PURPOSE: This retrospective study was aimed to determine prognostic factors after radical resection of an ampullary carcinoma. METHODS: Medical records of patients with adenocarcinoma of the ampulla of Vater who had undergone pancreaticoduodenectomy between Dec. 1994 and May 2002 were reviewed. This study included 59 men and 40 women with a mean age of 58.9 years. 62 patients underwent Whipple procedures, 36 patients, pylorus preserving pancreaticoduodenectomy and 1 patient, total pancreatectomy. Actuarial survival rates were calculated using the Kaplan-Meier method. A Cox proportional hazards model was used to test the independent predictors of survival. P<0.05 was considered statistically significant. RESULTS: The overall 5-year survival rate was 45.4% with 3% mortality and 34.3% morbidity. According to the pTNM stage, the 5-year survival rates were 91.7%, 54.3%, 28.5% and 0% at stages I, II, III, and IV (P<0.01), respectively. The patient survival was significantly impaired by the depth of invasion, lymph node metastasis and intraoperative transfusion (P<0.05). In a multivariate analysis, only lymph node metastasis was a statistically independent prognostic factor. CONCLUSION: pTNM stage is a good prognostic indicator for an ampullary carcinoma after pancreaticoduodenectomy and patients with lymph node metastasis should be identified as high risk and considered as candidates for further adjuvant therapy.
Adenocarcinoma ; Ampulla of Vater ; Female ; Humans ; Lymph Nodes ; Male ; Medical Records ; Mortality ; Multivariate Analysis ; Neoplasm Metastasis ; Pancreatectomy ; Pancreaticoduodenectomy ; Proportional Hazards Models ; Pylorus ; Retrospective Studies ; Survival Rate

Obstruction of the common bile duct (CBD) by direct extension of a tumor is occasionally found in patients with a hepatic neoplasm, but a bile duct tumor embolus caused by intrabiliary transplantation of a free floating tumor is a rare complication of a hepatocellular carcinoma. A patient of ours was recently observed with a fragment of tumor from a primary hepatocellular carcinoma (HCC) that obstructed the distal CBD. A-46-year-old man was admitted to our hospital with a distal CBD mass, measuring 1.2x1.5 cm, found by a biliary computed tomography (CT) scan. Four month prior to his admission, he had undergone a right hemihepatectomy for a HCC accompanied by direct intrahepatic bile duct invasion, without obstructive jaundice. On admission, there were no abnormal findings in the physical and laboratory examinations. An Endoscopic retrograde cholangiopancreatography and papillotomy had been performed, which showed an irregular shaped filling defect in the distal CBD. Endoscopic nasobiliary drainage (ENBD) was carried out for biliary decompression. Partially extracted soft tissue from the CBD by ERCP revealed a HCC. On performed a pylorus- preserving pancreaticoduodenectomy, a 1cm sized tumor remnant was found attached to the mucosa of the intrapancreatic portion of the bile duct, but without any invasive growth into the submucosa. The tumor may have been an intrabiliary transplantation from the HCC in the right lobe through the bile duct. When an obstructive mass is found in the distal CBD, tumor embolus should be considered, and a radical pancreaticoduodenectomy can be adopted as a safe and effective treatment modality.
Bile Ducts ; Bile Ducts, Intrahepatic ; Carcinoma, Hepatocellular* ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct* ; Decompression ; Drainage ; Embolism* ; Humans ; Jaundice, Obstructive ; Liver Neoplasms ; Mucous Membrane ; Neoplastic Cells, Circulating ; Pancreaticoduodenectomy

