Laparoscopic cholecystectomy for early gallbladder carcinoma: long-term outcome in comparison with conventional open cholecystectomy.

BACKGROUND: The role of laparoscopic surgery for malignant gallbladder tumors remains uncertain. This study compared the surgical results of laparoscopic versus conventional open cholecystectomy for patients with early-stage gallbladder carcinoma and examined the role of laparoscopic surgery for early gallbladder carcinomas. METHODS: Data for the treatment of gallbladder carcinomas were gathered from Chang Gung Memorial Hospital (Linkou, Taiwan). A retrospective analysis of 40 patients with either stage 0 or stage 1 gallbladder carcinoma was performed. The patients were categorized into two groups on the basis of cholecystectomy procedures. The long-term outcomes for the two groups were compared. RESULTS: During the follow-up period, which ranged from 6.5 to 197.6 months, four patients in the conventional open cholecystectomy group encountered tumor recurrence, and one patient in the laparoscopic cholecystectomy group experienced distant tumor recurrence (p = 0.216). No local port-site tumor recurrence was identified in patients who underwent laparoscopic cholecystectomy. The overall 5-year survival rate in this series was 87.1%. A comparison of survival rates between the two groups demonstrated no significant difference (p = 0.340). CONCLUSION: The laparoscopic cholecystectomy procedure did not adversely influence the prognosis of patients with early-stage gallbladder carcinomas. Furthermore, meticulous removal of gallbladders during laparoscopic surgery, in which early gallbladder carcinoma can be managed successfully using laparoscopic cholecystectomy, achieved a satisfactory surgical result and a low port-site tumor recurrence rate.

Laparoscopic cholecystectomy for 58 end stage renal disease patients.

BACKGROUND: Since 1987, laparoscopic cholecystectomy (LC) has been widely used as the favored treatment for gallbladder lesions throughout the world. Because hemorrhage, infection, and delayed wound healing are the main causes of death after surgery for end-stage renal disease (ESRD), laparoscopic surgery is risky for ESRD patients. However, no information has been reported on such patients, so this study aimed to assess the safety of LC in ESRD patients. METHOD: From January 1994 to December 2003, the medical records of 58 ESRD patients under regular hemodialysis (HD) with gallbladder lesions undergoing LC were reviewed (ESRD-LC). The clinical features and outcomes of 6,182 patients with gallbladder lesions without ESRD undergoing LC were also summarized for comparison. RESULTS: Of 6,240 patients with gallbladder lesions undergoing LC, 58 (0.93%) had ESRD with regular HD. The ESRD-LC group clearly exhibited older age, higher frequency of associated disease, lower hemoglobin and platelet count, and elevated alkaline phosphatase, blood urea nitrogen, and creatinine values. However, only a higher frequency of high American Society of Anesthesiologists (ASA) grade and elevated creatinine value could differentiate ESRD-LC and LC patients by multivariate analysis. Similar blood loss, conversion rate, morbidity, mortality, and hospital stay were noted for the two groups. CONCLUSIONS: LC is safe for ESRD patients with gallbladder lesions. Only a higher frequency of high ASA grade and elevated creatinine value could differentiate ESRD-LC and LC patients. Similar blood loss, conversion rate, morbidity, mortality, and hospital stay were achieved by applying LC to treat ESRD patients. However, appropriate preoperative preparations and experienced operative techniques are still required to prevent mortality.

Surgical treatment of hepatolithiasis: long-term results.

