This study was conducted to develop an optimal strategy to achieve long-term survival after a liver resection for a hepatocellular carcinoma by analyzing the actual survival of 54 patients who underwent liver resections at least 5 years ago. The mean age was 50.5 years with a male-to-female ratio of 5 : 1. The positive rates for HBsAg and anti-HCV were 60.4% (32/53) and 10% (1/10), respectively. Seventy-eight percent of the patients had co-existing chronic liver disease. Seventy percent of the patients had either TNM stage III or IV cancer. Fifteen patients (27.8%) survived longer than 5 years after the operation. The median survival time of the 54 patients was 27 months. Prognostic factors of statistical significance were the Child class, gross type and size of the tumor, intrahepatic metastasis, portal vein invasion, serosal invasion, tumor grade, TNM stage, radicality of the operation, cancer recurrence, and disease-free interval. Although the prognosis for the patients with tumors larger than 5 cm was poor, two patients whose tumors were larger than 10 cm with satellite nodules survived longer than 5 years after undergoing complete tumor removal. For the 26 cases with no intrahepatic metastasis, there was no survival difference between the lobectomy group and the segmentectomy/subsegmentectomy group (43% vs. 42%). In those cases with satellite nodules in one segment of the liver, 80% of the lobectomy group lived longer than 5 years while none of the patients in the less-than-lobectomy group survived long-term (p=0.0060). Cancer recurred in 77.8% of the patients. It was the main cause of late death after surgery. Eighty-one percent of the recurrences occurred within 2 years after the operation. Nearly all the recurrences developed in the remnant liver. Among 15 long-term survivors, 6 patients experienced recurrence between the periods of 26 and 76 months after resection. A total of 4 patients (9.5%) out of these 42 patients were subjected to repeat resection for the recurrent tumor. One of these four patients underwent a third resection for a recurrence after the repeat resection. Although the extent of hepatic resection turned out to be a prognostic factor of little significance overall, the recurrence rate of the lobectomy group tended to be lower than that of the less-than-lobectomy group among the subset of long-term survivors (p=0.0572). For long-term survival, a systematic segmentectomy/ subsegmentectomy is adequate for those tumors without intrahepatic metastasis, while the presence of satellite nodules in that segment mandates a standard hepatic lobectomy. For long-term recurrence-free survival, a hepatic lobectomy is probably needed, even for tumors with no intrahepatic metastasis.
Carcinoma, Hepatocellular* ; Child ; Hepatitis B Surface Antigens ; Humans ; Liver Diseases ; Liver* ; Neoplasm Metastasis ; Portal Vein ; Prognosis ; Recurrence ; Survivors*

This study was conducted to clarify the strategy of surgical treatment for stage IV hepatocellular carcinoma (HCC), for which no effective treatment modality is present so far. There were 29 patients (20.3%) with stage IV HCC among 143 HCC patients who underwent partial liver resection during the period from Jan. 1985 through Jul. 1996 at our department. The mean age was 53 years with a range of 18 to 76 years. There were 23 men and 6 women with a ratio of 4:1. Positive rates for HBsAg and HCV Ab were 55.2% and 12.5%, respectively. Ninety per cent of the patients were complicated by chronic liver disease. Abdominal pain and/or mass were the predominating symptoms in about 60% of the patients. Serum AFP level was elevated above 20 ng/ml in 72.4% of the cases. Twenty-three patients harbored stage IV-A disease and 6 patients IV-B disease. The main surgical procedures used in the cases were trisegmentectomy in 3, lobectomy in 12, segmentectomy in 12, subsegmentectomy in 1 and wedge resection in 1. Additionally wedge resection of the liver was performed in 6 cases and ethanol injection in 9 cases. Among 11 cases with tumor thrombus in large portal veins, successful tumor thrombectomy was conducted in 7 of them. Out of 22 patients with stage IV-A HCC, complete tumor removal was possible in 8 and ethanol injection into the residual tumor was executed in another 6. The mean operation time was 282 minutes and the mean transfusion 4 pints. Four patients (13.8%) suffered from postoperative complications, 2 of whom succumbed to liver failure 2 months postoperatively. The cumulative survival rates at 1, 2, and 3 years after surgery were 33.5%, 15.7%, and 10.5%, respectively, with a median survival time of 10 months. The longest survivor is alive 58 months after surgery. Significant prognostic factors were gross portal vein thrmobosis, invasion into adjacent tissues, tumor rupture, and the development of complications. In particular, the survival of patients with stage IV-A HCC who underwent complete tumor removal was not statistically different from that of those who had an absolute noncurative operation plus intraoperative ethanol injection into the residual tumors. For stage IV-A HCC surgical treatment is considered to be effective when all the tumors can be removed or when the residual tumors can be treated by intraoperative ethanol injection.
Abdominal Pain ; Carcinoma, Hepatocellular* ; Ethanol ; Female ; Hepatitis B Surface Antigens ; Humans ; Liver ; Liver Diseases ; Liver Failure ; Male ; Mastectomy, Segmental ; Neoplasm, Residual ; Portal Vein ; Postoperative Complications ; Rupture ; Survival Rate ; Survivors ; Thrombectomy ; Thrombosis