PURPOSE: A pancreatic ductal adenocarcinoma is one of the most fatal cancers, as the majority of the patients present with locally advanced or metastatic tumors in the late stages of the disease. However, there is no simple, sensitive, noninvasive, and inexpensive test for the early detection of pancreatic ductal adenocarcinomas. In recent studies, S100A4 has emerged as an important protein in the tumorgenesis of pancreatic adenocarcinomas. METHODS: The possibility of the expression of S100A4 as a new tumor marker of pancreatic adenocarcinomas was confirmed using immunohistochemistry to 32-pancreatic ductal adenocarcinomas, 20 IPMN (intraductal papillary mucinous neoplasm), 8 serous cystadenomas, 5 chronic pancreatitis and 3 neuroendocrine tumors. RESULTS: Thirty-one (96.9%) ductal adenocarcinoma cases and 11 (55.5%) IPMN expressed S100A4, whereas all normal pancreatic tissues (47 cases), chronic pancreatitis and endocrine tumors did not. The expression of S100A4 was associated with the degree of dysplasia in IPMN, but not with the differentiation of ductal adenocarcinomas. CONCLUSION: The overexpression of S100A4 in adenocarcinomas and early emerging IPMN may suggest its potential as a diagnostic marker for the early detection of pancreatic ductal adenocarcinomas.
Adenocarcinoma* ; Carcinoma, Pancreatic Ductal ; Cystadenoma, Serous ; Humans ; Immunohistochemistry ; Mucins* ; Neuroendocrine Tumors ; Pancreas* ; Pancreatic Ducts ; Pancreatitis, Chronic ; Biomarkers, Tumor

OBJECTIVE: To determine the relation of Radiographic Scoring System and Scoliosis Research Society-22 (SRS-22), a revised form of health-related quality-of-life (HRQL) questionnaire in idiopathic adolescent scoliosis patients. METHOD: A patient group was made up of 41 adolescents who were diagnosed as idiopathic scoliosis. A control group of 17 persons with Cobb's angle <10degrees was established. To evaluate psychosocial condition, SRS-22 was used to collect the data on both patient and control group. Roentgenographic study was conducted to obtain the Radiographic Deformity Score and evaluate the curve pattern. RESULTS: Pain, self image/appearance, mental health and total score of SRS domains were found to be significantly different between patient and control group (p<0.05). Radiog raphic Deformity Score was positively correlated with pain and self image of SRS domains (p<0.05). However, the pattern of curve was found to be not correlated with SRS score. CONCLUSION: We could evaluate a psychologic condition of idiopathic adolescent scoliosis using Scoliosis Research Society-22 (SRS-22) health-related quality-of-life (HRQL) questionnaire. The more severe spinal deformity, it had the more negative influence on psychologic conditions in idiopathic adolescent scoliosis patients. Therefore, the clinician who is managing idiopathic adolescent scoliosis patients should consider their psychosocial conditions.
Adolescent* ; Congenital Abnormalities ; Humans ; Mental Health ; Surveys and Questionnaires ; Scoliosis*

PURPOSE: Recently, hemorrhages has been accepted the most serious complication with a high mortality after a pancreaticoduodenectomy. In particular, delayed massive hemorrhages that occur from a pseudoaneurysmal rupture at the peripancreatic large arteries are quite formidable. In most patient with pseudoaneurysmal bleeding, sentinel hemorrhages can be observed. Early angiography and transcatheter arterial embolization can be used effectively as initial diagnostic and treatment modalities for a pseudoaneurysm. The authors reviewed the hemorrhagic complications from pseudoaneurysms after a pancreaticoduodenectomy and present the clinical features and treatment modalities METHODS: Four hundred-fifty-four consecutive patients who underwent a pancreaticoduodenectomy between October 1994 and April 2002 were reviewed by a retrospective evaluation of their medical records. In 8 cases with hemorrhagic complications, pseudoaneurysms were determined by angiography to be the main cause of hemorrhage. The clinical characteristics, pre-hemorrhagic symptoms, treatments and outcomes were analyzed. RESULTS: Hemorrhagic complications occurred in 35 (7.7%) out of 454 cases of pancreaticoduodenectomy. In 8 (22.8%) out of 35 cases, the hemorrhage burst from the pseudoaneurysms. In 1 out of 8 cases, the hemorrhage originated from a pseudoaneurysm on the proper hepatic artery, 1 case on the right hepatic artery, 1 case on the inferior pancreatoduodenal artery and on ligated gastroduodenal artery-stump in the remainder. Three cases had intra-abdominal complications such as a pancreatic fistula. Sentinel bleeding were observed in 7 cases, bleeding from the surgical drains in 4 cases, hematemesis in 5 cases and melena in 1 case. In all cases, arterial embolization was attempted and 6 cases were successful. Two cases required surgery. There was 1 mortality from hepatic failure after the embolization. CONCLUSION: Delayed massive hemorrhages after a pancreaticoduodenectomy should be ruled out when determining whether they are associated with an arterial pseudoaneurysmal rupture. Sentinel bleeding, which can be used as a warning sign of pseudoaneurysmal rupture, can be detected with close observation. Transcatheter arterial embolization is an effective modality to control bleeding from an arterial pseudoaneurysm initially.
Aneurysm, False* ; Angiography ; Arteries ; Hematemesis ; Hemorrhage* ; Hepatic Artery ; Humans ; Liver Failure ; Medical Records ; Melena ; Mortality ; Pancreatic Fistula ; Pancreaticoduodenectomy* ; Retrospective Studies ; Rupture

