the round ligament.