PURPOSE: The aim of this prospective, randomized study was to evaluate the effects and adverse effects of nebulized L-epinephrine compared with nebulized budesonide in children with moderate to severe croup. METHODS: Children were eligible for the study if their croup scores fell in the moderate to severe range(scores>4) in the AMC from May 1995 till May 1996. The patients were randomly assigned to receive either 5ml(1 : 1000) of L-epinephrine aerosols(n=9) or 500microgram of budesonide aerosols (n=8). Croup score, O2 saturation by pulse oximeter, heart rate, and blood pressure were recorded before treatment and at 5, 15, 30, 60, 120 minutes after aerosol treatment. Nine patients were enrolled in the nebulized L-epinephrine group and 8 in the nebulized budesonide group, respectively. There were no statistical differences in age, sex and croup score before treatment between the two groups. RESULTS: Total croup score significantly decreased at 15 minutes after treatment in the L-epinephrine group(P<0.05) but at 120 minutes after treatment in the budesonide group(P<0.05). Treatment failed in 1(1/9) patient in the L-epinephrine group and 2(2/8) patients in the budesonide group, who received intramuscular dexamethasone injections. The rebound phenomenon at 120 minutes after treatment was found in 1 patient from both groups. There were no significant changes of heart rate and blood pressure before and after treatment in both groups. CONCLUSION: The treatment using nebulized L-epinephrine showed a more prompt clinical improvement than the treatment using nebulized budesonide and without any significant adverse effects. So it can be recommended for emergent management in children with moderate to severe croup.
Aerosols* ; Blood Pressure ; Budesonide* ; Child ; Croup* ; Dexamethasone ; Heart Rate ; Humans ; Prospective Studies*

PURPOSE: The aim of this prospective, randomized study was to evaluate the effects and adverse effects of nebulized L-epinephrine compared with nebulized budesonide in children with moderate to severe croup. METHODS: Children were eligible for the study if their croup scores fell in the moderate to severe range(scores>4) in the AMC from May 1995 till May 1996. The patients were randomly assigned to receive either 5ml(1 : 1000) of L-epinephrine aerosols(n=9) or 500microgram of budesonide aerosols (n=8). Croup score, O2 saturation by pulse oximeter, heart rate, and blood pressure were recorded before treatment and at 5, 15, 30, 60, 120 minutes after aerosol treatment. Nine patients were enrolled in the nebulized L-epinephrine group and 8 in the nebulized budesonide group, respectively. There were no statistical differences in age, sex and croup score before treatment between the two groups. RESULTS: Total croup score significantly decreased at 15 minutes after treatment in the L-epinephrine group(P<0.05) but at 120 minutes after treatment in the budesonide group(P<0.05). Treatment failed in 1(1/9) patient in the L-epinephrine group and 2(2/8) patients in the budesonide group, who received intramuscular dexamethasone injections. The rebound phenomenon at 120 minutes after treatment was found in 1 patient from both groups. There were no significant changes of heart rate and blood pressure before and after treatment in both groups. CONCLUSION: The treatment using nebulized L-epinephrine showed a more prompt clinical improvement than the treatment using nebulized budesonide and without any significant adverse effects. So it can be recommended for emergent management in children with moderate to severe croup.
Aerosols* ; Blood Pressure ; Budesonide* ; Child ; Croup* ; Dexamethasone ; Heart Rate ; Humans ; Prospective Studies*

PURPOSE: When performing donor screening for living donor liver transplantation (LDLT) for an adult patient with end- stage liver disease, ABO blood group incompatibility is the most common cause of donor exclusion. To cope with this problem without performing ABO-incompatible LDLT, living donor exchange program has been maintained at the Asan Medical Center, Seoul, Korea since September 2003. Here we introduce the clinical experience of 6 cases of adult LDLT allocated by living donor exchange program. METHODS: From February, 1997 to December 2006. 1208 cases of adult LDLT were performed in our institution. Among them, there were 6 cases allocating through donor exchange program to avoid ABO blood group mismatching. Three sets of 2 donor-recipient combination pairs were made after direct one-to-one donor-recipient matching. RESULTS: Two sets of donor exchange LDLT were performed on elective surgery basis, but one in emergency situation. Two living donors and 2 recipients underwent LDLT operations at the same time at the same institution. All 6 living donors recovered well. All of the 6 recipients are doing well to date although 1 recipient had undergone prolonged intensive care for surgical complications. There was no emotional or psychological conflict related to donor exchange program. CONCLUSION: This is the world-first report on donor exchange adult LDLT. Although this is a preliminary report with only 3 sets, donor exchange program for adult LDLT appears to be a feasible modality to promote LDLT. We believe it can be applicable to a wider population of LDLT after widespread consensus formation.
Adult ; Blood Group Incompatibility ; Critical Care ; Consensus ; Donor Selection ; Emergencies ; Humans ; Korea ; Liver ; Liver Diseases ; Liver Transplantation ; Living Donors ; Phosphatidylethanolamines ; Tissue Donors