BACKGROUND: Hepatolithiasis is a common disease in East Asia and is prevalent in Taiwan. Surgical and nonsurgical procedures for management of hepatolithiasis have been discussed, but long-term follow-up results of surgical treatment of hepatolithiasis are rarely reported. METHODS: We conducted a retrospective study of case records of patients with hepatolithiasis who underwent surgical or nonsurgical percutaneous transhepatic cholangioscopy treatment. Of 614 patients with hepatolithiasis seen between January 1984 and December 1988, 427 underwent follow-up after surgical (380) or percutaneous transhepatic cholangioscopy (47) treatment for 4 to 10 years and constituted the basis of this study. RESULTS: Long-term results of 427 patients with hepatolithiasis after surgical and nonsurgical treatment within 4 to 10 years of follow-up were recurrent stone rate 29.6% (105 of 355), repeated operation 18.7% (80 of 427), secondary biliary cirrhosis 6.8% (29 of 427), late development of cholangiocarcinoma 2.8% (12 of 427), and mortality rate 10.3% (44 of 427). The patients with hepatectomy had a better quality of life (symptom-free) with a lower recurrent stone rate (9.5%), lower mortality rate (2.1%), and lower incidence of secondary biliary cirrhosis (2.1%) and cholangiocarcinoma (0%) than did the nonhepatectomy group (p < 0.01). The patients without residual stones after choledochoscopy had a better quality of life than did the residual stone group (p < 0.01). CONCLUSIONS: Long-term follow-up study of hepatolithiasis after surgical treatment revealed a high recurrent stone rate (29.6%) that required repeated surgery and a high mortality rate (10.3%) resulting from repeated cholangitis, secondary biliary cirrhosis, and late development of cholangiocarcinoma. Patients who received hepatectomy or without residual stones after choledochoscopy had a good prognosis and quality of life.

Upper gastrointestinal tract ablation for patients with extensive injury after ingestion of strong acid.

OBJECTIVE: Extensive corrosive injury involving the structures beyond the pylorus caused by ingestion of strong acid has a poor prognosis. We reviewed six cases of patients who underwent total upper gastrointestinal tract ablation to see the effect of this extensive procedure for such an injury. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Six patients who ingested more than 250 mL of 20N hydrochloric acid were treated in the Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China, from 1986 to 1992. RESULTS: Three patients with preoperative metabolic acidosis and renal failure died of multiple organ failure within the first postoperative month. The other three patients survived the acute stage. While being readied for a late reconstructive procedure, sepsis developed in one patient due to cholecystostomy leakage about 1 year postoperatively. Another patient died of respiratory failure after development of aspiration pneumonia due to poor drainage of a spit fistula, after surviving for 6 months. Only one patient had a good recovery following a full reconstruction procedure and restoration of the continuity of the gastrointestinal tract. CONCLUSIONS: Three of six patients died in the hospital. The risk factors were preoperative metabolic acidosis, renal failure, and an upper jejunal resection greater than 100 cm in length. Early and aggressive approaches to resect all the necrotic tissue certainly provide good chances to survive the acute stage and later reconstruction.

Hepatic resection in 120 patients with hepatocellular carcinoma.

During the 11-year period from 1977 through 1987, hepatic resections were carried out in 120 patients with hepatocellular carcinoma (HCC). Twenty-five had HCCs smaller than 5 cm in diameter. There were 97 male and 23 female patients, with an average age of 51.5 years. Among them, 45.8% had liver cirrhosis and 80.8% were positive for hepatitis B surface antigen. Fourteen with ruptured HCCs underwent hepatic resection to control the intra-abdominal hemorrhage. Operative mortality within one month after surgery was 4.1%. The postoperative course was complicated by pleural effusion in 5.8%, subphrenic abscess in 2.5%, postoperative bleeding in 1.6%, hepatic failure in 1.6%, and bile leakage in 0.8% of the patients. The overall five-year survival rate in this series was 25.9%, while survival for the last five years was better (42.3% vs 11.9% for patients treated between 1977 and 1982). The cumulative survival rate had no relation to tumor rupture or liver cirrhosis. The group of patients with smaller tumors (diameter, less than 5 cm) or without vascular invasion by tumor had better survival.

Postoperative recurrence of hepatocellular carcinoma. Two hundred five consecutive patients who underwent hepatic resection in 15 years.

