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A Composite Tumor of the Ampulla of Vater: Signet-ring Cell and Neuroendocrine Carcinoma: A Case Report.

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):85-88.

Most tumors affecting Vater's ampulla are adenocarcinomas. Other histological variants or mixed forms are less frequent, even rare. We treated a rare case of composite signet-ring cell carcinoma and well differentiated neuroendocrine carcinoma of the ampulla of Vater in a 72-year-old Korean man with abdominal discomfort and jaundice for two weeks. Computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP) revealed a 2 cm protruding mass with an abrupt narrowing of the distal common bile duct. Pancreaticoduodenectomy was performed. An ill-defined nodular 2 cm mass in the ampulla of Vater invaded the entire duodenal wall and pancreatic parenchyma with duct dilatation of the remaining common bile duct and pancreatic duct. Two out of twenty regional lymph nodes were positive for metastases. Histopathologically, the tumor was composed of mucinous adenocarcinoma with predominant signet-ring cell components (80%) and well-differentiated neuroendocrine carcinoma (20%). There were intermingled and transitional areas between both elements as well as amphicrine tumor cells with dual differentiation. By Immunohistochemistry, the adenocarcinoma with signet-ring cells was positive for CK7 and CEA and the neuroendocrine carcinoma was diffusely positive for CK7, synaptophysin and chromogranin but negative for insulin and CEA. Of the two metastatic peripancreatic lymph nodes, one was a neuroendocrine carcinoma and the other was an adenocarcinoma. The postoperative course was uneventful. The patient refused adjuvant chemotherapy and was discharged to home 13 days later. The patient died of multiple liver metastases and carcinomatosis 11 months after surgery.
Adenocarcinoma ; Adenocarcinoma, Mucinous ; Aged ; Ampulla of Vater* ; Carcinoma ; Carcinoma, Neuroendocrine* ; Cellular Structures ; Chemotherapy, Adjuvant ; Cholangiopancreatography, Endoscopic Retrograde ; Common Bile Duct ; Dilatation ; Humans ; Immunohistochemistry ; Insulin ; Jaundice ; Liver ; Lymph Nodes ; Neoplasm Metastasis ; Pancreatic Ducts ; Pancreaticoduodenectomy ; Synaptophysin

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Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy.

Ji Woong HWANG ; Song Cheol KIM ; Kwan Tae PARK ; Haeng Chul SHIN ; Duck Jong HAN

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):77-84.

BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic distal pancreatectomy were compared. METHOD: From March 2005 to June2007, we studied 95 patients at Asan Medical Center. These patients had benign pancreatic disease in the distal pancreas, e.g. a cystic neoplasm. These patients underwent a distal pancreatectomy with or without spleen-preservation using laparoscopic or exploration surgery. We divided these patients into two groups i.e. laparoscopy (n=60) and exploration (n=35), and compared the outcomes of the two groups retrospectively. RESULT: There was no difference in demographic features between the two groups. Laparoscopic resection required a median time of 208 mins, compared with 190 mins for the open resection. (p>0.05) The laparoscopic patients started a liquiddiet on postoperative day three, and required a median hospital stay of 11 days, compared with 4.5 days and 16 days for the open resection surgery, respectively. (p<0.001) The overall postoperative complication rate was 28.3% for the laparoscopic group compared with 22.9% for the open group. (p>0.05) The pancreatic fistula rate was lower in the laparoscopic patient group than in the open group. (8.3% vs. 14.3%) (p>0.05) The rate of spleen-preservation was higher in the laparoscopy group than the open group. (25% vs. 5.7%), (p>0.05) CONCLUSION: The results of this study showed that the laparoscopic distal pancreatectomy had a similar surgical time, an early start of the diet, a shorter hospital stay, and a higher spleensaving rate, compared to exploration surgery. Therefore, considering the benefits of laparoscopic surgery, it appears to be the preferred approach, with or without spleen-preservation, for treating benign distal pancreatic disease.
Chungcheongnam-do ; Diet ; Humans ; Laparoscopy* ; Length of Stay ; Operative Time ; Pancreas ; Pancreatectomy* ; Pancreatic Diseases ; Pancreatic Fistula ; Postoperative Complications ; Retrospective Studies

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Management of a Bleeding Pseudoaneurysm after Pancreaticoduodenectomy: 27 cases experience in single-center.

