Over the 1 year 3 month period from 7/11/1997 until 10/30/1998, we have attempted graft salvage with tacrolimus conversion in a total of 11 patients (mean age 41 years, range 31~64 years) with ongoing rejection on baseline CsA immunosuppression after failure of high dose corticosteroid to reverse rejection. The indications for conversion to tacrolimus were ongoing biosy confirmed rejection in all patients. Seven grafts showed vascular rejection and 4 had cellular rejection on biopsy. The median interval to tacrolimus conversion was 4 days (range 1 days to 840 days) after transplantation. Three patients (27.3%) were dialysis-dependent owing to the severity of rejection. All patients (100%) have been successfully rescued and graft function of the patients improved from an average serum creatinine level of 7.3 3.6 mg/dl to 1.4 0.5 mg/dl. During the mean follow-up of 8.1 months after conversion, there were 10 complications following tacrolimus conversion including cytomegalovirus (CMV) infection in 2 patient, herpes esophagitis in 1, aspergillosis pneumonia in 1, pneumocystis carinii pneumonia in 1, new-onset diabetes mellitus in 4, tremor in 1 and bleeding due to thrombocytopenic thrombocytopenic purpura (TTP) in 1. Two of these postconversion complications resulted in patient death. Treatment with tacrolimus may successfully suppress ongoing acute rejection, even if high dose corticosteoid treatment have failed to reverse rejection. Base on these data, we recommend that tacrolimus be used for refractory rejection therapy. An additional anti-infective prophylaxis seems to be necessary in preventing severe complications after rejection therapy.
Allografts* ; Aspergillosis ; Biopsy ; Creatinine ; Cytomegalovirus ; Diabetes Mellitus ; Esophagitis ; Follow-Up Studies ; Hemorrhage ; Humans ; Immunosuppression ; Pneumonia ; Pneumonia, Pneumocystis ; Purpura, Thrombocytopenic ; Tacrolimus* ; Transplants ; Tremor

Posttransplant lymphoproliferative disease(PTLD) represents a diverse lymphoproliferative disorder ranging from non-specific reactive hyperplasia to malignant immunoblastic sarcoma developed in a setting of immunosuppression following organ or cellular transplantation. It is often associated with Epstein-Barr virus infection and high dose immunosuppression. EBV detection and immunotyping including immunoglobulin clonality is crucial for prediction of prognosis and treatment modality. We report one case of PTLD developed 5 months after renal transplantation in 33 year-old man. Clinical manifestion was submandibular mass, and EBV was detected by in situ hybridization. Histology and immunotyping revealed immunoblastic lymphoma andl lambda chain monoclonality. He has been treated with reduction of immunosuppression, acyclovir and radiotherapy, and is in stable condition with normal renal function at postoperative 11months without evidence of disease reccurrence.
Acyclovir ; Adult ; Herpesvirus 4, Human ; Humans ; Hyperplasia ; Immunoglobulins ; Immunosuppression ; In Situ Hybridization ; Kidney Transplantation* ; Lymphoma ; Lymphoma, Large-Cell, Immunoblastic ; Lymphoproliferative Disorders ; Prognosis ; Radiotherapy

OBJECTIVE: The aim of this study was to evaluate effect of pulsed radiofrequency (PRF) neuromodulation of suprascpaular nerve (SSN) in patients with chronic shoulder pain due to adhesive capsulitis and/or rotator cuff tear. METHODS: The study included 11 patients suffering from chronic shoulder pain for at least 6 months who were diagnosed with adhesive capsulitis (n=4), rotator cuff tear (n=5), or adhesive capsulitis+rotator cuff tear (n=2) using shoulder magnetic resonance imaging or extremity ultrasonography. After a favorable response to a diagnostic suprascapular nerve block twice a week (pain improvement >50%), PRF neuromodulation was performed. Shoulder pain and quality of life were assessed using a Visual Analogue Scale (VAS) and the Oxford Shoulder Score (OSS) before the diagnostic block and every month after PRF neuromodulation over a 9-month period. RESULTS: The mean VAS score of 11 patients before PRF was 6.4+/-1.49, and the scores at 6-month and 9 month follow-up were 1.0+/-0.73 and 1.5+/-1.23, respectively. A significant pain reduction (p<0.001) was observed. The mean OSS score of 11 patients before PRF was 22.7+/-8.1, and the scores at 6-month and 9 month follow-up were 41.5+/-6.65 and 41.0+/-6.67, respectively. A significant OSS improvement (p<0.001) was observed. CONCLUSION: PRF neuromodulation of the suprascapular nerve is an effective treatment for chronic shoulder pain, and the effect was sustained over a relatively long period in patients with medically intractable shoulder pain.
Adhesives ; Bursitis ; Chronic Pain ; Extremities ; Failed Back Surgery Syndrome ; Follow-Up Studies ; Humans ; Magnetic Resonance Imaging ; Nerve Block ; Quality of Life ; Rotator Cuff ; Shoulder Pain* ; Shoulder* ; Spinal Cord Stimulation ; Ultrasonography