OBJECTIVES: To report the results of our investigation of the postoperative intrahepatic recurrent rates and the patterns of recurrence and to determine the factors that influenced these patterns of recurrence. DESIGN: Case series. SETTING: Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. PATIENTS: Between 1977 and 1991, 162 men and 43 women with hepatocellular carcinoma underwent hepatic resection. RESULTS: The surgical mortality rate was 4.4%. Of the 196 patients who were discharged from the hospital, 114 have since died and 20 were not available for follow-up. The overall cumulative recurrent rates for the last 5 years (1987 through 1991) were 59.7%, 65.0%, 76.5%, 77.0%, and 79.7%, respectively. Eighty patients experienced intrahepatic recurrence. Of these, 21 (26.2%) had recurrence near the resected stump, 43 (53.8%) had a single nodular recurrence in the remnant liver, and 16 (20%) had wide-spread multinodular recurrence. The patients with resected margins of less than 1 cm in diameter had relatively higher recurrence rates than those with resected margins of greater than 1 cm in diameter. All recurrences were noted within 3 years of the resection. The preoperative serum alpha-fetoprotein levels were directly related to the length of time to recurrence (ie, the higher the serum alpha-fetoprotein level, the sooner the recurrence). CONCLUSIONS: The postoperative intrahepatic remnant rate is very high; 80% by 5 years after resection. The preoperative serum alpha-fetoprotein level and adequacy of the cut margin significantly influenced the recurrence rate.

Pyogenic liver abscesses in patients with malignant disease: a report of 52 cases treated at a single institution.

BACKGROUND: Prognosis of pyogenic liver abscesses in patients with malignant disease is generally considered poor. The discrepancy between the outcomes of liver abscesses caused by hepatopancreatobiliary malignant disease and those caused by other malignant diseases, however, to our knowledge has never been investigated. OBJECTIVES: To clarify the clinical course of pyogenic liver abscess in patients with different types of cancer, and to compare outcomes in abscesses caused by hepatopancreatobiliary malignant disease and other malignant disease. DESIGN: Retrospective review of case series in our experience from 1980 through 1993. SETTING: Tertiary care university teaching hospital. PATIENTS: Fifty-two patients with pyogenic liver abscess related to the underlying cancer were divided into 2 groups. Group 1 (n=32) was composed of patients with cancer originating from the hepatic parenchyma, bile duct, and pancreas; group 2 (n=20) was composed of patients with cancer originating from other sites. INTERVENTIONS: Parenteral antibiotics, percutaneous drainage, surgical drainage, or hepatectomy, in combinations, were employed. MAIN OUTCOME MEASURES: Patient characteristics, symptoms, laboratory data, abscess characteristics, microbiological study, management, and outcome of the 2 groups were analyzed. RESULTS: Thirteen patients (41%) in group 1 and 16 patients (80%) in group 2 had undergone prior anticancer treatment. Jaundice was encountered more often in group 1 than in group 2 (29 patients [91%] vs 6 patients [30%], respectively, P=.001), whereas nausea and vomiting were more frequently seen in group 2 than in group 1 (17 patients [52%] vs 6 patients[31%], respectively, P=.04). Leukocytosis, hypoalbuminemia, hyperbilirubinemia, and reversed albumin-globulin ratio were more pronounced in group 1 than in group 2 (P=.001, .02, .003, and .03, respectively). Abscesses communicating with the intrahepatic biliary tree were more frequently encountered in group 1 than in group 2 (11 patients [34%] vs 2 patients [10%], respectively, P=.03). Escherichia coli and Klebsiella pneumoniae predominated in group 1, while the bacteria species in group 2 were more diverse. The hospital mortality rates of group 1 and group 2 were 28% (9 of 32 patients) vs 10% (2 of 20 patients) (P=.04), respectively. Twenty-three patients (72%) of group 1 died of uncontrolled biliary sepsis or progressive cancer or both within 6 months after the diagnosis, while 17 patients (85%) of group 2 survived longer than 1 year without relapse of the abscess and continued with anticancer treatment. CONCLUSIONS: Pyogenic liver abscess could be a presentation of hepatopancreatobiliary malignant disease at the preterminal stage, and carries a grave prognosis. Pyogenic liver abscess in patients with nonhepatopancreatobiliary malignant disease has a better chance of favorable outcome.

