Complications requiring reoperation after gastrectomy for gastric cancer: 17 years experience in a single institute.

INTRODUCTION: Morbidity and mortality rates following gastric cancer surgery are still high. The present study documented complications requiring reoperation after gastrectomy for gastric cancer and described surgical management for each complication. MATERIALS AND METHODS: Between 1987 and 2004, 8,033 patients underwent gastrectomy at the Department of Surgery, College of Medicine, Yonsei University, and the records were reviewed. RESULTS AND DISCUSSION: The most frequent complication was intestinal obstruction (88 patients, 54.3%), followed by intraabdominal bleeding (15, 9.3%), wound dehiscence or evisceration (15, 9.3%), incisional hernia (15, 9.3%), anastomotic leakage (seven, 4.2%), acalculous cholecystitis (five, 3.1%), duodenal stump leakage (five, 3.1%), intraabdominal abscess without leakage (five, 3.1%), bowel perforation (five, 3.1%), bile peritonitis due to hepatic duct injury (one, 0.6%), and biliary stricture (one, 0.6%). There were ten cases of hospital mortality (6.2%) from intraabdominal bleeding (four patients), intestinal obstruction (four patients), and anastomotic leakage (two patients). The most common long-term complication requiring reoperation was intestinal obstruction (69, 75.8%) due to adhesive formation rather than technical failure, while short-term complications were surgery-related and associated with high hospital mortality (14.1%). CONCLUSION: Proper preoperative preparation and faultless surgical skills are required during initial surgery to reduce complications and the need for reoperation.

Diagnosis of hepatic steatosis and fibrosis by transient elastography in asymptomatic healthy individuals: a prospective study of living related potential liver donors.

BACKGROUND: This prospective study aimed to assess the ability of transient elastography to identify histologic parameters, including steatosis, in asymptomatic healthy individuals such as potential liver donors, and to compare these findings with results in liver disease patients. METHODS: Forty-seven patients with abnormal liver function and/or hepatitis symptoms and 80 living related potential liver donors were consecutively enrolled, and liver biopsy and a Fibroscan test were performed in each subject. Histologic parameters were evaluated according to METAVIR scale by a single pathologist. RESULTS: In liver disease patients, stiffness was significantly correlated with fibrosis stage (Spearman correlation coefficient, 0.700; P < 0.001), and the optimal stiffness cutoff values for F >or= 2, F >or= 3, and F = 4 were 7.35, 8.85, and 15.1 kPa respectively. In potential liver donors, however, stiffness was not correlated with fibrosis (0.023; P = 0.851). In the latter group, the area under the receiver-operating characteristics curve was 0.70 (95% confidence interval, 0.58-0.81), and the optimal stiffness cutoff value was 4.00 for F >or= 2, which was lower than that in liver disease patients. Steatosis was not correlated with stiffness (0.088; P = 0.463) in potential liver donors. CONCLUSIONS: Transient elastography has limited value for detecting steatosis in asymptomatic healthy individuals, and the cutoff value for fibrosis should be reevaluated in these subjects.

Adefovir dipivoxil alone or in combination with ongoing lamivudine in patients with decompensated liver disease and lamivudine-resistant hepatitis B virus.

The purpose of this prospective study was to evaluate the efficacy and safety of adefovir dipivoxil with or without ongoing lamivudine in decompensated lamivudine-resistant chronic hepatitis B patients. Forty-six hepatitis B e antigen (HBeAg)-positive patients with decompensated liver function and lamivudine-resistant hepatitis B virus (HBV) were assigned to adefovir dipivoxil monotherapy (n=18) or combination therapy with ongoing lamivudine (n=28) according to their own preference. After 24 weeks of treatment, 83% of monotherapy and 86% of combination therapy showed serum HBV DNA below detection limit (<0.5 pg/mL). Alanine aminotransferase (ALT) normalized in 78% and 82% respectively. Median Child-Pugh-Turcotte (CPT) score or Model for End-Stage Liver Disease (MELD) score reduced significantly by 3 or 5 point in monotherapy and 2 or 2 point in combination therapy respectively. There were no significant differences in rate of undetectable serum HBV DNA, median change of ALT and median reduction of CPT or MELD scores between the two groups. In conclusion, both adefovir dipivoxil monotherapy and combination therapy with ongoing lamivudine result in comparable virologic, biochemical, and clinical improvements in HBeAg-positive patients with decompensated liver function and lamivudine-resistant HBV. Combination with lamivudine showed no additional benefit over monotherapy during 24 weeks of treatment in these patients.