Young Nam ROH ; Hyung Geun LEE ; Dong Do RYU ; Kwang Yeol PAIK ; Jin Seok HEO ; Seong Ho CHOI ; Dong Wook CHOI

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):69-76.

PURPOSE: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding pseudoaneurysms after pancreaticoduodenectomy. METHOD: The medical records of 905 consecutive patients who underwent pancreaticoduodenectomies between October 1994 and February 2007 were reviewed retrospectively. In 27 cases with hemorrhagic complications, pseudoaneurysms were diagnosed as the main cause of bleeding. The clinical characteristics, course, management, and outcomes were reviewed. RESULT: In 27 cases (3.0%) of the 905, the bleeding pseudoaneurysms were diagnosed by angiography, during surgery or clinically. In 11 cases, the hemorrhage was from the pseudoaneurysm on the ligated gastroduodenal artery-stump, in five it was from the right hepatic artery, in four from the proper hepatic artery or common hepatic artery, and two from the right gastric artery. Twelve cases had pancreatic leakage. Sentinel bleedings were observed in 21 cases, there were 11 cases of bleeding from the surgical drains, eight cases from the GI tract, and in two cases from both. In 23 cases, arterial embolization was attempted and 18 cases were successful. Four cases had secondary pseudoaneurysmal bleeding. After embolization at the common or proper hepatic artery, six cases had liver abscess or infarction and there was one case of hepatic failure. CONCLUSION: Delayed massive hemorrhage after pancreaticoduodenectomy should be ruled out to determine whether it is associated with an arterial pseudoaneurysm rupture. Transcatheter arterial embolization is an effective modality for control of the bleeding from an arterial pseudoaneurysm.
Aneurysm, False* ; Angiography ; Arteries ; Gastrointestinal Tract ; Hemorrhage* ; Hepatic Artery ; Humans ; Infarction ; Liver Abscess ; Liver Failure ; Medical Records ; Pancreaticoduodenectomy* ; Retrospective Studies ; Rupture

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Analysis of Outcomes after Curative Resection of Ampullary Carcinoid Tumor.

Sea Hyun KWON ; Shin HWANG ; Sung Gyu LEE ; Young Joo LEE ; Duck Jong HAN ; Kwang Min PARK ; Song Cheol KIM ; Je Ho RYU ; Jeong Ik PARK ; Hyo Jun LEE

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):64-68.

PURPOSE: Ampullary carcinoid tumors are rare and therefore the clinicopathologic characteristics and prognosis after radical surgery have yet to be clarified. The goal of this study was to analyze the outcome of ampullary carcinoid tumors in patients who underwent radical curative resection. METHODS: From January 1998 to December 2005, 10 patients (3.4%) were diagnosed with an ampullary carcinoid tumor among 294 patients who underwent pancreatoduodenectomy for various ampullary neoplasms. The clinical findings from these 10 patients were retrospectively analyzed. RESULTS: The mean patient age was 58.0 +/- 13.4 years and seven were male. A standard pancreatoduodenectomy was performed in three patients and pylorus-preserving pancreatoduodenectomy in seven. An R0 resection was achieved in all 10 patients. The mean tumor size was 2.1 +/- 1.3 cm. Synaptophysin staining was positive in 10 and chromogranin staining was positive in eight patients. The overall and disease-free survival rates were 90% and 80% at 1 year and 64% and 56% at 3 years, respectively. Univariate analyses revealed that a maximum tumor diameter > or = 2 cm and tumor invasion beyond the ampulla were significant risk factors for tumor recurrence. CONCLUSIONS: The results of this study showed that performing a radical resection is the treatment of choice, with the intention of total tumor removal and the possibility of cure.
Carcinoid Tumor* ; Carcinoma, Neuroendocrine ; Disease-Free Survival ; Humans ; Intention ; Male ; Pancreaticoduodenectomy ; Prognosis ; Recurrence ; Retrospective Studies ; Risk Factors ; Synaptophysin

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Clinical Predictive Factors for Acute Gangrenous Cholecystitis.