Prognostic study of gastric cancer without serosal invasion: reevaluation of the definition of early gastric cancer.

BACKGROUND: Early gastric cancer, a term defined by Japanese researchers in the 1960s, is equivalent to pT1 tumor stage regardless of nodal status. Recently, there were suggestions to exclude node-positive pT1 gastric cancer from this entity and to consider node-negative pT2 gastric cancer as early gastric cancer. STUDY DESIGN: A survival analysis was conducted of 294 patients who underwent resection for gastric cancers confined within the gastric wall (pT1, n = 164; pT2, n = 130) between 1986 and 1992. RESULTS: The cumulative 5-year survival rate was 93.5% for pT1 patients and 67.9% for pT2 patients, with an overall survival of 82.5%. There was a significant difference in the 5-year survival rate between node-positive and node-negative pT1 patients (72.8% versus 95.6%; p = 0.0095). The 5-year survival rate of node-negative pT2 patients (80.4%) was significantly worse than that of node-negative pT1 patients (p = 0.011) but was not significantly better than that of node-positive pT1 patients (p = 0.4). If excellent prognosis is a prerequisite for the definition of early gastric cancer, then node-positive pT1 cancer and node-negative pT2 cancer should not be considered early gastric cancer. CONCLUSIONS: In the 1990s, now that new imaging techniques such as endoscopic ultrasonography has been introduced, the preoperative staging of gastric cancer can be made more accurately than in the 1960s, when the term "early gastric cancer" was defined. Because the prognosis of early gastric cancers, if subcategorized by nodal status, is not homogeneously excellent, a reevaluation of the definition of early gastric cancer may be necessary.

Video-assisted endoscopic thyroidectomy.

BACKGROUND: Several experimental and clinical reports concerning endoscopic parathyroid surgery have appeared. However, reports concerning minimally invasive surgery for thyroid remains rare. Herein we present a new method, called video-assisted endoscopic thyroidectomy (VAET), for the management of various benign thyroid diseases. METHODS: In all, 16 consecutive patients who underwent VAET for benign thyroid diseases were retrospectively studied. The study group included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle's tumor and simple cyst in 1 each. A 2 to 3 cm transverse incision was made on the suprasternal notch. The wound was deepened to expose the underlying trachea from which the plane of the thyroid fascia was accessed directly, and the working space was established with lifting method using conventional instrument. All surgical procedures could be manipulated and monitored under laparoscopy without gas insufflation. The ultrasonically activated scalpel was the principal instrument used for VAET. RESULTS: All 16 patients underwent VAET successfully without conversion to open thyroidectomy. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation less than 40 minutes. The tumor size ranged from 3.5 cm to 8.0 cm (mean 5.8 cm). There were no surgical complications. All patients but 1 were discharged on postoperative day 2. During follow-up, all patients demonstrated euthyroid function and satisfactory cosmetic results. CONCLUSIONS: VAET emerges as a promising minimally invasive surgical technique replacing conventional thyroidectomy for benign thyroid diseases in selected cases, with the advantage of satisfactory cosmetic results.

Laparoscopic treatment for Mirizzi syndrome.

