Bronchobiliary fistula is a rare condition. It is defined by the presence of a passage between the biliary tract and the bronchial tree. Many conditions can give rise to the developement of such a communication. The patient was a 71-year-old man who had obstructive jaundice due to liver mass. At first, we inserted an uncovered metallic stent for biliary drainage. However, the bile duct was perforated due to the trapping of a catheter in the distal end of the deployed stent. The operation was performed immediately, but only the sump draingage was placed in the retroperitoneum because the perforation site could not be found. After 20 days from the procedure, the patient complained of bilioptysis because of a bronchobiliary fistula. We inserted a covered stent into the previous uncovered metallic stent. Bilioptysis rapidly resolved after the successful procedure. We report a case of iatrogenic bronchobiliary fistula which was managed by endoscopic biliary stenting.
Aged ; Bile Ducts ; Biliary Tract ; Catheters ; Drainage ; Fistula* ; Humans ; Jaundice, Obstructive ; Liver ; Stents

BACKGROUND: To find the patients who have a significant chance of cure with living donor liver transplantation (LDLT) among the patients suffering with beyond-Milan hepatocellular carcinoma (HCC), we retrospectively analyzed the tumor factors that could affect a good prognosis after LDLT for patients who suffer with beyond Milan HCC. METHODS: Between March 2005 and May 2007, 18 cases of LDLT for beyond Milan HCC were performed. None of the patients had preoperative radiological evidence of vascular invasion. Excluding the 3 cases of in-hospital mortality, we analyzed the survival, the disease-free survival and the prognostic factors for recurrence in 15 beyond Milan HCC patients. The mean follow-up period was 18.8degrees +/- 8.8 months (range: 4-34 months). RESULTS: The two-year survival and disease-free survival rates after LDLT were 61.7% and 31.1%, respectively, in 15 beyond-Milan patients. Among them, 9 patients had recurrence of HCC during follow-up. The one-year survival rate after tumor recurrence was 55.5%. An alphafetoprotein (AFP) level < 400 ng/mL, Edmonson-Steiner histology grade I and II and the presence of graft rejection were analyzed as the good prognostic factors of disease-free survival after LDLT for beyond-Milan HCC (p < .05). The patients with negative preoperative positron emission tomography (PET) findings (n = 5) showed a better prognosis than the PET-positive patients (n = 10) with statistical significance (p = .05). CONCLUSION: Allowing that HCC patients exceed the Milan criteria, we can find the potentially curable candidates for LDLT with using tumor biologic markers such as a serum AFP level < 400 ng/mL, negative PET uptake or low grade histology, as assessed by preoperative needle biopsy. Further investigation is needed to evaluate the relation between graft rejection and tumor recurrence after liver transplantation.
Biomarkers ; Biopsy, Needle ; Carcinoma, Hepatocellular ; Disease-Free Survival ; Follow-Up Studies ; Graft Rejection ; Hospital Mortality ; Humans ; Liver ; Liver Transplantation ; Living Donors ; Positron-Emission Tomography ; Prognosis ; Recurrence ; Retrospective Studies ; Stress, Psychological ; Survival Rate

PURPOSE: During liver transplantation (LT), complications of the hepatic artery have been decreased because of microsurgery in reconstruction of hepatic artery has been widely adopted. However, in an early step of the LT program, hepatic artery reconstruction generally tends to be done with the help of a micro-surgeon from the the plastic surgery in most of Korean medical centers. In our center, we also have done reconstruction of the hepatic artery using a microscope and the skills of a plastic surgeon. We did this between Feb, 2005 and Jun, 2008 for liver transplantations. The increased the need for micro-surgeons in liver surgery as increased the cases of liver transplantation steadily. After training general surgeons of the surgical department who had no experience with microsurgery, we invested in the micro-surgery of hepatic artery reconstruction. Here we report the result of that investment. METHODS: Liver transplant patients (n=176) were enrolled between Feb, 2005 and Jul, 2009. Between Jul, 2008 and Jul, 2009, 28 cases of reconstruction of the hepatic artery were done by a general surgeon who had micro-surgery training. Before training in hepatic artery reconstruction, the general surgeon spent 3 months being introduced to micro-surgery in the micro animal laboratory. Because the training was repeated, the surgeon became skilled in doing artery anastomosis using rat's abdominal aorta. At the same time, we trained a plastic surgeon to do hepatic artery reconstruction during liver transplantation as the first assistant. From Jul, 2008 to the present time, the general surgeon was exclusively in charge of hepatic artery reconstruction during liver transplantation. Hepatic artery reconstruction was done using a microscope. Stitching was done using 8-0 or 9-0 nylon, and an interrupted end-to-end anastomosis was done. After hepatic artery reconstruction, artery flow was confirmed by ultrasonic doppler. For group A patients, left lobe grafts were used in 33, right lobe grafts in 73, dual grafts in 6, and whole liver grafts in 36. RESULTS: For group B patients, left lobe grafts were used in 1 and right lobe grafts in 21, while whole liver grafts were used in 6. In Group A, hepatic artery complications occurred in 5 cases (3.3%), and in Group B such complications did not occur (0%). There was no statistical difference (p=0.312). CONCLUSION: For hepatic artery reconstruction, during micro-surgery under a surgical microscope, it is thought that it is best to invest in a general surgeon who has been trained in micro-surgery. We suggest that a general surgeon is suitable for hepatic artery reconstruction after only a short time of micro surgery training.
Animals ; Aorta, Abdominal ; Arteries ; Fees and Charges ; Hepatic Artery ; Humans ; Investments ; Liver ; Liver Transplantation ; Microsurgery ; Nylons ; Surgery, Plastic ; Transplants ; Ultrasonics