Jong Tae JEE ; Kwang Sik CHUN ; In Sang SONG

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):58-63.

PURPOSE: The postoperative morbidity and mortality for acute gangrenous cholecystitis (AGC) are higher than for acute nongangrenous cholecystitis (ANGC). However, preoperative predictive factors for the outcome of gangrenous cholecystitis have not been identified. The goal of this study was to determine the preoperative clinical predictive factors for the outcome of surgical treatment for acute gangrenous cholecystitis. METHODS: From January 2005 to December 2006, the medical records of 173 patients who underwent laparoscopic cholecystectomy for acute cholecystitis were reviewed and analyzed retrospectively. RESULTS: Among 173 patients with acute cholecystits, 57 (32.9%) had pathologically confirmed gangrenous cholecystits. Six variables were found to be associated with gangrenous cholecystits by univariate analysis: an age > or = 55 years, the presence of associated diseases, hypertension, fever (> or =37 degrees), an increased white blood cell count (> or = 15,450/mm3) and glucose. Four variables were identified that were associated with gangrenous cholecystits by multivariate analysis: an age > or = 55 years, the presence of associated diseases, hypertension, and an increased white blood cell count (> or =15450/mm3). CONCLUSION: The results of this study suggest that patients with an age > or = 55 years, the presence of associated diseases, hypertension, and an increased white blood cell count (> or =15450/mm3) have an increased risk of gangrenous cholecystitis and require immediate surgery.
Cholecystectomy, Laparoscopic ; Cholecystitis* ; Cholecystitis, Acute ; Fever ; Glucose ; Humans ; Hypertension ; Leukocyte Count ; Medical Records ; Mortality ; Multivariate Analysis ; Retrospective Studies

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Analysis of Survival After Portal Vein Resection (PVR) In Combination With Hepatectomy For Hilar Cholangiocarcinoma: An Audit of 51 Cases.

Gi Won SONG ; Sung Gyu LEE ; Young Joo LEE ; Kwang Min PARK ; Shin HWANG ; Ki Hun KIM ; Chul Soo AHN ; Deok Bog MOON ; Tae Yong HA ; Je Ho RYU ; Jeong Ikk PARK ; Hyo Jun LEE ; Chan Wook KIM

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):47-57.

PURPOSE: Although a portal vein resection (PVR) can increase the chance for a successful curative resection, there is debate concerning the balance between the risk of the procedure and the effect on survival in patients with hilar cholangiocarcinoma. Therefore, we performed a retrospective study to determine the safety and survival after PVR for hilar cholangiocarcinoma. METHODS: We analyzed the cumulative survival rate and the associated clinical factors in 301 patients undergoing surgical intervention between June 1989 and June 2005. We divided 259 patients undergoing resection into two groups (51 PVR+ and 208 PVR-) and compared the survival and clinicopathological data. RESULTS: The 1-, 3- and 5-year survival rate of 186 patients undergoing curative resection was 83.3, 42.0 and 29.3%, respectively. The Bismuth-Corlette type IV, the infiltrative type, presence of perineural invasion, lymphovascular tumor emboli and lymph node metastases were more frequent in the PVR+ group. The survival rate was significantly lower in the PVR+ group but seven patients have survived for more than 5 years. Five (9.8%) operative mortalities occurred. However, the mortality directly related to the PVR was present in only one case. The morbidity and postoperative liver function were not different in comparisons between the two groups. In the PVR+ group, tumor invasion into the portal vein was observed in 28 of 51 patients. The tumor invasion on pathological examination did not affect survival in the PVR+ group. CONCLUSION: The results of this study showed that PVR in combination with hepatectomy, for hilar cholangiocarcinoma, could be performed with acceptable safety. Although the PVR has a negative impact on survival, a hepatectomy combined with a PVR can offer long-term survival to a few patients with advanced hilar cholangiocarcinoma.
Cholangiocarcinoma* ; Hepatectomy* ; Humans ; Klatskin's Tumor ; Liver ; Lymph Nodes ; Mortality ; Neoplasm Metastasis ; Portal Vein* ; Retrospective Studies ; Survival Rate

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Clinical Analysis of Focal Nodular Hyperplasia of the Liver in 11 Patients.