BACKGROUND/AIMS: Although diagnosis and surgical treatment for distal common bile duct cancer have enormously advanced, survival is not satisfactory and its prognostic factors are still being debated. Thus, we evaluated the outcomes and prognostic factors after major resection for distal extrahepatic cholangiocarcinoma (dCC). METHODS: One hundred and fifty-four patients who underwent major resection such as pancreaticoduodenectomy for dCC were retrospectively analyzed. We investigated clinical features, postoperative complications, survival, and prognostic factors of dCC. CONCLUSIONS: One hundred and three (66.9%) male and 51 (33.1%) female patients were enrolled and their mean age was 59.6 (31-78) years. Among them, 97 patients (63.0%) underwent Whipple's procedure, 45 (29.2%) pylorus-preserving pancreaticoduodenectomy, 7 (4.5%) total pancreatectomy, and 5 (3.3%) hepatopancreaticoduodenectomy, respectively. Mean follow-up duration was 26.6 (0.4-108.5) months. The postoperative morbidity and mortality were 42.2% and 1.3%, respectively. Five-year survival rate was 32.8% and mean survival duration was 47.2 (39.1-55.3) months. Type of biliary drainage (percutaneous transhepatic biliary drainage), lymph node status (positive), and cellular differentiation (moderate or poor) were significant indicators for death in multivariate analysis of resectable dCC. CONCLUSIONS: Moderate or poor cellular differentiation and lymph node metastasis may be independent poor prognostic factors for resectable dCC.
Adult ; Aged ; Bile Duct Neoplasms/mortality/*surgery ; *Bile Ducts, Extrahepatic ; Biliary Tract Surgical Procedures ; Cholangiocarcinoma/mortality/*surgery ; Female ; Humans ; Male ; Middle Aged ; Prognosis ; Risk Factors ; Survival Rate

