Laparoscopic surgery for fallopian tube torsion due to benign tumour in the third trimester of pregnancy: a case report and literature review.

Isolated fallopian tubal torsion is rare among women of reproductive age, and it is even rarer during pregnancy. Despite its rare incidence, it is important to consider this diagnosis to facilitate prompt and effective intervention. We present the case of a pregnant woman in her third trimester who presented with acute right abdominal pain. A 32-year-old primigravida woman at 29 weeks and four days of gestation visited the emergency department with acute right flank and abdominal pain. Sonography and MRI revealed the presence of a right adnexal cystic mass. Exploratory laparoscopy revealed isolated right tubal torsion and a normal ovary. To avoid torsion recurrence, we performed laparoscopic right salpingectomy. The remainder of her gestation was uneventful. Histopathological examination revealed serous cystadenoma with haemorrhagic infarction. We reviewed the literature for cases of isolated tubal torsion in the past 11 years. Twenty-three case reports were included in this study, and the average time from presentation to surgical intervention was 35.6 hours. In these cases, most of the patients underwent laparotomy and had good pregnancy outcomes. Although the approach may vary depending on the situation, the laparoscopic approach should be preferred to laparotomy in the third trimester of pregnancy.

Randomized controlled study comparing the analgesic effects of intravenous patient-controlled analgesia and patient-controlled epidural analgesia after open major surgery for pancreatobiliary cancer.

BACKGROUND: This randomized clinical trial was performed to compare pain scales between intravenous patient-controlled analgesia (IV-PCA) and patient-controlled epidural analgesia (PCEA) in patients undergoing open surgical resection of major pancreatobiliary malignancies. METHODS: One hundred ten patients were randomly assigned to the PCEA or IV-PCA group. We compared the numeric rating scale pain score during ambulation on postoperative day (PD) 2 and at rest (at 06:00, 12:00, and 18:00) from PD 1 to 7, the serum level of troponin I on PD 1, and the incidence of postoperative complications between the two groups. RESULTS: There were no significant differences in the pain scores during ambulation on PD 2, at rest up to PD 7, serum troponin I level, and postoperative complication rates. The incidences of nausea (20.4% vs. 6.3%; p = 0.039) and drowsiness (20.4% vs. 0%; p = 0.001) were higher in the IV-PCA group and the rate of dysuria (0% vs. 14.6%; p = 0.004) was higher in the PCEA group. CONCLUSION: PCEA showed no superiority over IV-PCA in terms of postoperative pain relief or morbidity after major open surgery for pancreatobiliary malignancies. The method of analgesia should be considered based the characteristics of the patient, surgeon, anesthesiologist, and institute.

Angiopoietin-1 and -2 and vascular endothelial growth factor expression in ovarian grafts after cryopreservation using two methods.

OBJECTIVE: The favored method of preserving fertility in young female cancer survivors is cryopreservation and autotransplantation of ovarian tissue. Reducing hypoxia until angiogenesis takes place is essential for the survival of transplanted ovarian tissue. The aim of this study was to investigate the role of angiopoietin-1 (Angpt-1), angiopoietin-2 (Angpt-2), and vascular endothelial growth factor (VEGF) in ovarian tissue grafts that were cryopreserved using two methods. METHODS: Ovarian tissues harvested from ICR mice were divided into three groups: group I (control), no cryopreservation; group II, vitrification in EFS (ethylene-glycol, ficoll, and sucrose solution)-40; and group III, slow freezing in dimethyl sulfoxide. We extracted mRNA for VEGF, Angpt-1, and Angpt-2 from ovarian tissue 1 week following cryopreservation and again 2 weeks after autotransplantation. We used reverse transcriptase-polymerase chain reaction to quantify the levels of VEGF, Angpt-1, and Angpt-2 in the tissue. RESULTS: Angpt-1 and Angpt-2 expression decreased after cryopreservation in groups II and III. After autotransplantation, Angpt-1 and Angpt-2 expression in ovarian tissue showed different trends. Angpt-1 expression in groups II and III was lower than in group I, but Angpt-2 in groups II and III showed no significant difference from group I. The vitrified ovarian tissues had higher expression of VEGF and Angpt-2 than the slowfrozen ovarian tissues, but the difference was not statistically significant. CONCLUSION: Our results indicate that Angpt-2 may play an important role in ovarian tissue transplantation after cryopreservation although further studies are needed to understand its exact function.

Proximal Resection Margins: More Prognostic than Distal Resection Margins in Patients Undergoing Hilar Cholangiocarcinoma Resection.