[Usefulness of reagent strips for the diagnosis of spontaneous bacterial peritonitis].

BACKGROUND/AIMS: Spontaneous bacterial peritonitis (SBP) is one of the potentially life-threatening complications for patients with liver cirrhosis, and it has a mortality rate of over 20%. Early diagnosis of SBP and immediate use of an adequate antibiotic therapy are very important for achieving a better prognosis. The aim of our study was to assess the usefulness of reagent strips for making the rapid diagnosis of SBP. METHODS: A diagnostic paracentesis procedure was performed upon hospital admission in 257 cirrhotic patients (187 males, 70 females; mean age: 54 years) with ascites. Each fresh sample of ascitic fluid was tested using a reagent strip, and the result was scored as 0, 1+, 2+ or 3+. The leukocyte count, polymorphonuclear cell count, blood bottle culture, and chemistry of ascites were also done. RESULTS: We diagnosed 79 cases of SBP and 2 cases of secondary bacterial peritonitis by means of the polymorphonuclear cell count and the classical criteria. When a reagent strip result of 3+ was considered positive, the test's sensitivity was 86% (70 of 81), the specificity was 100% (176 of 176), and the positive predictive value was 94%. Furthermore, when a reagent strip result of 2+ or more was considered positive, the test sensitivity was 100% (81 of 81), the specificity was 99% (174 of 176), and negative predictive value was 99%. CONCLUSIONS: The use of reagent strips is a very sensitive and specific tool for the rapid diagnosis of SBP in cirrhotic patients. A positive result should be an indication for empirical antibiotic therapy, and a negative result may be useful as a screening test to exclude SBP.

Autoimmune chronic pancreatitis relapsing despite the maintenance dose of steroid.

Autoimmune chronic pancreatitis is a disease characterized by diffuse swelling of the pancreas, irregular narrowing of the main pancreatic duct and elevated levels of serum IgG, and lymphoplasmacytic infiltration is observed on histologic examination. Steroid therapy can dramatically reverse the clinical symptoms and the histologic and radiologic findings. It is known that recurrence is very rare after successful steroid treatment. Furthermore, there have not yet been any reports about a case that relapsed during maintenance therapy with low dose steroid. We experienced a rare case of autoimmune chronic pancreatitis that relapsed despite maintenance therapy with low-dose steroid, and the patient again responded to high-dose steroid.

Importance of Gly-13 for the coenzyme binding of human UDP-glucose dehydrogenase.

UDP-glucose dehydrogenase (UGDH) is the unique pathway enzyme furnishing in vertebrates UDP-glucuronate for numerous transferases. In this report, we have identified an NAD(+)-binding site within human UGDH by photoaffinity labeling with a specific probe, [(32)P]nicotinamide 2-azidoadenosine dinucleotide (2N(3) NAD(+)), and cassette mutagenesis. For this work, we have chemically synthesized a 1509-base pair gene encoding human UGDH and expressed it in Escherichia coli as a soluble protein. Photolabel-containing peptides were generated by photolysis followed by tryptic digestion and isolated using the phosphopeptide isolation kit. Photolabeling of these peptides was effectively prevented by the presence of NAD(+) during photolysis, demonstrating a selectivity of the photoprobe for the NAD(+)-binding site. Amino acid sequencing and compositional analysis identified the NAD(+)-binding site of UGDH as the region containing the sequence ICCIGAXYVGGPT, corresponding to Ile-7 through Thr-19 of the amino acid sequence of human UGDH. The unidentified residue, X, can be designated as a photolabeled Gly-13 because the sequences including the glycine residue in question have a complete identity with those of other UGDH species known. The importance of Gly-13 residue in the binding of NAD(+) was further examined with a G13E mutant by cassette mutagenesis. The mutagenesis at Gly-13 had no effects on the expression or stability of the mutant. Enzyme activity of the G13E point mutant was not measurable under normal assay conditions, suggesting an important role for the Gly-13 residue. No incorporation of [(32)P]2N(3)NAD(+) was observed for the G13E mutant. These results indicate that Gly-13 plays an important role for efficient binding of NAD(+) to human UGDH.