PURPOSE: Simple closure, regardless of using an omental patch, continues to be the preferred option for many surgeons. It is a easy, quick and safe operation, and it can be applied to all situations by every surgeon. The purpose of this study was to investigate the feasibility of routinely using laparoscopic repair for treating perforated peptic ulcer. METHODS: A retrospective review was carried out on 68 consecutive patients who underwent patch repair for a perforated peptic ulcer; 11 underwent laparoscopic repair and 57 underwent open repair. Laparoscopic repair was performed by one surgeon at the same hospital between March, 2006 and February, 2009. Both groups were compared according to the Mann-Whitney U-test. A p value <0.05 was considered to be significant. RESULTS: Statistical significance (p<0.05) between two groups (laparoscopic vs. open) was present regarding to the postoperative morbidity (0 vs. 16 cases, respectively), the hospital stay (4.8 vs. 12.7 days, respectively), the postoperative day of resuming an oral diet (3 vs. 5.7 days, respectively). The mean operative time of laparoscopic repair (78 minutes) was shorter than that of open repair (82 minutes) but this was not statistically significant (p=0.81). We excluded using a pain scale or assessing the use of analgesics in this study because of the popularity of IV PCA (intravenous patient-controlled analgesia). CONCLUSION: Laparoscopic primary repair is a safe emergency procedure for treating perforated peptic ulcer patients.
Analgesics ; Diet ; Emergencies ; Humans ; Length of Stay ; Operative Time ; Passive Cutaneous Anaphylaxis ; Peptic Ulcer ; Retrospective Studies

PURPOSE: There are a number of conditions that can lead to a hypercoagulable state, however, protein C and S deficiencies are frequently described as causes of the hypercoagulable states. The aim of this study was to evaluate the clinical features and prognosis of vascular diseases associated with protein C and/or S deficiencies and to determine an adequate treatment modality for such cases. METHODS: We prospectively evaluated 7 cases with vascular disease caused by protein C and/or S deficiencies confirmed with serologic tests. RESULTS: Four patients showed venous thrombosis, 1 peripheral arterial insufficiency, 1 cerebral venous thrombosis and peripheral arterial insufficiency, and 1 portal vein thrombosis. Surgical intervention was required in 5 patients. Full anticoagulation with heparin sodium followed by warfarin sodium was done in all patients. CONCLUSION: Protein C and S deficiencies may influence clinical management. Patients presenting with atypical vascular involvement without evidence of other risk factors should be evaluated for a hypercoagulable state. Once the diagnosis is made, patients should be treated with full anticoagulation.
Diagnosis ; Heparin ; Humans ; Prognosis ; Prospective Studies ; Protein C* ; Risk Factors ; Serologic Tests ; Vascular Diseases* ; Venous Thrombosis ; Warfarin

BACKGROUND: Currently, the incidence of chronic pancreatitis is increasing due to the change of diet and high alcohol consumption in our country. Regarding more effective treatment of chronic pancreatitis, surgical intervention is favored for the control of intractable pain, various complications from the pancreatitis, suspected malignancy, and amelioration of progressively deterioratory exocrine and endocrine pancreas functions. We attempted to evaluate the various indications for an operation, various surgical treatments, and their results. METHODS: We retrospectively reviewed the clinical records of 50 patients with chronic pancreatitis who were managed surgically between July 1989 and Feb. 1998. RESULTS: The indications for operation were intractable pain in 25 cases, suspected malignancy in 12 cases, biliary obstruction in 4 cases, pancreatic pseudocyst in 7 cases, and treatment of Diabetes Mellitus in 2 cases. We performed 11 drainage procedures, 8 Peustow-Gillesby operations and 3, DuVal operations 2 combined denervations, 28 pancreatic resections 12 pancreaticoduodenectomies, duodenum-preserving resection of the pancreas head 12, distal pancreatectomies, 3 total pancreatectomies and a combined denervation, 9 bypass procedures and 2 pancreas transplantations in 2 cases. The follow-up period were from 1 month to 9 years and 7 months with a mean of 2 years and 11 months. The results were good in 23 cases (51 .1%), fair in 16 cases (35.6%) and poor (no change or aggravation) in 6 cases (13.3%). Postoperative mortality developed in 1 case due to postoperative aspiration pneumonia and sepsis after the bypass procedures. Late mortality occurred in 2 cases, one due to sepsis from uncontrolled DM and the other is rupture of the pseudoaneurysm of the anastomotic vessel after transplantation. CONCLUSIONS: Surgical procedures are the mainstays of definite treatment modality in chronic pancreatitis. Operations should be selected properly for each case. Pancreas or islet transplantation is another treatment option for the control of irreversible exocrine and endocrine pancreatic dysfunction.
Alcohol Drinking ; Aneurysm, False ; Denervation ; Diabetes Mellitus ; Diet ; Drainage ; Follow-Up Studies ; Head ; Humans ; Incidence ; Islets of Langerhans ; Islets of Langerhans Transplantation ; Mortality ; Pain, Intractable ; Pancreas ; Pancreas Transplantation ; Pancreatectomy ; Pancreatic Pseudocyst ; Pancreaticoduodenectomy ; Pancreatitis ; Pancreatitis, Chronic* ; Pneumonia, Aspiration ; Retrospective Studies ; Rupture ; Sepsis