BACKGROUND: Cystic neoplasms of the pancreas are rare tumors that constitute about 10% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. This study was conducted to investigate the diagnostic accuracy and postoperative results for these rare tumors. METHODS: The authors reviewed retrospectively 7 patients with cystic neoplasms of the pancreas who had been treated surgically in the period from 1986 through 1998 at the Department of Surgery, Paik Hospital, Seoul. RESULTS: There were 3 serous cystadenomas, 3 mucinous cystadenomas, and 1 papillary and cystic neoplasm. All 7 patients were women. The mean age of the patients was 36.7 years, 45 years for the serous tumors and 37 for the mucinous tumors. Two patient had diabetes mellitus. Major symptoms were abdominal pain (71%) and an abdominal mass (29%). One patient with a mucinous cystadenoma presented with bleeding from gastric varix which developed as a consequence of a splenic vein obstruction by the tumor. The positive rate for CEA was 33.3%, and that for CA 19-9 was 50.0%. No patient showed an abnormally elevated serum amylase level. Computed tomography was helpful in differentiating cystic tumors from pseudocysts or adenocarcinomas of the pancreas. The sites of the lesions were the tail in 3 cases, the body in 2cases, and the head in 2 cases. A distal pancreatectomy was performed in 5 cases, a pylorus-preserving pancreatoduodenectomy in 1 case, and enucleation of the cyst in 1 case. All the patients were alive at 3 to 145 months postoperatively and showed no evidence of disease. CONCLUSION: We conclude that the prognosis for resected cystic neoplasms of the pancreae is good. The correct preoperative differential diagnosis of pancreatic cystic lesions is important for planning the appropriate management, even though the clinical and the radiological features of these lesions are not always reliable.
Abdominal Pain ; Adenocarcinoma ; Amylases ; Cystadenoma ; Cystadenoma, Mucinous ; Cystadenoma, Serous ; Diabetes Mellitus ; Diagnosis, Differential ; Esophageal and Gastric Varices ; Female ; Head ; Hemorrhage ; Humans ; Mucins ; Pancreas* ; Pancreatectomy ; Pancreatic Cyst ; Pancreatic Neoplasms ; Pancreaticoduodenectomy ; Prognosis ; Retrospective Studies ; Seoul ; Splenic Vein