BACKGROUND: Mirizzi syndrome is an uncommon complication of longstanding gallstone disease resulting in obstructive jaundice and remains surgically challenging. Mirizzi syndrome is generally considered a contraindication to laparoscopic surgery. We present the surgical experience of 11 consecutive patients with Mirizzi syndrome who were diagnosed correctly preoperatively and treated laparoscopically. METHODS: From January 1991 to December 2001, 4,560 patients underwent laparoscopic cholecystectomy for gallbladder lesions, 11 (0.24%) of whom were diagnosed with Mirizzi syndrome. RESULTS: The 11 patients diagnosed with Mirizzi syndrome included four men and seven women, with ages ranging from 21 to 72 years (median, 54). There were 10 patients with Mirizzi syndrome type I (one was caused by gallbladder cancer in the neck), and 1 patient with type II, according to McSherry's classification. Right upper quadrant abdominal pain was the most common symptom, occurring in all 11 patients. All 11 patients were diagnosed correctly preoperatively by endoscopic retrograde cholangiography (ERCP) with 100% sensitivity. Four of the 11 patients (36.4%) were converted to open procedure. The postoperative course was uneventful, except for one patient complicated with a residual common bile duct stone. Hospital stay ranged from 4 to 33 days (median, 7). CONCLUSIONS: Mirizzi syndrome is an uncommon disorder. Preoperative suspicion is crucial for correct preoperative diagnosis. ERCP is the most useful tool for correct preoperative diagnosis and consequent prevention of common bile duct injury during operation. Should Mirizzi syndrome be diagnosed, laparoscopic treatment is a feasible and safe procedure, especially for type I Mirizzi syndrome.

Laparoscopic cholecystectomy in 226 cirrhotic patients. Experience of a single center in Taiwan.

BACKGROUND: Since 1987, laparoscopic cholecystectomy (LC) has been widely used as the favored treatment for gallbladder lesions. However, cirrhosis and portal hypertension have been considered relative or absolute contraindications to LC. This study aimed to assess the safety of LC in cirrhotic patients. METHOD: The medical records of 226 cirrhotic patients with gallbladder lesions who had undergone LC from 1991 to 2000 were reviewed, including demographics, severity of cirrhosis, laboratory data, operative morbidity, operative mortality, and hospital stay. Furthermore, the clinical features and outcomes of 4030 patients with gallbladder lesions without cirrhosis that had undergone LC were also summarized for comparison. RESULTS: Of 4256 patients with gallbladder lesions that had undergone LC, 226 (5.6%) had cirrhotic livers. The cirrhotic group patients clearly exhibited the trends of older age, worse liver function, higher blood loss, and higher mortality compared to the noncirrhotic group patients. CONCLUSIONS: This study presents the clinical features and outcomes of 226 cirrhotic patients who underwent LC. LC, once considered contraindicated in patients with cirrhosis, is a feasible procedure for most Child's A and B patients with cholecystolithiasis. Minor morbidity, an acceptable conversion rate, and shorter hospital stay can be achieved by applying LC to treat cirrhotic patients. However, appropriate preoperative preparations and meticulous operative techniques are required to reduce blood loss during laparoscopy and even mortality.

Laparoscopic cholecystectomy for gallbladder lymphangiomas.

Intraabdominal lymphangiomas are rare benign tumors that can be difficult to diagnose preoperatively. The clinical presentation of these tumors is variable and potentially misleading. Therefore, complex imaging studies are required to evaluate this condition. Ultrasound and CT scan are important to make the correct preoperative diagnosis and also provide important information regarding location, size, and adjacent organ involvement. The treatment of choice is complete excision. This report describes two patients with cystic lymphangiomas originating in the gallbladder. The correct diagnosis was made preoperatively in one patient, and both patients were treated successfully by laparoscopy.

Bacteremia following postoperative choledochofiberscopy--a prospective study.

BACKGROUND/AIMS: The following investigation was undertaken in order to determine the frequency and clinical consequences of bacteremia after postoperative choledochofiberscopy. MATERIALS AND METHODS: A total of 100 patients were prospectively studied for the frequencies of bacteremia after postoperative choledochoscopy. RESULTS: Positive blood cultures were obtained in 15%; at 5-minutes period in seven patients, at 15-minutes in eight patients and at 30-minutes in two patients. There were two patients with positive cultures at 5 minutes and 10 minutes periods. All the bacteria species cultured were aerobes. Enterococcus, E-coli and Klebsilla were the most commonly cultured bacteria. The frequencies of occurrence of bacteremia seemed not be influenced by the existence of residual stones, session of the endoscopy and duration of the procedure. Six of the 15 bacteremic patients developed cholangitis within 24 hours of the procedure. They all recovered with antibiotic treatment. Patients with negative blood cultures were not found with cholangitic symptoms after the postoperative choledochoscopy. CONCLUSIONS: The results of our study indicated that fifteen percent of patients undergoing postoperative choledochofiberscopy are associated with bacteremia. We believe that with adequate aseptic preparation and meticulous, gentle manipulation, routine prophylactic antibiotics may not be necessary for postoperative choledochoscopy in selected conditions.