Carcinoid tumors of the gastrointestinal tract are usually localized in the appendix, the small intestine and the rectum. Carcinoid of the ampulla of Vater is an extremely rare lesion. The clinical manifestations of the carcinoid of the ampulla of Vater are nonspecific, and preoperative diagnosis is difficult because the tumor grows submucosally. Endoscopy is the main diagnostic procedure; but big and deep biopsies are needed to confirm to histologic nature of the tumor. Carcinoid of the ampulla of Vater have specific clinical features that distinguishes it from the duodenal and small bowel carcinoid. The management of this tumor for cure requires radical pancreaticoduodectomy or local excision with lymph node dissection. We experienced one case of carcinoid in a 61- year-old woman who had epigastric pain. We report a patient and review the literature, giving special attention to the clinical picture and treatment of this disease.
Ampulla of Vater* ; Appendix ; Biopsy ; Carcinoid Tumor* ; Diagnosis ; Endoscopy ; Female ; Gastrointestinal Tract ; Humans ; Intestine, Small ; Lymph Node Excision ; Rectum

Pancreas transplantation has became an accepted form of therapy for insulin dependent DM (IDDM). However, rejection remains the major cause of graft loss in pancreas allografts. To overcome the immunologic graft loss following pancreas allograft, early reliable method for rejection is crucial. The purpose of this study was to evaluate the significance of urine amylase (UA) levels as a reliable and sensitive indicator of pancreas allograft rejection retrospectively. Over a 15-month study period from August '97 to Cotover '98, 9 pancreas transplants with bladder drainage were performed at our center. Among which 6 pancreas transplantation alone (PTA) and 3 simultaneous pancreas-kidney transplantation (SPK) were performed. The diagnosis of rejection was based on clinical criteria (fever, tenderness, leukocytosis) and serology such as, a reduction in UA level. Rejection was developed in 5 patients (56%), including 4 PTA and 1 SPK recipients. Mean UA level during normal allograft function was 89,365 U/L, whereas level heralding rejection was 14,760 U/L (P<0.05). After steroid pulse therapy, first rejection episode result in 100% reversal of rejection and the UA level returned toward normal (mean 95,437 U/L). However more than one rejection episode resulted in poor outcome (all the graft were lost). Overall, reversal of rejection occurred in 63% of cases, with 2 PTA and 1 SPK lost due to rejection. Monitoring pancreas-allograft function by UA allows for the timely diagnosis and successful treatment of pancreas-allograft rejection. For more than one rejection episodes, more potent immunosuppressants are through needed to be improve the graft survival.
Allografts* ; Amylases* ; Diagnosis ; Drainage ; Early Diagnosis* ; Graft Survival ; Humans ; Immunosuppressive Agents ; Insulin ; Pancreas Transplantation* ; Pancreas* ; Retrospective Studies ; Transplants ; Urinary Bladder