PURPOSE: Even though the therapeutic gold standard of hilar cholangiocarcinoma (HCCA) resection is cancer-free resection margin (RM), surgical treatment still remains challenging. This study evaluated the prognostic significance of RM status in resected HCCA patients and identified survival prognostic factors. MATERIALS AND METHODS: We reviewed records of 96 HCCA patients who underwent surgery from 2001 to 2012 and analyzed the RM status and prognostic factors that affecting survival. RESULTS: Negative RM (n=31, 33%) was significantly associated with better survival vs. positive RM (n=65, 67%) (mean survival time [MST], 33 months vs. 21 months; p=0.011). Margins with histological findings of non-dysplastic epithelium, low-grade dysplasia, and carcinoma in situ were not associated with survival differences (MST, 33 months vs. 33 months vs. 30 months; p=0.452), whereas positive margins were associated with poorer survival relative to carcinoma in situ (MST, 30 months vs. 21 months; p=0.050). Among patients with R0 resection, narrow (≤ 5 mm) and wide (> 5 mm) margins were not associated with survival differences (MST, 33 months vs. 30 months; p=0.234). Although positive proximal RM was associated with poorer survival compared to negative RM (MST, 19 vs. 33; p=0.002), no survival difference was observed between positive and negative distal RMs (MST, 30 vs. 33; p=0.628). Proximal RM positivity (hazard ratio [HR], 2.688; p=0.007) and nodal involvement (HR, 3.293; p < 0.001) were independent survival prognostic factors. CONCLUSION: A clear RM, especially proximal RM status, was significant prognosticator, and proximal bile duct resection to the greatest technically feasible extent may be necessary, with careful consideration of the potential morbidity and oncologic outcomes after resection. However, an aggressive approach to obtain a negative distal RM might be controversial and should be considered carefully, depending on the patient's status.

Effects of preoperative ultrasound-guided transversus abdominis plane block on pain after laparoscopic surgery for colorectal cancer: a double-blind randomized controlled trial.

BACKGROUND: Although laparoscopic colorectal surgery decreases postoperative pain and facilitates a speedier recovery compared with laparotomy, postoperative pain at trocar insertion sites remains a clinical concern. The objective of this study was to assess the effects of a preoperative ultrasound-guided transversus abdominis plane (TAP) block on pain after laparoscopic surgery for colorectal cancer. METHODS: In total, 58 patients scheduled to undergo laparoscopic surgery following a diagnosis of colorectal cancer were included in this study. The patients were randomized into TAP and control groups; the TAP group patients received a preoperative ultrasound-guided bilateral TAP block with 0.5 mL/kg of 0.25 % bupivacaine, while the control patients received the block with an equal amount of saline. Pain on coughing and at rest was assessed during postanesthetic recovery (PAR; 1 h after surgery) and on postoperative days (PODs) 1 (24 h), 2 (48 h), and 3 (72 h) by an investigator blinded to group allocations using the numeric rating scale (NRS). The primary outcome was pain on coughing on postoperative day (POD) 1. RESULTS: Fifty-five patients were included in the final analysis, including 28 in the TAP and 27 in the control groups. The pain intensity on coughing and at rest during PAR and on PODs 1, 2, and 3 showed no significant differences between groups. Furthermore, there was no significant difference in postoperative opioid consumption, sedation scores, nausea scores at the four time points, complication rates, and length of hospital stay between groups. CONCLUSIONS: In colorectal cancer patients undergoing laparoscopic colorectal surgery, a TAP block did not offer enough benefit for clinical efficacy in terms of postoperative pain or analgesic consumption.

Survival analysis after liver resection for hepatocellular carcinoma: A consecutive cohort of 1002 patients.

BACKGROUND AND AIM: The improvements in surgical technique and perioperative management in the recent decades may warrant revisit for survival outcomes and prognostic factors after liver resection for hepatocellular carcinoma (HCC). This study aimed to analyze the survival outcomes after liver resection for HCC for a consecutive cohort of 1002 patients. METHODS: This study was performed by analyzing the clinicopathological and follow-up data of 1002 consecutive patients who underwent liver resection for HCC from April 2001 to December 2013. Prognostic factors were investigated by univariate and multivariate analysis, using the Cox's proportional hazards model. RESULTS: The overall incidence of postoperative complications was 16.1% (n = 161), with an in-hospital mortality rate of 0.3% (n = 3). The rates of 1-, 3-, and 5-year overall survival were 91.9%, 78.9%, and 69.5%, while the rates of 1-, 3-, and 5-year recurrence-free survival were 71.7%, 51.7%, and 43.7%, respectively. Multivariate analysis showed that patient age, platelet count, intraoperative estimated blood loss (EBL), tumor number, Edmond-Steiner grade, microvascular invasion, major vessel invasion, and intrahepatic metastasis were independent significant prognostic factors affecting the overall survival. Platelet count, intraoperative EBL, maximal tumor size, major vessel invasion, capsule formation, intrahepatic metastasis, cirrhosis, and the pathological stage were independent prognostic factors for recurrence-free survival. CONCLUSIONS: Survival of patients with HCC after resection should be stratified by various perioperative clinicopathological factors. Platelet count and intraoperative EBL could be considered as one of the powerful predictors of the prognosis and recurrence of HCC in such patients.