BACKGROUNDS/AIMS: This study is intended to investigate the clinicopathological features of the intraductal papillary neoplasms of the intrahepatic bile duct (IPNB), especially focused on malignant changes. METHODS: From the institutional database of liver resection cases (Asan Medical Center, University of Ulsan College of Medicine), 18 patients who met the definition of IPNB were selected. They had undergone liver resection between February 2002 and October 2006; thus, the follow-up period was more than 5 years. RESULTS: Of the 18 patients, 11 patients were male. Their mean age was 61.3+/-6.7 years. There were no differences between the non-malignant and malignant lesions, in the comparison of the CEA levels (5.6+/-2.7 vs.12.6+/-31.1 ng/ml, p=0.439) and the CA19-9 levels (29.2+/-34.7 vs.31.9+/-30.2 ng/ml, p=0.871). The common radiologic findings were: intraductal growing mass in 10; bile duct dilatation in 6; and saccular duct dilatation in 2. Left and right hepatectomies were performed in 15 and 3, respectively. Five patients showed benign lesions of IPNB, and 13 patients revealed malignant lesions of intraductal papillary adnocarcinoma or cholangiocarcinoma. All 4 patients with benign lesions survived for a mean period of 53 months without recurrence. In 13 patients with the malignant lesions, 1-year, 3-year, and 5-year survival rates were 100%, 84.6%, and 59.2%, respectively. CONCLUSIONS: We concluded that intrahepatic IPNB is a rare type of biliary neoplasm which includes a histological spectrum, ranging from benign disease to invasive malignancy. The long-term survival was anticipated after complete curative resection.
Academic Medical Centers ; Bile Ducts ; Bile Ducts, Intrahepatic ; Cholangiocarcinoma ; Dilatation ; Follow-Up Studies ; Hepatectomy ; Humans ; Liver ; Male ; Recurrence ; Survival Rate

PURPOSE: This study was designed to analyze the prognosis following segmental bile duct resection (BDR) versus pancreatoduodenectomy (PD) for mid bile duct (mBD) cancer. METHODS: During the 4 years between 2003 and 2006, 55 patients underwent surgical resection for mBD cancer in our institution. Medical records were reviewed retrospectively. They were divided into two groups, a BDR group (n=24) and a PD group (n=31) according to the extent of resection. RESULTS: Median follow-up was 43 months. Overall 3- and 5-year survival rates were 56.0% and 33.8%, respectively. The BDR group had lower tumor stages than the PD group (p=0.011). R0 resection was achieved in 17 (70.8%) of the BDR group and 30 (96.8%) of the PD group. Median survival periods were 43 and 34 months after R0 and R1 resections, respectively (p=0.715). Recurrence occurred in 41 patients after a mean period of 18 months. Three- and 5-year survival rates were 62.5% and 27.2% after BDR, respectively, and 51.5% and 34% after PD, respectively (p=0.715). No significant risk factors for shorter patient survival times was identified. Aggressive treatment of recurrence did not appear to prolong patient survival. CONCLUSION: The extent of resection for mBD cancer did not affect the survival outcome when R0 resection was achieved. Considering the operative risk in patients with older ages or co-morbidities, PD should be considered only after obtainment of simultaneous tumor-free radial and proximal longitudinal resection margins.
Bile ; Bile Duct Neoplasms ; Bile Ducts ; Follow-Up Studies ; Humans ; Medical Records ; Pancreaticoduodenectomy ; Prognosis ; Recurrence ; Retrospective Studies ; Risk Factors ; Survival Rate

