Laparoscopic Cholecystectomy in a Hemophiliac Patient with Factor VIII Inhibitor

Hemophilia A is a severe bleeding disorder resulting from the lack of functional blood coagulation factor VIII. Accordingly, operations on patients with hemophilia A, except in a few cases, are performed with the administration of factor VIII. However, in those hemophilia A patients administered factor VIII inhibitor, factor VIII replacement therapy is ineffective. The treatment of hemophilic patients with factor VIII inhibitor is undertaken to utilize the hemostatic capacity of the activated forms of FVII, FIX and FX contained within prothrombin complex concentrates, which are purposely manufactured to contain Factor Eight Inhibitor Bypassing Activity (FEIBA) during surgery. Further, in the last few years, a new product, recombinant activated FVII (FVIIa, Novo-VII), which is thought to ensure hemostasis by binding, directly or in complex with tissue factor, to negatively charged phospholipids on the surface of activated platelets, has been licensed. Recently, we experienced a GB stone, with acute cholecystitis, in a fifty year old hemophilia A man treated with factor VIII inhibitor. Under medication with FEIBA and Novo-VII, a laparoscopic cholecystectomy was performed. Here, this case is reported, with a review of the literature.ope

Recurrence Patterns and Risk Factors of Early Recurrence after Curative Resection of Ampulla of Vater Cancer

Purpose: Carcinomas of the ampulla of Vater have a higher resection rate, lower recurrence rate and more favorable prognosis than other malignant tumors of the periampullary region. This is because they usually presents with symptoms at an early stage due to their special anatomic location. Because of their relative low incidence, there have been few reports on the patterns and risk factors of a recurrence after a curative resection. The aim of this study was to evaluate the patterns and risk factors of a recurrence after a curative resection of ampulla of Vater cancer. Methods: The medical records of 87 regularly followed-up patients from a total of 102 patients with a carcinoma of the ampulla of Vater, who had undergone a curative surgery between January 1992 and December 2002, were retrospectively reviewed. Of these patients, 37 were diagnosed as recurrent, with the patterns and clinicopathological risk factors of the recurrence analyzed. Results: The average time to recurrence after a curative resection was 29.3±35.3 months, with liver metastasis being the most frequent (40.5%). The mean age of the patients in which a recurrence occurred was 54.9±10.1 years. There were 18 male and 19 female patients. The average tumor size in the recurred group was 2.5±2.0 cm. The recurrences were classified as early and late if they occurred within 18 months and after 18 months, respectively. The risk factors affecting an early recurrence were the gross morphology of tumor(ulcer formation) and cell differentiation (poorly differentiated). A univariate analysis showed lymph node metastasis to be a statistically significant risk factor, but age, gender, degree of tumor invasion depth and cell differentiation were not statistically significant. Conclusion: Lymph node metastasis is the most important risk factor affecting a recurrence after a curative resection of ampulla of Vater cancer, with the tumor gross morphology and cell differentiation important factors in an early recurrence. Further study on postoperative chemotherapy or radiotherapy in patients with lymph node metastasis, an ulcerative tumor type or poorly differentiated cell type, with a long-term follow-up on many patients will be needed.ope

Clinical Study of Method about Insertion and Removal of Endopouch through Umbilical Port without Laparoscopic Monitoring during Laparoscopic Surgery

Purpose: The purpose of this study is to evaluate the clinical outcomes of new technique about insertion and removal of Endopouch through umbilical port without laparoscopic monitoring during laparoscopic surgery. Methods: From January 2003 through December 2003, 1030 patients treated by laparoscopic appendectomy and cholecystectomy were enrolled. All laparoscopic appendectomies and cholecystectomies were performed using the conventional method (control group) and new method (study group), alternatively. Clinical characteristics and postoperative results between control group and study group were compared. Results: 654 patients underwent laparoscopic appendectomy (327 control group and 327 study group), and 376 patients underwent laparoscopic cholecystectomy (188 controlgroup and 188 study group). There were no differences in demographic characteristics and postoperative complications including operative time and postoperative hospital stay between control and study group (p＞0.05). Conclusion: The method using this new technique is a safe and effective procedure for organ retrieval after laparoscopic appendectomy or cholecystectomy. We believe that more experience of this tissue removal during laparoscopic surgery will contribute to technical development that can reduce complications during laparoscopic surgery.ope

Inflammatory pseudotumor of the liver treated by hepatic resection: a case report.