PURPOSE: Although living donor liver transplantations (LDLTs) are widely performed, a shortage of living donors exists continuously, which makes it difficult to find the optimal graft. A high portal venous pressure (PVP) is mainly related to small for size syndrome (SFSS), and low portal venous flow (PVF), to ischemic liver damage, leading to potential liver failure after surgery. We reviewed the literature in search of optimal PVP and PVF values during LDLTs, and tried to determine the clinical meaning of measurements of PVP and PVF for liver transplantation. METHODS: Between June, 2008 and June, 2009, we did 38 LDLTs. PVP and PVF were measured in 13 patients after laparotomy, after implantation of graft and after splenectomy. In addition, compliance (PVF/PVP) and compliance (mL/min/mmHg/g) per unit graft weight were calculated. Splenectomy was done when continuously maintained portal hypertension (>20 mmHg) occurred even after implantation. Splenectomy was also done for patients who presented preoperatively with splenomegaly and pancytopenia. RESULTS: After graft implantation, portal venous pressure decreased (16.8+/-4.1 mmHg vs. 14.7+/-3.1 mmHg)(p=.003), whereas portal venous flow increased (1236.4+/-725.3 mL/min vs. 1916.9+/-603 mL/min)(p=.019). Also, after splenectomy, portal venous pressure/flow decreased (16.4+/-3.7 mmHg vs. 13.8+/-3.3 mmHg)(p=.009)/(2136.4 mL/min vs. 1619.1+/-336.3 mL/min) (p=.001). Finally, after implantation, compliance increased (60+/-40 mL/min/mmHg vs. 126+/-18 mL/min/mmHg)(p=.007). CONCLUSION: After splenectomy, compliance remained constant (126+/-18 mL/min/mmHg vs. 122+/-34 mL/min/mmHg)(p=.364). After implantation of the graft, portal pressure decreased and portal venous flow increased. The compliance of the graft was not influenced by splenectomy. This shows that splenectomy is a good method to control high portal pressure without influencing the compliance of the graft.
Compliance ; Humans ; Hypertension, Portal ; Laparotomy ; Liver ; Liver Failure ; Liver Transplantation ; Living Donors ; Pancytopenia ; Portal Pressure ; Splenectomy ; Splenomegaly ; Transplants

BACKGROUND: This prospective and cross-sectional study was conducted to assess the risk factors for coronary artery disease in the selected Korean Pateints. METHOD: We analyzed clinical parameters and biochemical parameters in 158 subjects; 98 subjects with significant coronary artery disease as proven by coronary angiography(stable angina pectoris : 55, unstable angina pectoris : 30, post-myocardial infarction angina pectoris : 13) and 58 normal subjects as proven by coronary angiography, from November 1993 to April 1994 in Seoul National University Hospital. RESULTS: 1) Old age, male gender, history of diabetes and smoking, high low density lipoprotein cholesterol level, high lipoprotein (a) level and high fibrinogen level were identified and risk factors for coronary artery disease on simple logistic regression analysis. 2) Lp(a) was positively related to fibrinogen(r=0.23), cholesterol(r=0.23) and low density lipoprotein cholesterol(r=0.28). 3) High fibrinogen level, old age, and male gender were independent risk factors of significant coronary artery disease in the selected Korean Population on multiple stepwise logistic regression analysis. CONCLUSION: High fibrinogen level, old age, and male gender six were independent risk factors of significant coronary artery disease in the selected Korean Population of multiple stepwise logistic regression analysis. These findings could not deny the role of cholesterol in coronary artery disease, but suggested that factors related to thrombosis and fibrinolysis, may play more important role in Korean patients coronary artery disease.
Angina Pectoris ; Angina, Unstable ; Cholesterol ; Cholesterol, LDL ; Coronary Angiography ; Coronary Artery Disease* ; Coronary Vessels* ; Cross-Sectional Studies ; Fibrinogen* ; Fibrinolysis ; Humans ; Infarction ; Lipoprotein(a) ; Lipoproteins ; Logistic Models ; Male ; Prospective Studies ; Risk Factors* ; Seoul ; Smoke ; Smoking ; Thrombosis