Obstructive jaundice secondary to hepatocellular carcinoma rupture into the common bile duct: choledochoscopic findings.

BACKGROUND/AIMS: Hepatocellular carcinoma presenting as obstructive jaundice caused by floating tumor debris in the common bile duct is rare. We report choledochoscopic findings in this rare condition. METHODOLOGY: From January 1981 to December 1995, 28 patients received surgical treatment for obstructive jaundice secondary to hepatocellular carcinoma rupture into the common bile duct. Among them, intra-operative choledochoscopy was performed in 18 patients. RESULTS: Choledochoscopic findings revealed tumor thrombus and an intraluminal yellowish nodular mass in all patients, blood clots in the bile duct in 8 patients, and the appearance of acute erythematous cholangitis in 4 patients. Choledochoscopy revealed that the site of hepatoma rupture was from the right intrahepatic duct in 9 patients, from the left hepatic duct in 7 patients, and from the hepatic hilum in 2 patients. Choledochoscopically guided hepatic resection was performed in 4 patients. CONCLUSIONS: Intra-operative choledochoscopy reveals the characteristic finding of an intraluminal yellowish nodular mass in patients with malignant obstruction of the bile duct due to hepatocellular carcinoma. Hepatic resection with a free margin of the involved hepatic duct can be achieved by a choledochoscopically guided operation.

Laparoscopic cholecystectomy in cirrhotic patients.

BACKGROUND/AIMS: Laparoscopic and open cholecystectomy are the safest procedures for all diseases related to stones in the gallbladder as they have a low morbidity and mortality rate. However, the safety of laparoscopic cholecystectomy in cirrhotic patients has not been investigated. The goal of this study was to evaluate the safety of laparoscopic cholecystectomy in cirrhotic patients. METHODOLOGY: A retrospective study of laparoscopic cholecystectomy in cirrhotic versus non-cirrhotic patients was performed. Between January 1991 and November 1994, 605 laparoscopic cholecystectomies for symptomatic gallbladder diseases were performed. There were 21 patients in the cirrhotic (group A) and 584 patients in the non-cirrhotic (group B). RESULTS: There was no operative mortality in either group and the postoperative complication rates were 4.8% and 5.8% in group A and B, respectively (p > 0.05). Prolonged operative time in group A was 84.47 +/- 36.01 min vs group B 62.20 +/- 25.37 min (p < 0.01). The estimated intraoperative blood loss in group A was larger than in group B (140.76 +/- 201.19 ml vs 35.02 +/- 50.11 ml, p < 0.01). The readmission rate was higher in group A (9.5%) than in group B (1.37%) (p < 0.05). The hospital stay in group A and B were 4.12 +/- 2.15 D, 3.50 +/- 1.50 D respectively (p > 0.05). The incidence of conversion and re-operation rates indicated no difference between cirrhotic and non-cirrhotic groups. CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed in mild cirrhotic patients with more operative times and meticulous management of intraoperative bleeding.

Secural pancreaticojejunal anastomosis for the pancreaticoduodenectomy.

BACKGROUND/AIMS: This report presents the results of two methods for minimizing complications following a Whipple operation. MATERIALS AND METHODS: In the past five years, continuous duct to mucosal suture with end to side anastomosis of the pancreaticojejunostomy was utilized in 30 patients. Another 50 patients received interrupted duct to mucosal suturing with end to side anastomosis of the pancreaticojejunostomy in the past five to ten years. RESULTS: None of the first set of 30 patients suffered leakage after the operation. Ten of the 50 patients (20%) developed leakage postoperatively and 3 (6%) died. The group with continuous duct to mucosal suture had significantly less complications than those with interrupted duct to mucosal suturing (P < 0.05). Late follow up of the patients with continuous duct to mucosal suture using echogram, no one had stricture of the anastomosis. CONCLUSION: The continuous duct to mucosal suture of the pancreaticojejunostomy is a very safe procedure, minimizing the operative morbidity and mortality of the Whipple operation.