BACKGROUND: Cutaneous malignant melanoma represents a tumor arising within the melanocytic systems of the skin. Once considered an uncommon cancer, melanoma is now rising in incidence at a rate faster than any other cancer. OBJECTIVE: The purpose of this study was to investigate the clinico-pathological characteristics of malignant melanoma. METHODS: A total of 61 patients with malignant melanoma were enrolled in this retrospective study. We classified malignant melanoma as follows; ALMM, acral lentigious malignant melanoma, NMM, nodular malignant melanoma, SSMM, superficial spreading malignant melanoma, MM, mucosal melanoma, LMM, lentigo maligna melanoma. We used the staging system of American Joint Committee on Cancer to evaluate the clinical status in our subjects. The hospital charts and histopathological slides of patients with malignant melanoma diagnosed at Asan Medical Center from 1989 to 1999 were reviewed. Immunohistochemical study was performed for S-100 and HMB-45 in 10 cases and for Ki-67 in 5 cases. RESULTS: 1. The male to female ratio was 1.3. The mean age at diagnosis was 52.6 years. ALMM was the most common type(52.5%) in this study. ALMM and NMM developed in elderly persons, while SSMM developed in younger persons. Malignant melanomas arising from pre-existing mole were 10 cases(16.4%). 2. In forty two cases(68.9%), malignant lesions were limited to skin, but 19 cases(31.1%) were disseminated to lymph nodes, skin or internal organ at the initial examination. Sole and heel were the favored sites in ALMM. Lower extremities and back were the favored sites in NMM and SSMM. Four patients were initially presented with metastatic symptoms such as dyspnea, abdominal mass, headache, or axillary mass, and cutaneous malignant melanoma eventually were diagnosed as their origin. 3. Histopathologically, 6 cases were categorized into amelanotic type and 1 case was into desmoplastic type. 4. More than a half cases developed metastases to other organs. Common metastatic sites were lymph nodes, lung, brain, skin, liver, bone, and bladder in decreasing order of frequency. 5. The five-year survival rate was 100% in stage IA, IB, and IIA but 0% in stage IV. Face, chest and lower extremities showed worse prognosis. Men had worse prognosis than women. NMM revealed the lowest 5-year survival rate(30%). CONCLUSION: Among the prognostic factors such as locations, clinical types, ages, and gender, the stages at the initial presentation was the most important predictable value in our study. Therefore, the early recognition of malignant melanoma is the key to possible cure.
Aged ; Brain ; Chungcheongnam-do ; Diagnosis ; Dyspnea ; Female ; Headache ; Heel ; Humans ; Hutchinson's Melanotic Freckle ; Incidence ; Joints ; Liver ; Lower Extremity ; Lung ; Lymph Nodes ; Male ; Melanoma* ; Neoplasm Metastasis ; Prognosis ; Retrospective Studies ; Skin ; Survival Rate ; Thorax ; Urinary Bladder

PURPOSE: Islet cell tumors are a rare disease that can be cured by surgical management if they are early diagnosed. However, diagnosis and localization are difficult due to their small size and varied clinical manifestations. We analyzed the clinicopathologic features, the diagnosis and the surgical management of islet cell tumors. METHODS: We retrospectively analyzed the case histories of 30 patients had undergone pancreatic surgery for islet cell tumors between April 1990 and December 1999. RESULTS: The islet-cell tumors included 16 insulinomas, 4 gastrinomas, 1 glucagonoma, one insulin-gastrin secreting tumor, and 8 nonfunctioning tumors. The major clinical manifestations were neuroglycopenic (94%) and adrenergic (75%) symptoms in cases of an insulinoma, abdominal ulcer symptoms (100%) in the cases of a gastrinoma, diabetis mellitus (100%) in the cases of a glucagonoma, and abdominal pain (63%) and a mass (25%) in nonfunctioning tumor. The preoperative tumor localization tools were angiography, transhepatic portal vein sampling, endoscopic ultrasonography, computed tomography, and octreotide scans which had sensitivities of 56%, 71%, 55.5%, 43.3%, and, 25% respectively. The surgical treatments were enucleation (38%) or segmental resection (25%) for insulinomas, pancreaticoduodenectomy with total gastrectomy (25%) or total pancreatectomy (25%) for gastrinomas, and pylorus preserving pancre aticoduodenectomy (38%) or regional pancreatectomy (26%) for nonfunctioning tumors. Malignant islet cell tumors were presenting cases (30%). Two patients died with postoperative complications on post operative day 3 and 35; the others survived during the follow-up period (1 month-10 years). Islet cell tumors with multiple endocrine neoplasm type I occurred in five (17%) cases; in three cases, the tumors were malignant. CONCLUSION: The early diagnosis and vigorous attempt to resect the lesion in islet cell tumors of the pancreas should be carried out for the long-term survival.
Abdominal Pain ; Adenoma, Islet Cell* ; Angiography ; Diagnosis ; Early Diagnosis ; Endosonography ; Follow-Up Studies ; Gastrectomy ; Gastrinoma ; Glucagonoma ; Humans ; Insulinoma ; Islets of Langerhans* ; Octreotide ; Pancreas* ; Pancreatectomy ; Pancreaticoduodenectomy ; Portal Vein ; Postoperative Complications ; Pylorus ; Rare Diseases ; Retrospective Studies ; Ulcer