Inflammatory pseudotumor (IPT) of the liver is rare benign tumor. When the diagnosis of IPT is established with biopsy, simple observation or conservative therapy is preferred because of the possibility of regression. But IPT is unresponsive to the conservative treatment, surgical resection should be considered. We experienced a 63-year-old male, who was suspected hepatocellular carcinoma in abdominal computed tomography (CT) and magnetic resonance image (MRI) scan, presented with 2-month history of intermittent fever and weight loss. Percutaneous ultrasound guided core biopsy confirmed IPT of the liver. Non-steroidal anti-inflammatory drugs and antibiotics were administered for 8 and 4 weeks, respectively, but fever continued. So, extended right hepatectomy was performed for IPT of the liver and then fever subsided. The patient remains well during a follow-up period of 12 months.ope

Treatment Modalities for Adrenal Metastasis from Hepatocellular Carcinoma

Purpose: The adrenal gland is one of most the common sites for an extrahepatic metastasis from a hepatocellular carcinoma (HCC). However, there are no definitive guidelines for the treatment of adrenal metastasis. This study examined the effect of each therapeutic modality in an attempt to clarify the treatment strategy for adrenal metastases from a HCC. Methods: This study reviewed the records of 11,770 consecutive HCC patients in the Yonsei University Medical Center from 1991 to 2005. Among the 11,770 patients, 648 were diagnosed with an extrahepatic metastasis. Of the extrahepatic metastases, 45 (6.9%) had an adrenal metastasis. Among these 45 patients, 15 patients with multiorgan metastases including the adrenal gland were excluded leaving 30 patients for review. The survival duration was evaluated according to the treatment modality, which included an adrenalectomy, non-surgical treatment (TACE, Chemotherapy), and conservative treatment. Results: There were 24 men and 6 women, and the average age was 52.3 years (±9.1 years). The location of the adrenal metastasis was in the Rt, Lt, and both glands in 17 (56.7%), 9 (30.0%), and 4 (13.3%) patients, respectively. The initial HCC had been treated by a hepatectomy in 6 patients, and by non-surgical treatments such as TACE, chemotherapy and radiotherapy in 24 patients. The adrenal metastasis was treated by an adrenalectomy in 5 patients, by non-surgical treatment in 19 patients, and by conservative treatment in 6 patients. The overall median survival duration in the 30 cases was 11.1 months. The median survival time of the adrenalectomy, non-surgical treatment and conservative treatment groups was 21.4 months, 11.1 months, and 2.2 months respectively. The difference in the cumulative survival according to the treatment modality was statistically significant. Conclusion: The prognosis of an adrenal metastasis from HCC is quite poor. However, an adrenalectomy for an adrenal metastasis from a HCC is a safe procedure, and an acceptable way of achieving long-term survival.ope

Transduodenal Local Resection for Low Risk Group Ampulla of Vater Cancer Patients

Purpose: A carcinoma of the ampulla of Vater has more favorable prognosis than other malignant tumors of the periampullary region, because it is symptomatic at an early stage. However, local resection of an ampullary carcinoma remains controversial. The aim of this study was to evaluate the treatment results of ampulla of Vater carcinomas, according to operation type in low risk group patients. Methods: The records of 17 low risk group patients, among 120 patients with ampulla of Vater cancer, who underwent curative surgery beyween 1992 and 2002, were reviewed. All specimens were critically reviewed by a single expert pathologist. The relationship between surgical outcomes and operation type were assessed. Results: There were 10 men and 7 women, with a median age of 57.8 years. 13 of the 17 patients underwent the Whipples operation or a PPPD, and 4 underwent a transduodena1 local resection (TDLR). The operation time was shorter in the TDLR group, and was statistically significant. Among the 17 patients, only one had a recurrence in the inguina area 33 months after the PD. Conclusion: Transduodenal local resection is a recommendable operation for low risk Ampulla of Vater cancer patients. During the operation, it is essential to accurately evaluate the depth of invasion, cell differentiation and positivity of the resecticln margin using frozen sections.ope

Clinical Characteristics of Sarcomatoid HCC in Single Hospital Experience

Purpose: Sarcomatoid hepatocellular carcinoma (HCC) is a rare neoplasm and it has been found in only 1.8% of the surgically resected HCC patients, and in only 3.4∼9.4% of the autopsied HCC cases. The pathogenesis of this tumor has't yet been thoroughly clarified, and such a tumor has been variously referred to as spindle cell carcinoma, sarcomatoid carcinoma, pseudosarcoma, or carcinosarcoma. There is only a little difference between the clinical characteristics of the sarcomatoid HCC and those of ordinary HCC. The diagnosis of the sarcomatoid HCC is made by pathological and immunohistochemical techniques after surgical resection, biopsy, or autopsy. Methods: We reviewed the 10 cases of pathologically confirmed sarcomatoid HCC that were registered at the Yonsei University Medical Center from 1992 to 2004. Results: Surgical operation was performed in seven cases, and curative resection was done only in five. Three patients were treated with chemotherapy or transarterial chemoembolization (TACE) with or without concurrent radiotherapy after the diagnosis of sarcomatoid HCC by liver biopsy. Six patients expired within 4 months after the diagnosis. The 6 month and 12 month survival rates for sarcomatoid HCC were 40% and 20%, respectively. The 6 month survival rates for radical resection and non-radical resection were 60% and 0%, respectively. The difference in cumulative survival according to the treatment of sarcomatoid HCC was statistically significant. Conclusion: The prognosis of sarcomatoid HCC is very poor; therefore, curative resection, adjuvant chemoradiotherapy, and close follow-up are necessary for patients suffering with sarcomatoid HCC.ope