PURPOSE: Surgical strategies for an adult choledochal cyst are influenced by the Todani-type, and the existence of a combined malignancy. This study was conducted to evaluate the characteristics of asymptomatic an adult choledochal cyst that influence the surgical strategy. METHODS: Fifty-seven adult patients (age> or =16 years) received an operation for a choledochal cyst, at the Samsung medical center, between Aug. 1995 and Jul. 2003. Asymptomatic patients were defined as those diagnosed incidentally with a choledochal cyst, who had no symptoms related with a choledochal cyst. Evaluation of PBM (pancreaticobiliary maljunction) was available in 38 patients with a proper cholangiogram. RESULTS: There were 15 and 42 asymptomatic and symptomatic patients, respectively. The mean-age (38 years-old) and gender-ratio (M: F=14: 43) were no different between the two groups. In preoperative blood tests, the titers of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were slightly higher in the symptomatic group, but were still around the upper normal limit. The total bilirubin, amylase and CA19-9 levels were no different between the two groups. The operations in the symptomatic group required longer times and greater transfusion volumes than the asymptomatic group (4.5 vs. 3.5 hrs and 0.24 vs. 0 units, respectively). The proportion of the Todani-types, types of PBM, incidence of malignancy and gallstones were no different between the two groups. Seven malignancies, 3 common bile duct cancers and 4 gall bladder cancers, were found, and an age >40 years was the only risk factor of a combined malignancy. CONCLUSION: There was no considerable difference to influence the surgical strategy between the asymptomatic and symptomatic choledochal cyst patients. However, old patients, especially over 40, may need a more aggressive surgical therapy.
Adult* ; Alanine Transaminase ; Alkaline Phosphatase ; Amylases ; Aspartate Aminotransferases ; Bilirubin ; Choledochal Cyst* ; Common Bile Duct ; Gallbladder Neoplasms ; Gallstones ; Hematologic Tests ; Humans ; Incidence ; Risk Factors

PURPOSE: The diagnosis and treatment of insulinoma are very important because the tumor can induce critical and permanent neurological deficit. The purpose of this study was to gain an understanding of the clinical features of insulinomas and to establish the diagnostic and therapeutic strategies. METHODS: 17 patients, preoperatively diagnosed with insulinomas and who had undergone surgical management between January, 1998 and March 2004, at the Department of Surgery, Samsung Medical Center, were analyzed. RESULTS: After the operation the 17 patients were diagnosed pathologically; 13 insulinoma, 2 nesidioblastosis, 1 endocrine tumor and 1 endocrine carcinoma. The male to female ratio was 7: 10, with a mean age of 52.3 years. All the patients had symptoms of Whipple triad. The mean duration of symptoms to surgery was 18 months. The preoperative mean blood sugar, plasma insulin, C-peptide and insulin to glucose ratio were 39.6 mg/dl, 47.4muU/ml, 4.8 ng/ml and 1.02 respectively. Preoperative localization was achieved in 15 patients by combining ultrasonography, angiography, abdominal CT and intra-arterial calcium stimulated venous sampling and sensitivity of those examinations were 60, 61.5, 73.3 and 91.7%, respectively. Intraoperative localization was also performed by a combination of manual palpation and intraoperative ultrasonography in 15 patients, with retrospective sensitivities of 86.6 and 100% respectively. The frequenies of head, body and tail were 6: 3: 6. In 2 nesidioblastosis patients, the localization failed both pre- and intraperatively. The types of operations included 11 enucleations, 3 distal pancreatectomies, 2 blind subtotal pancreatectomies and a distal pancreatectomy combined with an extended left hemihepatectomy and intraoperative radiofrequency ablation (RFA) for one patient accompanied by multiple liver metastase. 13 insulinomas were benign, small (mean diameter 1.5 cm, maximum 2.3 cm) and solitary, with the exception of one patient with MEN I. The symptoms of hypoglycemia and the laboratory values were improved in all patients after the operation. CONCLUSION: Insulinomas may be readily localized using sensitive diagnostic tools, such as intra-arterial stimulated venous sampling or intraoperative ultrasonography with manual palpation. If possible, enucleation may be a curative and feasible procedure for benign insulinomas. However, in the case of a highly suspicious nesidioblastosis, a blind partial pancreatectomy may be used as a trail method.
Angiography ; Blood Glucose ; C-Peptide ; Calcium ; Catheter Ablation ; Diagnosis ; Female ; Glucose ; Head ; Humans ; Hypoglycemia ; Insulin ; Insulinoma* ; Liver ; Male ; Multiple Endocrine Neoplasia Type 1 ; Nesidioblastosis ; Palpation ; Pancreas* ; Pancreatectomy ; Plasma ; Retrospective Studies ; Tomography, X-Ray Computed ; Ultrasonography