PURPOSE: Although curative resection of hilar cholangiocarcinoma (HCCC) remains a difficult challenge, only curative resection with tumor free margins can guarantee a favorable outcome. In this report, we retrospectively analyzed the survival data after surgical resection of HCCC to determine the survival rate and the related factors at a single, large-volume medical institute. METHODS: Between June 1989 and June 2005, surgical intervention with curative intent was performed on 301 patients. We retrospectively analyzed the survival data via a review of the medical record. RESULTS: Among the 259 cases of resection, curative (R0) resection with tumor-free margins was achieved in 186 cases (71.8%). Of these 186 cases, 177 patients underwent various types of hepatectomy with caudate lobectomy and bile duct resection. Combined pancreatoduodenectomy was performed in 19 patients and portal vein resection was performed in 51 patients. In-hospital mortality developed in 11(4.3%) of the 259 patients who underwent resection. The 1-, 3- and 5-year survival rates of patients who underwent R0 resection were 83.3, 42.0 and 29.3%, respectively. Univariate analysis revealed that curability, T stage, lymph node involvement, histologic differentiation and perineural invasion were associated with patient survival. Multivariate analysis showed that curability and lymph node involvement were statistically significant prognostic factors. CONCLUSION: Tumor-positive margins and lymph node involvement resulted in poor outcomes. Intensive perioperative management and a surgeon's aggressive efforts to attain clearance of tumor can minimize the postoperative mortality and maximize survival for patients with HCCC.
Bile Ducts ; Cholangiocarcinoma* ; Hepatectomy ; Hospital Mortality ; Humans ; Klatskin's Tumor ; Lymph Nodes ; Medical Records ; Mortality ; Multivariate Analysis ; Pancreaticoduodenectomy ; Portal Vein ; Retrospective Studies ; Survival Rate

BACKGROUNDS/AIMS: Although the survival rate after surgical resection of peripheral cholangiocarcinoma is low, surgical resection is only potentially curative therapy. The aim of this study is to evaluate clinicopathological factors affecting survival after surgical resection of peripheral cholangiocarcinoma. METHODS: Between February 1990 and December 2005, surgical intervention with curative intent was performed on 318 patients and 292 patients underwent resection. We retrospectively analyzed survival data of 318 patients and clinicopathological factors affecting survival by reviewing the medical record. RESULTS: Among the 292 cases of resection, curative resection with tumor-free margin (R0) has been resulted in 221 cases. The 1-, 3-, 5- and 10-year survival rate of R0 resection were 74.9, 46.9, 36.9 and 15.2%, respectively. The survival rate of patient undergoing R0 resection was significantly better than that of R1, R2 or nonresection. Multivariate analysis showed that curative resectability, macroscopic type of tumor and lymph node metastasis were statically significant independent prognostic factors. CONCLUSIONS: The survival after surgical resection of peripheral cholangiocarcinoma depends on curability of surgical resection, macroscopic type of tumor and status of lymph node. Particullary in R0 resection for intraductal growth type without lymph node metastasis, there is great chance for long-term survival. Surgical resection attaining tumor free margin should be attempted if liver function and general condition of patient are acceptable for hepatectomy.
Aged ; Bile Duct Neoplasms/diagnosis/*mortality/surgery ; *Bile Ducts, Intrahepatic ; Cholangiocarcinoma/diagnosis/*mortality/surgery ; Female ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Multivariate Analysis ; Predictive Value of Tests ; Retrospective Studies ; Survival Rate ; Treatment Outcome

The wall of normal proximal bile duct is occasionally thin with close approximation to the right hepatic artery. Thus, isolation of this hepatic artery can result in excessive weakening of the remnant proximal bile duct wall during hemiliver graft harvest. This type of injury can induce ischemic stricture of the donor common bile duct. This study aimed to review the clinical sequences of such ischemic type donor bile duct injuries primarily managed with endoscopic and radiological interventional treatments. A retrospective review of medical records was performed for two living donors who suffered from ischemic type donor bile duct injury. They were followed up for more than 10 years. The right and left liver grafts were harvested from these two donors. Bile duct anatomy was normal bifurcation in one and anomalous branching in the other. Bile duct stenosis was detected in them at 2 weeks and 1 week after liver donation. They underwent endoscopic balloon dilatation and temporary stent (endoscopic retrograde biliary drainage tube) insertion. After keeping the tube for 2 months, the tube was successfully removed in one donor. However, endoscopic treatment was not successful, thus additional radiological intervention was necessary in the other donor. On follow-up over 10 years, they are doing well so far with no recurrence of biliary stricture. Based on our limited experience, interventional treatment with subsequent long-term follow-up appears to be an essential and choice treatment for ischemic type biliary stricture occurring in liver living donors.
Bile Ducts ; Common Bile Duct ; Constriction, Pathologic* ; Dilatation ; Drainage ; Follow-Up Studies ; Hepatic Artery ; Humans ; Ischemia ; Liver* ; Living Donors* ; Medical Records ; Recurrence ; Retrospective Studies ; Stents ; Tissue Donors ; Transplants

