Cytomegalovirus (CMV) infection is prevalent worldwide, although the symptomatic illness is usually confined to immunocompromised individuals. It can produce stomatitis, esophagitis, gastritis, duodenitis, and ulceration of the esophagus, stomach, duodenum, ileum, and colon within the gastrointestinal tract. Bleeding and perforation can also occur at these sites. The most common site of intestinal perforation is the colon, followed in frequency by the distal ileum and appendix. Herein, a recently experienced case of ileal perforation due to a CMV infection, in a patient with acquired immunodeficiency syndrome is reported, with a review of the literature.
Acquired Immunodeficiency Syndrome* ; Appendix ; Colon ; Cytomegalovirus Infections* ; Cytomegalovirus* ; Duodenitis ; Duodenum ; Esophagitis ; Esophagus ; Gastritis ; Gastrointestinal Tract ; Hemorrhage ; Humans ; Ileum ; Intestinal Perforation ; Stomach ; Stomatitis ; Ulcer

BACKGROUND: With improvements in the performance of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing hepatobiliary and pancreatic diseases, anomalous unions of the pancreaticobiliary duct (AUPBD) have come to our attention in recent years. Such unions are thought to be a factor in the development of carcinomas of the pancreaticobiliary system. The purpose of the present study was to evaluate the clinical analysis of AUPBD for proper treatment. METHODS: During the past 4 years from January 1, 1993, to December 31, 1997, 28 adult patients with AUPBD, in whom the pancreaticobiliary ductal union and terminal biliary tract were opacified by ERCP, were seen at Asan Medical Center. We divided the types of AUPBD according to Kimura's classification. RESULTS: The ages of the patients (20 women and 8 men) with this anomaly ranged from 16 to 68 years. The patients' main complaints were abdominal pain (16 cases), indigestion (10 cases), jaundice (4 cases), and fever (2 cases). The common channel measured on direct cholangiograms was 15 mm to 42 mm long. All of the patients whose anomalies were confirmed by ERCP had combined diseases (benign diseases 20 cases, malignant diseases 8 cases). Of the 20 patients with benign diseases, the 15 patients who underwent operative treatments had no recurrent findings or symptoms, but all of the 5 patients who underwent conservative treatments had recurrent pancreatitis or indigestion. These 5 patients will still need to be followed up. For the 8 patients with malignant diseases, the 3 who did not undergo operations died of far-advanced cancer. Among the remaining 5 patients who underwent operative treatments, 1 patient died of cancer recurrence, but 4 patients have been alive since their operations. CONCLUSIONS: We think that all ERCP examinations have to be carried out with AUPBD in mind. It is important to remove the place that causes bile stasis and to stop backflow of pancreatic juice intothe bile duct in managing patients with this anomaly. Therefore, a prophylactic cholecystectomy and reconstruction of the biliary tract are both necessary in treating AUPBD.
Abdominal Pain ; Adult ; Bile ; Bile Ducts ; Biliary Tract ; Cholangiopancreatography, Endoscopic Retrograde ; Cholecystectomy ; Chungcheongnam-do ; Classification ; Dyspepsia ; Female ; Fever ; Humans ; Jaundice ; Pancreatic Diseases ; Pancreatic Juice ; Pancreatitis ; Recurrence

BACKGROUNDS/AIMS: Cholelithiasis is a prevalent diseases worldwide and it is known that its incidence is twice as common in cirrhotic patients compared with noncirrhotic patients. Liver cirrhosis is a critical factor contributing to morbidity and mortality in biliary tract surgery, as patient with cirrhosis are at particular risk of developing bleeding, infection and intractable ascites. Recently laparoscopic cholecystectomy has become the procedure of choice for cholelithiasis in the general population. This retrospective study was conducted to assess the effective treatment by comparing the results of open cholecystectomy versus laparoscopic cholecytectomy in cirrhotic patients. METHODS: Between January 1991 and December 1998, 53 patients with liver cirrhosis underwent cholecystectomy for cholelithiasis in the department of surgery at asan medical center. The patients were classified into two groups: one consisting of 18 patients who underwent open cholecystectomy and another consisting of 35 patients who underwent laparoscopic cholecystectomy. All cases that converse to an open cholecystectomy from a laparoscopic cholecystectomy were excluded from this analysis. RESULTS: No statistical difference was observed in the duration of surgery(OC: 110.6+/-32.6 vs. LC: 82.1 +/-26.7 min, p>0.05). Laparoscopic cholecystectomy was followed by a significantly smaller intraoperative blood loss(OC: 730.5+/-384.6 vs. LC: 324+/-168 ml, p<0.05), a earlier resumption of a normal diet(OC: 4.3+/-1.3 vs. LC: 1.3+/-0.4 days, p<0.05), and a shorter hospital stay(OC: 13.8+/-6.1 vs. LC: 4.7 +/-2.1 days, p<0.05) in comparison to open cholecystectomy. Postoperative complications in laparoscopic cholecystectomy group was significantly less(OC: 9 vs. LC: 4, p<0.05). There was no operative mortality in both group. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in compensated cirrhotic patients and may be the procedure of choice whenever cholecystectomy is indicated in a cirrhotic patient because it may be associated with more advantages.
Ascites ; Biliary Tract ; Cholecystectomy ; Cholecystectomy, Laparoscopic* ; Cholelithiasis ; Chungcheongnam-do ; Fibrosis ; Hemorrhage ; Humans ; Incidence ; Liver Cirrhosis* ; Liver* ; Mortality ; Postoperative Complications ; Retrospective Studies