Soft-tissue sarcomas account for 1% of all solid tumors. Of these, less than 15% will occur in the retroperitoneum. Late diagnosis and large tumor size make retroperitoneal sarcomas difficult to resect. Resection with wide margins in all directions is rarely possible owing to proximity to vital structures. Radiation therapy is limited in dosage and, as with chemotherapy, has only been successful in a limited number of cases. These problems result in a poor prognosis. A series of patients with retroperitoneal sarcoma was reviewed with a focus on issues of surgical management and prognostic factors. A retrospective analysis of 12 patients with retroperitoneal sarcomas who had undergone operations at the Department of Surgery, Inje University Paik Hospital, Seoul, from 1980 through 1996 was performed. The mean age of the 10 adult patients was 51 years; the male-to-female ratio was 2:1. Eighty-three percent of the patients presented with an abdominal mass. The mean diameter of the tumors was 18.3 cm. Leimyosarcomas(33%) and liposarcomas(25%) comprised the majority of the histologic types. The tumor grades were I, II, and III in 3 cases each. Resection of the tumor was possible in 75%(9/12) of the cases, although 17% of the resections were incomplete. Resection of adjacent organs was required in 66% of the cases. The resectability rose from 60% in 80s to 86% in 90s, with no statistical significance, possibly due to the small number of cases in this series. There was no postoperative morbidity or mortality. Actuarial 1-, 3-, and 5-year survival rates after resection were 75%, 60%, and 30%, respectively. Four of the 7(57%) patients who underwent complete resections had recurrence 3 to 33 months after surgery; this was notable for grade II or III tumors only. Two patients with grade I tumors are alive 65 and 102 months respectively after complete resection and show no evidence of the disease. One patient who underwent an incomplete resection of the tumor died 50 months after the operation. Only the tumor grade was a significant prognostic factor(p=0.0207). In conclusion, a wide en-bloc resection of a retroperitoneal sarcoma with a clear margin in all directions is a prerequisite for long-term survival. Aggressive follow-up for the first 3 years after a complete resection of a high-grade tumor is justified.
Adult ; Delayed Diagnosis ; Drug Therapy ; Follow-Up Studies ; Humans ; Mortality ; Prognosis ; Recurrence ; Retrospective Studies ; Sarcoma* ; Seoul ; Survival Rate

Primary hepatic sarcomas are uncommon, representing less than 1% of the primary malignant lesions of the liver. Three patients underwent resection for primary hepatic sarcoma at the Department of Surgery, Inje University Paik Hospital, Seoul: a 6 year-old girl with malignant mesenchmoma, a 74 year-old man with malignant fibrous histiocytoma and a 53 year-old man with rhabdomyosarcoma. Abdominal mass, fever with chills, and abdominal pain were the presenting symptoms, respectively. The patient with rhabdomyosarcoma was positive for HBsAg and had chronic active hepatitis. AFP level was elevated in this patient. CA 19-9 level was elevated in the patient with malignant fibrous histiocytoma. CEA levels were normal in all cases. All these tumors were hypodense on computed tomography. Malignant mesenchymoma was hypovascular and rhabdomyosarcoma was hypervascular on angiography. Immunohistochemical stains of the tumors were positive for vimentin but negative for epithelial markers, differentiating these lesions from other hepatic tumors. Electron microscopic examination was helpful in the diagnosis of the specific type of primary hepatic sarcoma. None had postoperative adjuvant chemotherapy or radiotherapy. The patient with malignant mesenchymoma, who underwent right hepatic trisegmentectomy, was disease free at 32 months. The patient with malignant fibrous histiocytoma, who underwent non-curative excision, died of the tumor at 2 months. The patient with rhabdomyosarcoma, who underwent posterior segmentectomy, was alive at 4 months. Resection of primary hepatic sarcoma should be executed if feasible, with potential survival measured in years, in view of the lack of other effective treatment modalities.
Abdominal Pain ; Aged ; Angiography ; Chemotherapy, Adjuvant ; Child ; Chills ; Coloring Agents ; Diagnosis ; Female ; Fever ; Hepatitis B Surface Antigens ; Hepatitis, Chronic ; Histiocytoma, Malignant Fibrous ; Humans ; Liver* ; Mastectomy, Segmental ; Mesenchymoma ; Middle Aged ; Radiotherapy ; Rhabdomyosarcoma ; Sarcoma* ; Seoul ; Vimentin