BACKGROUNDS/AIMS: Laparoscopic cholecystectomy (LC) has become a standard procedure for treatment of benign gallbladder diseases. There has been a small proportion of gallbladder cancer (GBC) which was incidentally found in the gallbladder specimen, and LC has been tried in some patients with faintly suspected GBC. This study intended to analyze the prognosis of patients with pT1b/T2 GBC who have undergone LC and the outcome of extended re-operation. METHODS: After analyzing the institutional profiles of 500 GBC patients who have undergone surgical resection, we selected 64 patients who underwent LC initially from January 1996 to December 2008 and whose gallbladder pathology was confined to pT1b or pT2 lesions. Of them, 34 patients (53.1%) underwent extended reoperation. Their medical records were reviewed retrospectively. RESULTS: In the LC only group (n=30), mean age of the 16 pT1 patients was 65.7+/-12.5 years and mean age of the 14 pT2 patients was 66.7+/-10.1 years. In the reoperation group (n=34), mean age of the 8 pT1b patients was 52.6+/-9.9 years and in 26 pT2 patients, mean age was 59.2+/-7.9 years. The reoperation group showed a younger patient age pattern than the LC only group (p=0.001). The types of reoperation were liver resection with lymph node (LN) dissection in 17, bile duct resection with LN dissection in 2, and hepatectomy and bile duct resection with LN dissection in 15. In the LC only group, the 5-year survival rate (5-YSR) was 70.3% in pT1b and 43.2% in pT2. In the reoperation group, 5-YSR was 62.5% in pT1b (n=8) and 59.5% in pT2 (n=26). A survival comparison between the two groups showed no significant survival gain in pT1 patients (p=0.69) and in pT2 patients (p=0.14). In our whole database analysis, 5-YSR of pT1bNx lesions was 70% after cholecystectomy and 78% after extended cholecystectomy. Lymph node metastasis was identified in 11% of pT1b lesions. For pT2N0 lesions, overall 5-YSR was 62% after R0 resection, showing no survival difference between primary extended surgery and LC-redo operation (p=0.45). CONCLUSIONS: The survival gain of reoperation was not evident in pT1b lesions. In contrast, some noticeable but not statistically significant survival difference was observed in pT2 lesions. Thus, reoperation for pT1b/T2 GBC following LC is indicated for individualized reasons, especially in patients with pT1b lesions. Old age was one of the important factors in deciding not to reoperate.
Bile Ducts ; Cholecystectomy ; Cholecystectomy, Laparoscopic ; Gallbladder ; Gallbladder Diseases ; Gallbladder Neoplasms ; Hepatectomy ; Humans ; Liver ; Lymph Nodes ; Medical Records ; Neoplasm Metastasis ; Prognosis ; Recurrence ; Reoperation ; Survival Rate

BACKGROUNDS/AIMS: According to 7th AJCC TNM staging system, gallbladder carcinoma (GBC) with lymph node (LN) metastasis is classified as N1 or N2; thus making the stage IIIB (N1) or IVB (N2). Stage IIIB consists of N1 status with wide coverage of T1-3, but T3N1 group often showed poorer outcomes than T1-2N1 groups. This study intended to assess post-resection prognosis of T3N1 versus other stage III subgroups. METHODS: We selected 103 patients from our institutional database of GBC who underwent R0 resection between July 1996 and June 2009 and whose GBC was confined to stage T3N0, T1-3N1 or T1-3N2. These patients were stratified into five groups, namely, T3N0 (n=26), T1N1 (n=13), T2N1 (n=35), T3N1 (n=20) and T1-3N2 (n=9), and were followed for > or =5 years or until death. RESULTS: Surgical procedures were minor liver resection (n=53), minor liver resection with bile duct resection (n=23), major liver resection (n=12), major liver resection with bile duct resection (n=5), and hepatopancreatoduodenectomy (n=12). Mean follow-up period was 57.2+/-68.5 months. Overall 5-year survival rate based on all-cause death and cancer-associated death, respectively, was 57.7% and 60.6% in T3N0, 15.4% and 15.4% in T1N1 (n=13), 28.6% and 28.6% in T2N1 (n=35), 5.0% and 5.7% in T3N1 (n=20), and 22.2% and 22.2% in T1-3N2. The survival outcome of T3N1 group was the poorest among the four stage III groups and was comparable to that of stage IVB (p=0.53). CONCLUSIONS: The prognosis of T3N1 GBC is unusually poor even after R0 resection, thus we suggest extensive LN dissection may be necessary in patients with T3 tumors for accurate prognostic evaluation and radical removal of potential nodal micrometastasis. Further validation of this result is necessary in large patient populations from multiple centers.
Bile Ducts ; Follow-Up Studies ; Gallbladder* ; Humans ; Liver ; Lymph Nodes ; Neoplasm Metastasis ; Neoplasm Micrometastasis ; Neoplasm Staging ; Prognosis ; Survival Analysis* ; Survival Rate