BACKGROUND: This prospective and cross-sectional study was conducted to assess the risk factors for coronary artery disease in the selected Korean Pateints. METHOD: We analyzed clinical parameters and biochemical parameters in 158 subjects; 98 subjects with significant coronary artery disease as proven by coronary angiography(stable angina pectoris : 55, unstable angina pectoris : 30, post-myocardial infarction angina pectoris : 13) and 58 normal subjects as proven by coronary angiography, from November 1993 to April 1994 in Seoul National University Hospital. RESULTS: 1) Old age, male gender, history of diabetes and smoking, high low density lipoprotein cholesterol level, high lipoprotein (a) level and high fibrinogen level were identified and risk factors for coronary artery disease on simple logistic regression analysis. 2) Lp(a) was positively related to fibrinogen(r=0.23), cholesterol(r=0.23) and low density lipoprotein cholesterol(r=0.28). 3) High fibrinogen level, old age, and male gender were independent risk factors of significant coronary artery disease in the selected Korean Population on multiple stepwise logistic regression analysis. CONCLUSION: High fibrinogen level, old age, and male gender six were independent risk factors of significant coronary artery disease in the selected Korean Population of multiple stepwise logistic regression analysis. These findings could not deny the role of cholesterol in coronary artery disease, but suggested that factors related to thrombosis and fibrinolysis, may play more important role in Korean patients coronary artery disease.
Angina Pectoris ; Angina, Unstable ; Cholesterol ; Cholesterol, LDL ; Coronary Angiography ; Coronary Artery Disease* ; Coronary Vessels* ; Cross-Sectional Studies ; Fibrinogen* ; Fibrinolysis ; Humans ; Infarction ; Lipoprotein(a) ; Lipoproteins ; Logistic Models ; Male ; Prospective Studies ; Risk Factors* ; Seoul ; Smoke ; Smoking ; Thrombosis

BACKGROUND: The tuberculin skin test (TST) has limitations in diagnosing a latent tuberculosis infection (LTBI). The interferon-gamma release assay (IGRA) was introduced to middle- and high-school students since 2009 by the Korea Centers for Disease Control and Prevention. The aim was to evaluate the utility of IGRA in diagnosing LTBI in middle- and high-school students. METHODS: From August 2007 to July 2009, among suspected LTBI students showing TST induration with a 10 mm diameter and over with a normal chest x-ray in school students of Jeju city, 341 students underwent a Quanti FERON-TB Gold In-Tube (QFT-IT) test to confirm LTBI. RESULTS: From 348 students showing a positive TST, a QFT-IT test was carried out on 341 students. The positive QFT-IT rate was 52.8% (=180/341). The positive QFT-IT rate was higher in high-school boys with a 15~19 mm diameter of induration in TST. CONCLUSION: With the introduction of IGRA for diagnosing LTBI in middle- and high-school students, approximately 47% of students who show a TST induration with a 10 mm diameter and over can avoid taking unnecessary preventive chemotherapy. These results suggest that IGRA is useful for diagnosing and controlling LTBI in Korean students.
Benzeneacetamides ; Centers for Disease Control and Prevention (U.S.) ; Disease Outbreaks ; Humans ; Interferon-gamma Release Tests ; Interferons ; Korea ; Latent Tuberculosis ; Piperidones ; Skin Tests ; Student Health Services ; Thorax ; Tuberculin