PURPOSE: From the early 1990s, operative mortality following pancreaticoduodenectomy have been decreased markedly. And severity of the postoperative complications also has been improved. Experienced hands in large volume hospitals and advances in supportive care have been considered as main reasons. Under this currency, indications for pancreaticoduodenectomy have been expanded, and extended pancreaticoduodenectomy has been tried more occasionally. METHODS: For 254 consecutive patients who underwent pancreaticoduodenectomy between Dec. 1998 and Mar. 2002, a retrospective analysis of operative mortality and postoperative complications was performed by reviewing of the medical records. RESULTS: Eighty-five patients were treated for common bile duct cancer, 58 patients for pancreatic cancer, 60 patients for ampulla of Vater cancer, 9 patients for duodenal cancer, 5 patients for advanced gastric cancer, 2 patient for gallbladder cancer, one patient for colon cancer and 34 patients for benign diseases or traumatic conditions. Standard pancreaticoduodecnectomies were performed in 169 patients, pylorus-preserving pancreaticoduodenectomies in 64 patients, total pancreatectomies in 15 patients and hepatopancreaticoduodenectomies in 6 patients. There was no postoperative 30-day or hospital mortality. Postoperative complications were occurred in 100 (39%) patients. The leading complication of this study is hemorrhage in 27 cases (11%) followed by pancreatic fistula in 17 cases (7%), delayed gastric emptying 16 cases (6%) and intraabdominal abscess in 11 cases (4%). There were no significant difference of the incidence of the complications between malignant diseases and benign, above 70-years old and below. Among them in 15 patients (15%) re-operative treatments were needed and in the remain conservative treatments were chosen. CONCLUSION: Operative mortality itself is no more limited factor for pancreaticoduodenectomy. Most of the complications following pancreaticoduodenectomy can be treated successfully and pancreaticoduodenectomy can be chosen as a safe and effective procedure not only in periampullary tumors but other benign diseases and even old age with same complication risk. But hemorrhagic complication and pancreatic fistula have been remained as serious problems on performing of pancreaticoduodenectomy.
Abscess ; Aged ; Ampulla of Vater ; Colonic Neoplasms ; Common Bile Duct ; Duodenal Neoplasms ; Gallbladder Neoplasms ; Gastric Emptying ; Hand ; Hemorrhage ; Hospital Mortality ; Humans ; Incidence ; Medical Records ; Mortality* ; Pancreatectomy ; Pancreatic Fistula ; Pancreatic Neoplasms ; Pancreaticoduodenectomy* ; Postoperative Complications ; Retrospective Studies ; Stomach Neoplasms

This study was performed to analyze the efficacy of the prophylactic use of octreotide (Novartis, Stein, Switzerland) for pancreatic fistula following a pancreaticoduodenectomy. The medical records of 190 patients who underwent a pancreaticoduodenectomy at the Samsung Medical Center in Seoul, Korea between January 2000 and December 2002 were reviewed. Patients were divided into either the octreotide (n = 81) or control group (n = 109). The octreotide group received subcutaneous injections of 100 microgramg of octreotide every 12 hours for more than five days after surgery. The control group was not treated with octreotide. The criterion of pancreatic fistula was the drainage of the amylase rich fluid, over 500 U/mL in the three days after surgery. The morbidity and mortality rates were 32.1% and 1.2% in the octreotide group and 31.2% and 0% in the control group, respectively. Pancreatic fistula was the second most common complication (8.4%). In the univariate analysis, octreotide was ineffective in reducing pancreatic fistula (p = 0.26). However, in the multivariate regression analysis, combined gastrectomy (p = 0.018), cellular origin of the disease (p = 0.049), and use of octreotide (p = 0.044) were the risk factors that increased the frequency of pancreatic fistula. Therefore, the routine use of octreotide after a pancreaticoduodenectomy should be avoided until a worldwide consensus is established.
Postoperative Complications/*prevention & control ; Pancreaticoduodenectomy/*adverse effects ; Pancreatic Fistula/*prevention & control ; Octreotide/*therapeutic use ; Middle Aged ; Male ; Humans ; Female