To develop a clinical practice guideline for vaccination in patients with autoimmune inflammatory rheumatic disease (AIIRD), the Korean College of Rheumatology and theKorean Society of Infectious Diseases developed a clinical practice guideline according to the clinical practice guideline development manual. Since vaccination is unlikely to cause AIIRD or worsen disease activities, required vaccinations are recommended. Once patients are diagnosed with AIIRD, treatment strategies should be established and, at the same time, monitor their vaccination history. It is recommended to administer vaccines when the disease enters the stabilized stage. Administering live attenuated vaccines in patients with AIIRD who are taking immunosuppressants should be avoided. Vaccination should be considered in patients with AIIRD, prior to initiating immunosuppressants. It is recommended to administer influenza, Streptococcus pneumoniae, hepatitis A, hepatitis B, herpes zoster, measlesmumps- rubella virus, human papillomavirus, and tetanus-diphtheria-pertussis vaccines in patients with AIIRD; such patients who planned to travel are generally recommended to be vaccinated at the recommended vaccine level of healthy adults. Those who live in a household with patients with AIIRD and their caregivers should also be vaccinated at levels that are generally recommended for healthy adults.

To develop a clinical practice guideline for vaccination in patients with autoimmune inflammatory rheumatic disease (AIIRD), the Korean College of Rheumatology and the Korean Society of Infectious Diseases developed a clinical practice guideline according to the clinical practice guideline development manual. Since vaccination is unlikely to cause AIIRD or worsen disease activities, required vaccinations are recommended. Once patients are diagnosed with AIIRD, treatment strategies should be established and, at the same time, monitor their vaccination history. It is recommended to administer vaccines when the disease enters the stabilized stage. Administering live attenuated vaccines in patients with AIIRD who are taking immunosuppressants should be avoided. Vaccination should be considered in patients with AIIRD, prior to initiating immunosuppressants. It is recommended to administer influenza, Streptococcus pneumoniae, hepatitis A, hepatitis B, herpes zoster, measles-mumps-rubella virus, human papillomavirus, and tetanus-diphtheria-pertussis vaccines in patients with AIIRD; such patients who planned to travel are generally recommended to be vaccinated at the recommended vaccine level of healthy adults. Those who live in a household with patients with AIIRD and their caregivers should also be vaccinated at levels that are generally recommended for healthy adults.

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

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

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: Cancer of the gallbladder, which is the eighth most common malignancy of the digestive system in Korea, is almost always associated with an unfavorable prognosis, and the clinical outcome has not improved much over the past couple of decades. This study was intended to examine our surgical experience and to evaluate the prognostic significance of the clinicopathological factors for a primary carcinoma of the gallbladder. METHODS: The data of 202 patients with gallbladder carcinomas operated on at our surgical department over a period of 10 years from May 1994 to Dec. 2003 were retrospectively reviewed. RESULTS: Overall, the 5-year survival was 46.8% with the median survival of 58.8 months. The histopathological type and grade, TNM stage, stage grouping, symptom, CA 19-9 level, and jaundice were significant prognostic factors. Among the 85 patients with T2 cancer, the outcome after a resection was better than that after simple cholecystectomy. CONCLUSION: A complete tumor resection and no lymph node involvement are associated with a good prognosis. The long-term survival may be achieved by an early diagnosis with a curative, radical resection. Additionally, a radical resection may be beneficial for patients with a T2 gallbladder carcinoma.
Cholecystectomy ; Digestive System ; Early Diagnosis ; Gallbladder Neoplasms ; Gallbladder* ; Humans ; Jaundice ; Korea ; Lymph Nodes ; Prognosis ; Retrospective Studies

PURPOSE: Hepatolithiasis causes many complications as well as an intrahepatic cholangiocarcinoma, which means that it should definitely be treated. However, it is difficult to make an accurate diagnosis for a concurrent cholangiocarcinoma prior to surgery. This study examined the surgical treatment for a hepatoithiasis with a hidden intrahepatic cholangiocarcinoma. METHODS: A retrospective analysis for patients who had undergone a hepatic resection for hepatolithiasis between September 1994 and July 2004 was made by comparing them in two groups. One group comprised of patients with hepatolithiasis only (group H) and the other group comprised of patients with hepatolithiasis and a hidden cholangiocarcinoma of which the preoperative diagnosis had failed (group HC). The prognostic factors, such as age, gender ratio (M: F), symptoms and the duration of their onset, tumor markers and total bilirubin, preoperative radiological findings, intraoperative findings, and operation type were analyzed. RESULTS: Group H consisted of 261 patients and the group HC consisted of 5. In group HC, 2 cases of tumor necrosis were misdiagnosed as a liver abscess, 1 case of hilar cholangiocarcinoma was misdiagnosed as severe cholangitis, and another case of intrahepatic cholangiocarcinoma was misdiagnosed as duct dilatation with periductal inflammatory proliferation. On the other hand, the presence of a history of a undergoing hepatobiliary surgery, the preoperative radiological findings of a liver abscess and lymphadenopathy, the type of surgery, and the site of the intrahepatic stones were statistically different in the two groups. CONCLUSION: A hidden cholangiocarcinoma should be suspected preoperatively in cases in whom there is a history of undergoing hepatobiliary surgery, the preoperative radiological findings of a liver abscess or lymphadenopathy. In addition, a meticulous exploration for a possible incidental tumor mass with an additional consultation of a frozen biopsy should be carried out intraoperatively to determine if the preoperative finding of a liver abscess is a tumor necrosis.
Bilirubin ; Biopsy ; Biomarkers, Tumor ; Cholangiocarcinoma* ; Cholangitis ; Diagnosis ; Dilatation ; Hand ; Humans ; Liver Abscess ; Lymphatic Diseases ; Necrosis ; Retrospective Studies

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: 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: 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