Peripheral cholangiocarcinoma (PCC) is defined as a malignancy of intrahepatic bile duct presenting as a focal liver mass, specifically, those located peripheral to the 2nd-order branchings of the bile duct. During the study period of 11 years from Jan. 1985 through Dec. 1995, a total of 12 patients underwent liver resection for PCC at the Department of Surgery, Inje University Paik Hospital, Seoul. This figure accounts for 8.3% of primary liver cancer. There were 9 men and 3 women with a ratio of 3:1, the mean age was 53.3 years with a range of 39 to 67 years. Twenty-five per cent of the patients had concomitant intrahepatic stone (IHS). HBsAg was positive in one case (8.3%) who had chronic hepatitis. No patient had liver cirrhosis. The accurate preoperative diagnosis of PCC in 3 cases was difficult because of the association with IHS. These 3 patients underwent surgery under the diagnosis of chronic cholangitis rather than PCC. CEA and CA 19-9 were elevated in 70% and 50% of the patients, respectively. In most cases concomitant measurement of CEA and AFP facilitated the differentiation between PCC and hepatocellular carcinoma. As to the tumor characteristics, 83% of the patients had tumors greater than 5 cm in diameter, indicating the advanced stage of the tumor at the time of resection. The site of origin of tumor mass was distributed more or less evenly between the hepatic lobes. The patients with mass-forming, expanding type of tumors made up 58% of the cases, infiltrating type 25%, and the remainder being the combination of both. A significant number of patients, 27%, had nodal metastasis. Two thirds of the patients underwent major hepatic resections. Segmentectomies here include the resection of lateral segment done as a treatment for IHS, which later proved to be cancer on histologic examination. There was no operative death among the 12 patients. The overall median survival time was 12 months. The overall survival rates at 1, 3, and 5 years were 42.4%, 42.4%, and 42.4%, respectively. Only the radicality of the resection was the statistically significant risk factor for survival by univariate analysis. The 5-year survival rate was 100% in 6 patients who had curative resection (no lymph node invasion, no peritoneal seeding, clear resection margin). The prognosis of patients with advanced PCC is unfavorable unless the tumor is entirely removed. In view of the association of IHS in a significant portion of the cases, the possible coexistence of the carcinoma should always be borne in mind when dealing with patients with IHS.
Bile Ducts ; Bile Ducts, Intrahepatic ; Carcinoma, Hepatocellular ; Cholangiocarcinoma ; Cholangitis ; Diagnosis ; Female ; Hepatitis B Surface Antigens ; Hepatitis, Chronic ; Humans ; Liver ; Liver Cirrhosis ; Liver Neoplasms ; Lymph Nodes ; Male ; Mastectomy, Segmental ; Neoplasm Metastasis ; Prognosis ; Risk Factors ; Seoul ; Survival Rate

PURPOSE: Postoperative as well as intention-to-treat outcomes of deceased donor liver transplantation (DDLT) for patients with hepatocellular carcinoma (HCC) within the Milan criteria were compared to outcomes for patients who underwent liver resection. The goal was to select the optimal therapeutic option for these patients. METHODS: Among 1363 patients diagnosed with HCC between Jan 2001 and Sep 2008, 57 underwent liver resection for HCC within the Milan criteria (LRX group) and 47 registered for DDLT (WAIT group). Thirteen patients underwent DDLT (LTX group), including 2 salvage DDLT for recurrent HCC after resection. The outcomes for the LRX group were compared with those for the LTX and WAIT groups. RESULTS: Child class B or C patients accounted for 5% in the LRX group and 81% in the WAIT group (p=0.000). Among 47 registrants in the WAIT group, 11 underwent DDLT after a mean waiting time of 282 days (LTX group). Tweleve patients were dropped from the waitlist due to death or disease progression after a mean time of 317 days after registration. There was 1 operative death in the LTX group 14 days after DDLT due to primary graft nonfunction. The 3-year overall and disease-free survival rates were comparable between the LRX and LTX groups. On the other hand, the LRX group showed a significantly better intention-to-treat outcome than the WAIT group. The 3-year survival rates were 80.4% for the LRX group and 52.0% for the WAIT group (p=0.002). CONCLUSION: For HCC patients within the Milan criteria, liver resection should be considered as their primary option of treatment in Korea, where the DDLT rate is below 6%.
Carcinoma, Hepatocellular ; Child ; Disease Progression ; Disease-Free Survival ; Hand ; Humans ; Korea ; Liver ; Liver Transplantation ; Survival Rate ; Tissue Donors ; Transplants

We experienced two cases of Boerhaave syndrome (spontaneous esophageal rupture). The first patient was a 62-year-old male who presented epigastric pain after several violent vomitings associated with alcohol ingestion. Diagnosis was done early and promptly in our emergency center and then definitive treatment was done only after 12hrs from onset of his symptom and he was discharged in relatively good condition 256ays after his admission. The second patient was a 44-year-old male who was transfered to our emergency center with chest pain, dyspnea and fever after vomitings associated with autobicycle accident. Diagnosis was delayed due to initial trauma oriented evaluation and incidious develpement of typical clinical findings and then he was managed conservatively but he died of multiple organ failure due to sepsis. We report these cases with literature review.
Adult ; Chest Pain ; Diagnosis ; Dyspnea ; Eating ; Emergencies ; Esophageal Perforation* ; Fever ; Humans ; Male ; Middle Aged ; Multiple Organ Failure ; Sepsis