Kee Ho SONG ; Kuhn Uk LEE ; Ju Hyun KIM ; Woo Young SHIN ; Hae Won LEE ; Nam Joon YI ; Kyung Suk SUH ; Kwi Won PARK

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):41-46.

PURPOSE: The purpose of this study was to determine the clinical features of focal nodular hyperplasia (FNH) and investigate its diagnosis and treatment. METHODS: Eleven patients with FNH treated from January 1997 to January 2007 were analyzed. The clinical findings of pathologically proven FNH were retrospectively reviewed. RESULTS: Among the eleven patients with 18 masses, the mean age was 29.5 (11~57) and the gender ratio (male:female) was 4:7. Four patients had clinical symptoms. Six patients had a solitary mass and five had multiple masses. The mean tumor diameter was 2.73 +/- 1.82 cm. The overall rate of a correct preoperative diagnosis was 0% (0/4) by ultrasound, 36.3% (4/11) by CT and 20.0% (2/10) by MRI. Only two patients had a central stellate scar in the mass. All patients underwent hepatic resection without complication. CONCLUSION: The results of this study showed that the combination of Dynamic CT and dual contrast MRI are important diagnostic methods for FNH. However, a definite preoperative diagnosis of FNH, without a central stellate scar, is very difficult. Surgical resection is recommended for patients with an uncertain diagnosis or clinical symptoms.
Cicatrix ; Diagnosis ; Focal Nodular Hyperplasia* ; Humans ; Liver* ; Magnetic Resonance Imaging ; Retrospective Studies ; Ultrasonography

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Liver Transplantation in Patients over Sixty Years of Age.

Jong Lyul LEE ; Ki Hun KIM ; Sung Gyu LEE ; Young Joo LEE ; Kwang Min PARK ; Shin HWANG ; Chul Soo AHN ; Deok Bog MOON ; Tae Young HA ; Gi Won SONG

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):34-40.

PURPOSE: Orthotopic liver transplantation is considered a standard procedure for patients with end-stage liver disease. Liver transplantation in older patients has increased, with generally acceptable results. In Korea we have an aging population. In this study, we retrospectively reviewed the results of liver transplantation in patients more than 60 years of age at Asan Medical Center. METHODS: Fifty-four patients, age 60 and over, received a liver transplantation at Asan Medical Center between January 1998 and June 2005. We retrospectively reviewed the medical records of these patients. All patients were assessed according to the following variables: age, gender, clinical features, indications for transplantation, surgical findings, the hospital stay following liver transplantation, days in the intensive care unit, complications, and survival. RESULTS: The mean age of the recipients was 62.4 years. The transplant indications were 28 cases of hepatocellular carcinoma and 15 of HBV related cirrhosis. There was postoperative mortality (up to 3 months) in seven patients (13.21%). The mean ICU and hospital stays were 8.04 and 36.8 days, respectively. Overall, the patient survival rates at 1, 3 and 5 years was 83.02%, 75.47% and 75.47%, respectively. CONCLUSIONS: The results of this study showed that chronologic age should not be a contraindication to liver transplantation, especially if the pretransplant evaluation shows no comorbid disease that could increase the mortality rate.
Aging ; Carcinoma, Hepatocellular ; Chungcheongnam-do ; Fibrosis ; Humans ; Intensive Care Units ; Korea ; Length of Stay ; Liver Diseases ; Liver Transplantation* ; Liver* ; Medical Records ; Mortality ; Retrospective Studies ; Survival Rate

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Surgical Outcome of Hepatic Resections for Hepatolithiasis.

Seung Je GO ; Min Koo LEE ; Joo Seung PARK ; Yoon Jung KANG ; Byung Sun CHO ; Chang Nam KIM ; Young Jin CHOI ; Hye Won PARK

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):28-33.

