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

PURPOSE: In about 1% of cases, incidental gallbladder cancers (iGBC) are found after routine cholecystectomy. The aim of this study is to compare clinical features of iGBC with benign GB disease and to evaluate factors affecting recurrence and survival. METHODS: Between January 1998 and March 2014, 4,629 patients received cholecystectomy and 73 iGBC patients (1.6%) were identified. We compared clinical features of 4,556 benign GB disease patients with 73 iGBC patients, and evaluated operative outcomes and prognostic factors in 56 eligible patients. RESULTS: The iGBC patients were older and concomitant diseases such as hypertension and anemia were more common than benign ones. And an age of more than 65 years was the only risk factor of iGBC. Adverse prognostic factors affecting patients' survival were age over 65, advanced histology, lymph node metastasis, and lymphovascular invasion on multivariate analysis. Age over 65 years, lymph node involvement, and lymphovascular invasion were identified as unfavorable factors affecting survival in subgroup analysis of extended cholecystectomy with bile duct resection (EC with BDR, n = 22). CONCLUSION: Prior to routine cholecystectomy, incidental GB cancer should be suspected especially in elderly patients. And advanced age, lymph node metastasis, and lymphovascular invasion are important prognostic factors in EC with BDR cohorts.
Aged ; Anemia ; Bile Ducts ; Cholecystectomy* ; Cohort Studies ; Gallbladder Neoplasms* ; Gallbladder* ; Humans ; Hypertension ; Lymph Nodes ; Multivariate Analysis ; Neoplasm Metastasis ; Prognosis ; Recurrence ; Risk Factors

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

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

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

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

Tuberculosis can involve any part of the gastrointestinal tract but 80~90% of patients present the disease in the ileocecal region. The cases of colon cancer coexisting with colonic tuberculosis are relatively rare and ascending colon is the predominant site of the combined disease. A 46-year-old man, without specific past medical or family history, showed multiple colonic polyps and ulcers on colonoscopic examination. After surgery, the surgical specimen disclosed adenocarcinoma in the ascending colon, eleven adenomatous polyps throughout the colon, and multiple tuberculous ulcers in the entire colon. Tuberculosis of terminal ileum was also accompanied. The association of colonic tuberculosis and colon cancer with multiple polyps in this case may have been coincidental. The preoperative colonoscopic examination and pathologic diagnosis by frozen section during operation are necessary for the adequate treatment.
Adenocarcinoma ; Adenomatous Polyps ; Colon* ; Colon, Ascending ; Colonic Neoplasms* ; Colonic Polyps ; Diagnosis ; Frozen Sections ; Gastrointestinal Tract ; Humans ; Ileum ; Middle Aged ; Polyps ; Tuberculosis* ; Ulcer

PURPOSE: Over the several decades, there has been a considerable improvement in the survival of patients who undergo renal transplantation due to newer immunosuppressive agents and development of surgical technique and post-operative management. However, life expectancy beyond 10 years is still considerably less than that in the general population. We studied the causes of patient death after kidney transplantation to determine the major causes of death, to decrease the mortality rate of patient and to increase the graft survival rate. METHODS: From Jan. 1990 to Dec. 2002, 1353 renal transplantation were performed at Asan Medical Center. There had been 63 cases of patient death and we reviewed the causes of death, recipient-donor relationship, immunosuppressive agents, history of rejection and the time of death after transplantation in these patients, retrospectively. RESULTS: The major causes of patient death were infection (36.5%), cardiovascular disease (14.3%), malignancy (9.5%), hepatic failure (11.1%), miscellaneous (11.1%) and unknown (22.2%). Thirty-nine (61%) of total death occurred in the first year of transplantation and major cause in first year of transplants was infection (46.2%). Of 63 deaths, 35(55.6%) were with graft function and 49 (77.8%) had history of rejection. The patients with brain- death donor had a higher death rate than that of the patients with living donors (3.7% vs 7.8%, P=0.002). The patients who had history of rejection have higher death rate than the patient with no history of rejection (22.6% vs 1.3%, P<0.001). CONCLUSION: Active efforts for the prevention of rejection and infection in early phase of transplantation and close surveillance of malignancy and cardiovascular disease in long-term follow up will decrease the death of transplanted patients and increase the graft survival rate.
Cardiovascular Diseases ; Cause of Death* ; Chungcheongnam-do ; Graft Survival ; Humans ; Immunosuppressive Agents ; Kidney Transplantation* ; Kidney* ; Life Expectancy ; Liver Failure ; Living Donors ; Mortality ; Retrospective Studies ; Tissue Donors ; Transplants

BACKGROUND: Many renal allograft patients were received blood transfusions in the pre- or posttransplant period. Before cyclosporine era, many studies showed that immunomodulation which induced by blood transfusion before renal allograft improved graft survival. However, the graft-protective effects of blood transfusion have been questioned in the recent studies. We compared the effects of perioperative blood transfusion on renal allograft rejection and graft survival in transfusion and nontransfusion groups. METHODS: 462 patients (127 cadaveric v.s 335 living) who were received renal allograft from January, 1994 to December, 1997 in our center were grouped into the transfusion and nontransfusion group. All the patients received same triple immunosuppressive regimens (cyclosporine, azathioprine, prednisone). Rejection and graft survival were analyzed retrospectively. Mean follow up period was 838 days (range: 5-1,640). RESULTS: Out of 462 patients, 389 (84.2%) were transfused and mean transfused volume was 4.56 0.38 pints. 73 (15.8%) showed rejection on biopsy. The transfusion group showed 61 (15.7%) rejections and nontransfusion group showed 12 (16.4%) rejections. There was no statistically significant difference of rejection between transfusion and nontransfusion group (p=0.86). Regardless of cadaveric and living renal allograft group, there was no difference of blood transfusion effect on rejection (p=0.53 v.s p=0.98). Rejection was one of the negative factor affecting graft survival significantly (p=0.00). In terms of graft survival, there was no difference between the transfusion and nontransfusion group (p=0.11) CONCLUSION: We conclude that pre- and posttransplant blood transfusions have no detectable beneficial or harmful effects on rejection and graft survival in renal allograft under the current cyclosporine based immunosuppressive medication.
Allografts* ; Azathioprine ; Biopsy ; Blood Transfusion* ; Cadaver ; Cyclosporine ; Follow-Up Studies ; Graft Survival* ; Humans ; Immunomodulation ; Retrospective Studies ; Transplants*

With the exception of aneurysms of the aorta and iliac segments, splenic artery aneurysms are the most common form of aneurysm found in the abdomen. The pathogenesis of splenic artery aneurysms may be largely congenital, in women, and atherosclerotic, in men. A blunt trauma may be one of the less common causes of splenic artery aneurysms. Furthermore, to our knowledge, the delayed development of a splenic artery aneurysm, after a blunt trauma, is extremely rare. We report a case of a 35-year-old man with the delayed development of a splenic artery aneurysm on a follow- up computed tomographic scan of the spleen, 2 weeks after injury. Our case showed that a follow-up computed tomographic scan, after a blunt trauma, provided valuable clinical information on the diagnosis and management of splenic injury for documentign the healing or the progression of the injury, even though some studies have suggested this has no particular value.
Abdomen ; Adult ; Aneurysm* ; Aorta ; Diagnosis ; Female ; Follow-Up Studies ; Humans ; Male ; Spleen ; Splenic Artery*