BACKGROUNDS/AIMS: Recent advances in ultrasonography have contributed to the early detection of gallbladder cancer. We attempted to predict the progression of the disease by comparing the sizes of polypoid lesions, and we suggest that the size of the lesion would be a useful guideline to determine an appropriate primary surgical approach for polypoid lesions of the gallbladder. METHODS: We have retrospectively analyzed 253 patients that, during the operation period from January 2009 to December 2011, had had ultrasonographically detected gallbladder polypoid lesions, and who underwent cholecystectomy at Ulsan university hospital. We have analyzed the demographic data of the patients, the preoperative size of polypoid lesions, and pathologic findings. RESULTS: Of a total of 253 patients, 235 patients had benign lesions, and 18 patients had malignant lesions. Among the malignant polyp patients, 11 had pT1 cancer, 6 had pT2 cancer, and 1 had pT3 cancer. The average size of polypoid lesions was 9.1+/-3.1 mm and that of malignant lesions was 28.2+/-16.4 mm. The receiver operating characteristic (ROC) curve of the benign and malignant groups shows that 14.5 mm is the optimal point of prediction of the malignancy. Of a total of 18 patients of GB cancer, 11 had pT1 and the average size of their polypoid lesions was 20.5+/-5.8 mm 7 had pT2 with a size of 39.1+/-20.7 mm. ROC curve analysis of the pT1 and pT2 groups shows that 27 mm would be the optimal point to predict T2 and above cancer. CONCLUSIONS: In the case of an early cancer, curative treatment can be achieved through a simple and minimally invasive laparoscopic cholecystectomy. We attempted to predict early cancer occurrence among polypoid lesions of the gallbladder using the simplest standard, size. Although there are some limitations, size can be a simple and easy way to evaluate polypoid lesions of the gallbladder.
Cholecystectomy ; Cholecystectomy, Laparoscopic ; Gallbladder Neoplasms* ; Gallbladder* ; Humans ; Polyps ; Retrospective Studies ; ROC Curve ; Ulsan ; Ultrasonography

BACKGROUND: The leading causes of late deaths after transplant were graft failure, malignancy, cardiovascular disease and renal failure. Diabetes mellitus (DM) is one of the greatest contributing factors to these late events, but also one of the most modifiable. This study was conducted to identify the incidence and time course of posttransplant diabetes mellitus (PTDM) after liver transplantation (LT) and evaluate the factors related to the development and reversal of PTDM. METHODS: Patients who underwent LT between 2002 and 2015 at Ulsan University Hospital, were followed for more than 3 months and had no history of preoperative DM were the subject of this study. The authors investigated the incidence and time course of PTDM. Recipient factors, donor factors and postoperative factors presumed to contribute to the development and reversal of PTDM were investigated. Moreover, the effects of PTDM on the survival of liver transplant recipients were also investigated. RESULTS: PTDM developed in 13 (16.5%) of 79 patients who fulfilled the inclusion criteria a median of 35 days after LT. There were no significant factors contributing to the development of PTDM. Five of the 13 PTDM patients recovered from the diabetic condition 5 to 38 months after the diagnosis of PTDM. Higher postoperative magnesium levels (P=0.022), development of acute cellular rejection (P=0.01), and steroid pulse therapy (P=0.045) were the predictive factors for reversal of PTDM. PTDM had no impact on patient survival (P=0.529). CONCLUSIONS: PTDM usually developed soon after LT operation and was reversible in 41% of the cases, especially when it is associated with steroid pulse therapy for acute cellular rejection. The association between serum magnesium level and reversibility of PTDM after LT needs further study to clarify the cause-and-effect relationship.
Cardiovascular Diseases ; Diabetes Mellitus* ; Diagnosis ; Humans ; Incidence ; Liver Transplantation* ; Liver* ; Magnesium ; Renal Insufficiency ; Risk Factors* ; Tissue Donors ; Transplant Recipients ; Transplants ; Ulsan