PURPOSE: Hepatolithiasis results in septic cholangitis, biliary stricture, hepatic atrophy, hepatic abscess, irreversible liver cirrhosis, and cholangiocarcinoma. Hepatic resection for hepatolithiasis is regarded as a more effective treatment for achieving complete removal of stones and preventing recurrence. The purpose of this study was to determine the surgical outcome of hepatic resections for hepatolithiasis. METHODS: From March 2001 to December 2006, 54 patients underwent hepatic resections for hepatolithiasis at the Department of Surgery, Eulji University Hospital. A retrospective review of the surgical outcome was carried out. RESULTS: The hepatolithiasis was located in the left intrahepatic duct (34 cases), right intrahepatic duct (7 cases) or both (13 cases). The operative procedures were as follows: a left hepatectomy in 34 patients, a left lateral sectionectomy in eight, a right posterior sectionectomy in three, a left trisectionectomy in three, a right hepatectomy in five, and a segmentectomy in 1. The postoperative complications were intraabdominal abscess in 10 patients, wound infection in 4, pleural effusion in 3, internal bleeding in 2, T-tube site leakage in 2, hepatic failure and pneumonia in 1. The factors that affect these complications were analyzed. Preoperative percutaneous transhepatic biliary drainage (PTBD) and operative hepaticojejunostomy increased the frequency of postoperative complications; these findings were statistically significant (p=0.035, p=0.006, respectively). Two patients were diagnosed with cholagiocarcinoma. Five patients had remaining stones and five patients had recurrent stones. CONCLUSION: Hepatic resection is a safe and effective procedure for treating hepatolithiasis. If possible, bypass procedures such as hepaticoenterostomy should be avoided to reduce postoperative complications.
Abscess ; Atrophy ; Cholangiocarcinoma ; Cholangitis ; Constriction, Pathologic ; Drainage ; Hemorrhage ; Hepatectomy ; Humans ; Liver Abscess ; Liver Cirrhosis ; Liver Failure ; Mastectomy, Segmental ; Pleural Effusion ; Pneumonia ; Postoperative Complications ; Recurrence ; Retrospective Studies ; Surgical Procedures, Operative ; Wound Infection

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The Analysis of the Cholesterol Contents of Intrahepatic Duct Stones in the West Gyeongnam Region.

Jeong In PARK ; Ji Ho PARK ; Young Tae JU ; Chi Young JEONG ; Eun Jung JUNG ; Young Joon LEE ; Sang Kyung CHOI ; Woo Song HA ; Soon Tae PARK ; Tae Hyo KIM ; Ok Jae LEE ; Soon Chan HONG

Korean Journal of Hepato-Biliary-Pancreatic Surgery.2007;11(4):22-27.

PURPOSE: Hepatolithiasis is a recurrent disease and common in Far East Asia. In Korea, almost all intrahepatic duct (IHD) stones were pigment stones 30~40 years ago. The nationwide cooperative study showed a higher cholesterol content of IHD stones compared to the previous data. Some reports have shown a close relationship between urbanization and the cholesterol content of stones. The purpose of this study was to evaluate the cholesterol content of IHD stones in the West Gyeongnam region and evaluate the associated clinical and demographic variables. METHODS: The IHD stones were removed surgically from twenty patients who had hepatolithiasis between July 2005 and April 2007. The stones were grouped by their gross findings. The cholesterol contents were measured quantitatively by infrared spectrophotometry and compared with the clinical variables. RESULTS: Among twenty patients, 19 had pigment stones and only one had gross evidence of a cholesterol stone. The cholesterol content of the stones were 30%~50% in 13 patients, 50~70% in 6 patients and over 70% in one patient. In urban patients, the cholesterol contents of the IHD stones were higher (567.029 mg/g) than in rural patients (421.822 mg/g)(p<0.05). All stones in rural patients were pigment stones; the stones of urban patients consisted of 5 pigment, 6 mixed and 1 cholesterol stone (p<0.05). CONCLUSION: The mean cholesterol content of the IHD stones was 508.946 mg/g; the content of the stone was significantly related to the residence of the patients. These results suggest that the cholesterol content of IHD stones are likely to increase in West Gyeongnam as urbanization increases.
Asia ; Cholesterol* ; Far East ; Humans ; Korea ; Spectrophotometry, Infrared ; Urbanization

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