Recurrences of hepatocellular carcinoma following initial remission by transcatheter arterial chemoembolization.

BACKGROUND AND AIMS: The aim of this study was: (i) to define the characteristics of hepatocellular carcinoma (HCC) associated with recurrences following initial remission by transcatheter arterial chemoembolization (TACE); (ii) to evaluate the patterns of recurrences; and (iii) find a better surveillance method of detecting recurrent HCC. METHODS: Out of 230 consecutive HCC patients who underwent TACE, 77 with initial remission were followed prospectively for at least 12 months. We compared the recurrence rates according to the characteristics of the tumors and analyzed the locations of the recurrent HCC. The diagnostic efficacies of CT scans with serum AFP, angiography and Lipiodol CT scan in detecting recurrent HCC were also evaluated. RESULTS: Recurrent HCC was detected in 40 patients during a median period of 27 months. The recurrence rate of multinodular HCC was higher than the single nodular type. All six patients with portal vein thrombosis recurred. Even though 45% of recurrences were adjacent to original tumors, 63% were separated from them (8% at both). Hepatocellular carcinoma with heterogeneous Lipiodol uptake tended to recur at the site adjacent to the original tumors more frequently than HCC with homogeneous Lipiodol uptake. Only 18 of 40 recurrent HCC were initially detected by serum alpha-fetoprotein (AFP) and CT scans: 19 by angiography and three only by Lipiodol CT scan. CONCLUSION: Our data indicated that HCC of the multinodular type and with portal vein thrombosis recur more frequently following initial remission by TACE. It is also suggested that regular angiography in addition to serum AFP and CT scan may be valuable in detecting recurrent HCC. Other treatment modalities may need to be combined to ablate tumors completely and to therefore reduce recurrences, especially in HCC with heterogeneous Lipiodol uptake.

Transforming growth factor-beta1 as a useful serologic marker of small hepatocellular carcinoma.

BACKGROUND: Although alpha-fetoprotein (AFP) is a useful serologic marker of hepatocellular carcinoma (HCC), it has been reported insufficiently sensitive in detecting small HCCs. Plasma transforming growth factor-beta1 (TGFbeta1) has been reported to be elevated in HCC patients compared with liver cirrhosis patients. It has been reported that TGFbeta1 mRNA was overexpressed in HCC, especially in patients with small HCC and well-differentiated HCC compared with patients with liver cirrhosis. The current study investigated the usefulness of TGFbeta1 compared with AFP in the diagnosis of small HCCs. METHODS: Thirty-eight patients with small HCC (< or = 3 cm), 31 patients with liver cirrhosis only, and 23 normal volunteers were studied. Using plasma TGFbeta1 and serum AFP levels measured at the time of diagnosis, the sensitivities and specificities were calculated in the diagnosis of small HCCs. RESULTS: Plasma TGFbeta1 and serum AFP levels were significantly higher in patients with small HCC than in those with liver cirrhosis. In diagnosing small HCCs, the cut-off values of plasma TGFbeta1 and serum AFP were 800 pg/mL and 200 ng/mL, respectively, where the specificities were over 95%. At the cut-off level of plasma TGFbeta1 and serum AFP, the sensitivities were 68% and 24%, respectively. CONCLUSIONS: The current results suggest that TGFbeta1 may be a useful serologic marker in detecting HCCs earlier because it shows higher sensitivity than, with specificity as, AFP in the diagnosis of small HCCs.