Malignancy in choledochal cysts.

BACKGROUND/AIMS: Malignancy in choledochal cysts is a rare condition. This study presents our experience with this condition, with emphasis on the clinical presentation, management and outcome. METHODOLOGY: Subjects included 80 adults with choledochal cysts treated from January 1979 to December 1995. Of these patients, 8 were found to have malignancy in the cyst and formed the basis of this study. RESULTS: Four patients had synchronous and 4 had metachronous carcinoma lesions arising in the choledochal cyst. The clinical presentation was: biliary tract infection in 5 patients, gastric outlet obstruction in 2 and right upper quadrant pain and body weight loss in 1. Operations for bile duct malignancy included total excision in 2 patients, choledochotomy with T-tube drainage in 2 patients, gastrojejunostomy in 2 patients, percutaneous transhepatic biliary drainage and gastrojejunostomy in 1 patient and metastatic lymph node biopsy only in 1. One patient died due to septic shock within 30 days of the operation (operative mortality). Postoperative survival time ranged from 4-13 months with a mean of 6.2 months. CONCLUSIONS: The frequency of malignancy in the choledochal cysts was 10% in the present series. Malignancy in the choledochal cyst should be highly suspected in patients with cholangitis symptoms, body weight loss and anemia. Prognosis in this disease entity is poor.

Intra-arterial infusion of octreotide to stop gastrointestinal tract bleeding that is difficult to manage surgically: a case report.

Intraluminal bleeding after gastrointestinal and bilopancreatic surgery continues to be a very difficult management problem. Herein, we report two cases of postoperative gastrointestinal bleeding which were successfully treated with intra-arterial infusion of octreotide. The two patients had undergone biliary tract surgery and experienced postoperative gastrointestinal bleeding. Abdominal angiography revealed extravasation from branches of the dorsal pancreatic artery and gastroduodenal artery in each patient, respectively. Transcatheter arterial embolization was performed, but without success in stopping the bleeding. The administration of octreotide via a regional arterial infusion finally stopped the bleeding in each of these two cases.

Prospective and randomized study of gabexate mesilate for the treatment of severe acute pancreatitis with organ dysfunction.

BACKGROUND/AIMS: Exaggerated production of various proteases may account for the late presence of organ dysfunction in acute pancreatitis. This study examined the effects of early administration of gabexate mesilate on the condition of patients with severe acute pancreatitis and organ dysfunctions. METHODOLOGY: Fifty-two patients with acute pancreatitis and organ dysfunction were enrolled. The treatment group included 26 patients receiving intravenous gabexate mesilate infusion at a dose of 100 mg/hr for 7 days. APACHE-II score, clinical and biochemical parameters were monitored intensively. RESULTS: Coagulopathy ileus, and abdominal pain was significantly improved with gabexate mesilate. Gabexate mesilate reduced the necessity for surgical intervention and peritoneal lavage. The 7-day-mortality and 90-day-mortality rates were also significantly reduced with gabexate mesilate therapy. CONCLUSIONS: There are strong indications from this study that early intravenous gabexate mesilate infusion results in improved survival in acute pancreatitis with organ dysfunctions.

Common bile duct and pancreatic injury after extracorporeal shock wave lithotripsy for renal stone.

Common bile duct and pancreatic injury are rare complications following extracorporeal shock wave lithotripsy. We reported a case of peripancreatic abscess with inflammation change of common bile duct and pancreatic head following extracorporeal shock wave lithotripsy for right renal stone. Its anatomical location and subsequent clinical course suggest it was related to trauma caused by the shock wave. It should be considered a relative contraindication to apply extracorporeal shock wave lithotripsy in cases of right renal stone associated with large gall stones.