PURPOSE: Tumor recurrence after partial hepatectomy for hepatocellular carcinoma is a major cause of death from this disease. Among those recurrences, when it occurs immediate during the postoperative period, it may due to the overt expression of pre-existing micrometastases or circulating disseminated cancer cells. Therefore; we evaluate herein the risk factors for the immediate postoperative period fatal recurrence to help establish effective preventive countermeasures against these fatal recurrences. METHODS: From 1994 to 2004, the 269 patients in this study all had greater than 6 months of follow-up after curative resection for HCC at our medical center. Those patients who had a fatal recurrence that included diffuse intra-hepatic recurrence or multiple systemic recurrence within 6 months after hepatectomy, and all of the patients who didn't have a fatal recurrence within 6 month after resection of HCC were compared. The clinicopathological factors associated with immediate postoperative recurrence were then analyzed. RESULTS: The overall postoperative mortality was 1%. There were 30 patients in the immediate postoperative group (the subjective group) among the total 269 patients. Among the subjective group patients, 20 patients had diffuse intra-hepatic recurrence and remained 10 patients had multiple systemic recurrence. The mean disease free survival period of the subjective group was 3.9+/-1.7 months and the mean survival period after recurrence was 6.7+/-6.1 months. On multivariate analysis, a serum alpha-fetoprotein level greater than 1, 000 ng/ml (p=0.019; odds ratio: 2.98), a tumor size greater than 6.5 cm (p=0.03; odd ratio: 2.98), and the presence of microvascular invasion (p=0.01; odd ratio: 4.89) were associated with the risk factors for immediate postoperative fatal recurrence. CONCLUSION: These findings can be important indicators to establish countermeasures against immediate postoperative period fatal recurrence, and the high risk patients would also be good candidates for clinical trials with adjuvant anti-cancer treatments such as early postoperative TACE, immunotherapy, anti-angiogenic treatment and so on.
alpha-Fetoproteins ; Carcinoma, Hepatocellular* ; Cause of Death ; Disease-Free Survival ; Follow-Up Studies ; Hepatectomy ; Humans ; Immunotherapy ; Mortality ; Multivariate Analysis ; Neoplasm Micrometastasis ; Odds Ratio ; Postoperative Period ; Recurrence* ; Risk Factors*

Phyllodes tumors of the breast are rare biphasic fibroepithelial neoplasms that may coexist with breast carcinomas. Herein, we report a case of invasive ductal carcinoma (IDC) within a borderline phyllodes tumor accompanied by extensive ductal carcinoma in situ (DCIS) in the same breast. A 72-year-old woman presented with a palpable lump in the right breast.Mammography showed an oval mass associated with segmental microcalcifications, and breast ultrasound (US) revealed a 2.3 cm oval mass and an associated non-mass lesion. Based on US-guided core needle biopsy, the initial biopsy result of the non-mass lesion suggested DCIS; however, the mass was diagnosed as a fibroepithelial lesion. Preoperative dynamic contrast-enhanced magnetic resonance imaging showed a rim-enhancing oval mass with areas of T2 hyperintensity, accompanied by segmental non-mass enhancement. The mass was highly suspicious for malignancy and was considered imaging-pathology discordant.Subsequently, the patient underwent mastectomy. Histopathological examination of the surgical specimens confirmed a borderline phyllodes tumor with an IDC within the tumor and an extensive intraductal component. The invasive carcinoma component was triplenegative breast cancer. This case highlights the diagnostic challenges of identifying coexisting carcinomas within phyllodes tumors and emphasizes the necessity for increased awareness among radiologists regarding this possibility.

Phyllodes tumors of the breast are rare biphasic fibroepithelial neoplasms that may coexist with breast carcinomas. Herein, we report a case of invasive ductal carcinoma (IDC) within a borderline phyllodes tumor accompanied by extensive ductal carcinoma in situ (DCIS) in the same breast. A 72-year-old woman presented with a palpable lump in the right breast.Mammography showed an oval mass associated with segmental microcalcifications, and breast ultrasound (US) revealed a 2.3 cm oval mass and an associated non-mass lesion. Based on US-guided core needle biopsy, the initial biopsy result of the non-mass lesion suggested DCIS; however, the mass was diagnosed as a fibroepithelial lesion. Preoperative dynamic contrast-enhanced magnetic resonance imaging showed a rim-enhancing oval mass with areas of T2 hyperintensity, accompanied by segmental non-mass enhancement. The mass was highly suspicious for malignancy and was considered imaging-pathology discordant.Subsequently, the patient underwent mastectomy. Histopathological examination of the surgical specimens confirmed a borderline phyllodes tumor with an IDC within the tumor and an extensive intraductal component. The invasive carcinoma component was triplenegative breast cancer. This case highlights the diagnostic challenges of identifying coexisting carcinomas within phyllodes tumors and emphasizes the necessity for increased awareness among radiologists regarding this possibility.