Under normal circumstances, attempts are made to match the recipient of an orthotopic liver transplant with the best available donor in terms of organ and body size. Occasionally, it may happen that a child's liver is transplanted into an adult recipient, either because of the need for an urgent transplantation when only a small donor is available or because there is no child recipient transplantable with the graft. After a child-donor's liver was transplanted into an adult recipient, we had the opportunity to observe the change in the size of the allograft over time by using serial computed tomography scans to evaluate change in graft size. Reported here are the results of the small-for-size live transplantation at Asan Medical Center.
Adult* ; Allografts ; Body Size ; Child* ; Chungcheongnam-do ; Humans ; Liver* ; Tissue Donors* ; Transplants

BACKGROUND: In Korea, the number of patients enrolled in liver transplantation registry exceeds the supply of cadaveric donor. This donor shortage leads to living donor liver transplantation(LDLT). Due to wide prevalence of hepatitis B in Korea, many healthy donors for LDLT shows hepatitis B surface antigen-negative[HBsAg(-)] and core antibody-positive [HBcAb(+)]. However, the risk of using graft livers from HBsAg(-) and HBcAb(+) donors has not been clearly defined. The aim of this study is to identify the safety of using HBcAb(+) donor and the effectiveness of passive immunoprophylaxis with hepatitis B immunoglobulin(HBIG) in non-hepatitis B virus induced cirrhotic recipients. METHODS: From December 1994 to July 1998, 59 patients underwent living donor liver transplantation at the Asan Medical Center. Among them, 35 cases were non-hepatitis B virus induced cirrhotic recipients. Of these 35 recipients, 14 patients received liver graft from HBsAg(-) and HBcAb(+) donors and prophylactic passive immunoprophylaxis with HBIG. RESULTS: Eleven cases remained HBsAg(-) with HBIG immunoprophylaxis. Three of 14 recipients who were HBsAg(-) converted to HBsAg(+) serologically after receiving HBcAb(+) donor liver. All of these 3 cases did not receive HBIG therapy. CONCLUSIONS: Passive immunoprophylaxis with HBIG may prevent non-hepatitis B induced cirrhotic recipients from converting to HBsAg(+) status by using HBcAb(+) donor. Our experience suggests that HBcAb(+) donors can be accepted as potential donors in living donor liver transplantation.
Cadaver ; Chungcheongnam-do ; Hepatitis B* ; Hepatitis* ; Herpesvirus 1, Cercopithecine ; Humans ; Korea ; Liver Transplantation* ; Liver* ; Living Donors* ; Prevalence ; Tissue Donors* ; Transplants

BACKGROUND: Central bisegmentectomy (CBS) of the liver is a resection of the medial and anterior segments for preserving more liver parenchyma and reaching the goal of a curative resection simultaneously. PURPOSE: In this paper, we describe the indications and the techniques for this surgical procedure. PATIENTS AND METHODS: We reviewed the case histories of 14 patietns who had undergone a CBS, including 9 with a hepatocellular carcinoma, 4 with hilar bile-duct cancer, 1 with metastatic colon cancer, and 1 with gallbladder cancer. Eight patients had undergone a CBS with an operating time of only 353 minutes; 5 cases had undergone a CBS and a caudate lobectomy plus bile-duct resection, requiring an operating time of 762 minutes. A hepaticojejunostomy to right posterior hepatic duct was added to one CBS case because of intrahepatic ductal variation. The surgical technique for the CBS only procedure was as follows: demarcation of the dissection line with a selective block of the glissonian cord, division of the medial and the lateral segments along the falciform ligament to expose the left hepatic vein, and division of the anterior and the posterior segments along the right hepatic vein. In the combined bile-duct-resection cases, complete dissection of the hepatoduodenal ligament and biliary reconstruction were added. RESULTS: The extent of liver resection, as estimated by CT volumetry, was about 42%, and the mean value of the real weights of the specimens was 474 gm. The preoperative hepatic function showed a 9.3% indocyanine-green retention rate at 15 minutes, and 5 out of 9 hepatocellular carcinoma cases revealed concomitant liver cirrhosis. For CBS and additional procedures, the curative resection rate reached 93%, and the survival rate was favorable. There were no operative mortalities or hepatic failures. CONCLUSIONS: For selected cases of centrally located liver tumors or hilar bile-duct cancer with limited hepatic reserve, CBS may provide a safe, curative resection.
Carcinoma, Hepatocellular ; Colonic Neoplasms ; Gallbladder Neoplasms ; Hepatic Duct, Common ; Hepatic Veins ; Humans ; Ligaments ; Liver Cirrhosis ; Liver* ; Mortality ; Survival Rate ; Weights and Measures