Fever, Thrombocytopenia and the Deterioration of Liver Function after Open Surgical Radiofrequency Ablation Therapy

The surgical resection is the only curative modality for hepatocellular carcinoma (HCC); however the surgical approach is limited by residual function of liver and multiplicity of tumor. The radiofrequency ablation (RFA) is introduced recently as a therapeutic modality, an alternative to percutaneous ethanol injection therapy (PEIT) for HCC. The advantages of open surgical RFA include better cancer staging with open intraoperative ultrasound, the availability of an intraoperative ultrasound guide system, the accessibility to tumors in all areas of the liver, avoidance of adjacent organ injury, the ability to perform hepatic inflow occlusion which reduces the heat-sink effect, and the possibility of combining RFA with hepatic resection. The complications after open surgical radiofrequency ablation are rarely reported. A 59 year old man with fever, thrombocytopenia and the deterioration of liver function after open surgical RFA was experienced. The patient’s hepatic function was given a Child-Pugh score of A6 points and the value of ICG R15 test was 55.2%. The open surgical RFA was performed on the S2, S3, S4 and S8. Although the patient was fully recovered without sequelae by conservative managements, the inclusion criteria have to be established carefully through following reviews on clinical results after open surgical RFA.ope

Solitary Paraaortic Lymph Node Metastasis of Primary Hepatocellular Carcinoma Misdiagnosed as Primary Retroperitoneal Tumor

The prognosis of primary hepatocellular carcinoma is very poor, and a curative resection is capable only in few selected patients. Most patients die from tumor recurrence. The rate of intrahepatic recurrence of hepatocellular carcinoma is much higher than extrahepatic recurrence or metastasis. The most common site of extrahepatic metastasis is lung, and followed by lymph nodes, bone and adrenal gland. Common sites of node metastasis are celiac lymph nodes and hepatoduodenal lymph nodes, however paraaortic lymph node metastasis is very rare. Here, we report an experience of solitary paraaortic lymph node metastasis from hepatocellular carcinoma which was misdiagnosed as primary retroperitoneal tumor by preoperative imaging studies.ope

Changes of Liver Volume and Functions after Hepatic Resection according to the Fibrosis (Stage of Chronic Hepatitis) of Liver Parenchyma

Purpose: The aim of this study was to assess the regeneration rate and functional recovery of the liver due to the stage of parenchymal fibrosis following a hepatectomy. Methods: We reviewed 41 patients that had undergone a hepatectomy for living liver donation and 35 for an HCC. The HCC patients were classified into three groups according to their histopathological status. The liver volume was serially estimated using CT scans before the operation, and on postoperative days (POD) 7 and 30. The liver function tests for AST, ALT and bilirubin were serially checked before the operation, immediately postoperative, and on POD 1, 3, 5, 7 and 30. Results: There were 61 and 15 males and females, respectively, with a mean age of 40 years. Patients were divided into four subgroups: parenchymal fibrosis, none (normal), periportal, septal and cirrhotic fibrosis. Within all the patients 55, 13 and 8 right lobectomy (RL), left lobectomy (LL) and left lateral segmentectomy (LLS), respectively, were performed. In the RL cases, the regeneration rate (RR) was significantly higher than those in the cases of LL and LLS. The RR of the fibrotic livers was significantly lower than that of normal livers, and became lower as the degree fibrosis increased. The RR at POD #7 was lowest in cirrhotic livers. The levels of Serum AST and ALT rapidly increased on the immediate postoperative day, and increased maxi-mally on POD #1, but thereafter decreased gradually, and recovered to normal on POD #30. The serum bilirubin level reached a maximal value on POD #2, and returned to normal on POD #7. Conclusion: The regenerative activity in chronic hepatitis patients is poor, especially in cases of severe fibrosis - cirrhosis. Therefore, in cases of major resection in HCC patients with chronic hepatitis, it is advisable to decide the extent of resection after confirmation of the stage of fibrosis.ope