BACKGROUND: A hepatocellular carcinoma (HCC) is an awesome malignancy; survival time is usually less than 1 year once symptoms and signs appear, irrespective of treatment. Screening tools are now available that make it possible to detect a preclinical HCC, which is usually small and surgically resectable. We studied the prognosis after hepatic resections of HCCs smaller than 5 cm and tried to clarify which effective treatments correlated with high survival rates by comparing the outcomes of major hepatic resections with those of limited hepatic resections. METHODS: Of the 105 cases treated from January 1, 1990, to December 31, 1998, at Asan Medical Center, all proved surgically to be small HCCs and pathologically to be HCC types. There were two categories of patients: those receiving a major hepatic resection (n=48) and those receiving a limited hepatic resection (n=57). RESULTS: The median age was 53 (range, 33-69), and the male:female ratio was 42:6 in the major resection group. The median tumor size was 3.4 cm, and the median resection margin was 2.6 cm. Major resections were done in 48 cases, including right lobectomies (32 cases), left lobectomies (9 cases), central bisegmentectomies (3 cases), extended left lobectomies (3 cases) and extended right lobectomy (1 case). The median age was 52 (range, 30-76), and the male:female ratio was 46:11 in the limited resection group. The median tumor size was 3.2 cm, and the median resection margin was 1.2 cm. Limited resections were done in 57 cases, including left lateral segmentectomies (12 cases), right posterior segmentectomies (10 cases), #6 subsegmentectomies (7 cases), left medial segmentectomies (7 cases), right anterior segmentectomies (6 cases), nonanatomical partial hepatectomies (5 cases), #5 #6 subsegmentec-tomies (2 cases), #8 subsegmentectomies (2 cases), caudate lobectomies (2 cases), #5 subsegmentectomies (2 cases), #5 subsegmentectomy caudate lobectomy(1 case), and #2 subsegmentectomy (1 case). The cumulative 5-year survival rate of the two groups was 69%. The cumulative 5-year disease-free survival rate of the major resection group was better than that of the limited resection group (80% vs 53%, p=0.01). CONCLUSIONS: Problems, including the relatively high recurrence rate after a limited hepatic resection, remain to be solved. It is necessary to perform adjuvant therapy to prevent recurrence in patients receiving a limited hepatic resection. We advocate a major hepatic resection for primary small hepatocellular carcinomas in order to prevent recurrence. Preoperative portal vein embolization can be a good modality in patients who will undergo major hepatic resections.
Carcinoma, Hepatocellular* ; Chungcheongnam-do ; Disease-Free Survival ; Hepatectomy ; Humans ; Mass Screening ; Mastectomy, Segmental ; Portal Vein ; Prognosis* ; Recurrence ; Survival Rate

PURPOSE: The majority of carcinomas of the biliary tract are often diagnosed at an advanced stage, despite improved diagnostic capabilities. Aggressive surgery is generally recommended in an attempt to cure the advanced disease because only complete resection of the tumor can provide a chance to improve the survival rate. Thus, the purpose of this research was to assess the effectiveness of a hepatopancreato duodenectomy (HPD) in patients with both advanced gallbladder cancer directly invading adjacent organs and diffuse bile-duct cancer by analyzing the long term results of an HPD. METHODS: Forty patients underwent an HPD at Asan Medical Center from December 1993 to May 1999, and their cases were retrospectively reviewed. Gallbladder cancers was present in 14 of the patients and bile-duct cancers in 24 cases; the other 2 cases were benign. Cancers were classified by using the criteria of the American Joint Commission on Cancer (AJCC). Survival curves were calculated by using the Kaplan-Meier method. The median follow-up was 35 months. RESULTS: Hepatectomies varied from a right trisegmentectomy to an S4aS5 subsegmentectomy. There were 19 (47.5%) major postoperative complications, including intraabdominal bleeding, intestinal obstruction, liver abscess, and others. Of the 14 patients experiencing tumor recurrence, 7 (50%) cases involved the remnant liver. There were 4 (10%) perioperative mortalities. The 5 (22.7%) patients who with stage IVa and IVb cancer (22 cases) survived more than 3 years are all still alive and without tumor recurrence. The 1-and 3-year cumulative survival rates for gallbladder cancer were 83.3% and 48.5%, respectively, and those for bile-duct cancer were 83.3% and 49.7%. The differences in survival between the groups was not statistically significant, excluding perioperative deaths. The median survival was 13.7 months. CONCLUSION: An HPD is indicated for either advanced gallbladdercancer or diffuse bile-duct cancer because complete resection through this surgical procedure can provide a chance to improve survival. It is necessary to decrease perioperative mortality and morbidity by complete preoperative evaluation, meticulous operative manipulation, and intensive postoperative care.
Biliary Tract ; Chungcheongnam-do ; Follow-Up Studies ; Gallbladder Neoplasms ; Hemorrhage ; Hepatectomy ; Humans ; Intestinal Obstruction ; Joints ; Liver ; Liver Abscess ; Mortality ; Postoperative Care ; Postoperative Complications ; Recurrence ; Retrospective Studies ; Survival Rate