Celiac axis stenosis as a rare but critical condition treated with pancreatoduodenectomy: report of 2 cases.

We describe 2 cases of patients with loss of hepatic arterial flow during surgery for pancreatic head cancer due to celiac stenosis caused by median arcuate ligament compression. The first case underwent pylorus-resecting pancreatoduodenectomy for pancreatic head cancer. After resection of the gastroduodenal artery, flow in the common hepatic artery disappeared, and celiac axis stenosis was identified. Interventional stent insertion was attempted, however, it failed due to the acute angle of the celiac orifice (os). This problem was resolved by arterial reconstruction. The second case underwent pylorus-preserving pancreatoduodenectomy for pancreatic head cancer and the same phenomenon occurred during the procedure. Interventional stent insertion was also tried; in this patient, however, it failed due to the acute angle of the celiac os. The problem was resolved by changing a femoral approach to a brachial approach, and the stent was inserted into the celiac os successfully.

High-dose hepatitis B immunoglobulin therapy in hepatocellular carcinoma with hepatitis B virus-DNA/hepatitis B e antigen-positive patients after living donor liver transplantation.

AIM: To investigate the impact of high-dose hepatitis B immunoglobulin (HBIG) on hepatocellular carcinoma (HCC) and hepatitis B virus (HBV) recurrence and overall survival after living donor liver transplantation (LDLT). METHODS: We investigated 168 patients who underwent LDLT due to HCC, and who were HBV-DNA/hepatitis B e antigen (HBeAg) -positive, from January 2008 to December 2013. After assessing whether the patients met the Milan criteria, they were assigned to the low-dose HBIG group and high-dose HBIG group. Using the propensity score 1:1 matching method, 38 and 18 pairs were defined as adhering to and not adhering to the Milan criteria. For each pair, HCC recurrence, HBV recurrence and overall survival were analyzed by the Kaplan-Meier method and the log rank test according to the HBIG dose. RESULTS: Among those who met the Milan criteria, the 6-mo, 1-year, and 3-year HCC recurrence-free survival rates were 88.9%, 83.2%, and 83.2% in the low-dose HBIG group and 97.2%, 97.2%, and 97.2% in the high-dose HBIG group, respectively (P = 0.042). In contrast, among those who did not meet the Milan criteria, HCC recurrence did not differ according to the HBIG dose (P = 0.937). Moreover, HBV recurrence and overall survival did not differ according to the HBIG dose among those who met (P = 0.317 and 0.190, respectively) and did not meet (P = 0.350 and 0.987, respectively) the Milan criteria. CONCLUSION: High-dose HBIG therapy can reduce HCC recurrence in HBV-DNA/HBeAg-positive patients after LDLT.

Torsion of a parasitic myoma that developed after abdominal myomectomy.

Iatrogenic parasitic myomas are rare. The condition is defined by the presence of multiple smooth-muscle tumorous nodules in the peritoneal cavity. This may be attributable to seeding of myoma particles during uterine surgery. The clinical course is usually indolent. The disease is often asymptomatic and is usually discovered only incidentally. A 38-year-old woman who had undergone abdominal myomectomy 7 months prior presented with acute abdominal pain and a huge pelvic mass. We performed exploratory laparotomy. A parasitic mass 17 cm in diameter with a twisted omental pedicle was identified. En bloc excision of the mass and omentum was performed, followed by total abdominal hysterectomy. Histopathological examination of multiple sections revealed features compatible with an infarcted leiomyoma. Thus, we present a very rare case of an iatrogenic, rapidly growing parasitic myoma complicated by omental torsion (which caused the acute abdominal pain). We also offer a literature review.

Clinicopathological features and prognosis of combined hepatocellular carcinoma and cholangiocarcinoma after surgery.

BACKGROUND: Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is a rare subtype of primary liver cancer consisting of both hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC). Because of the rarity of this tumor, its feature is poorly understood. The present study aimed to evaluate the clinicopathological features and long-term prognosis of patients with cHCC-CC after surgery and to compare with those of the patients with stage-matched HCC and CC. METHODS: The clinicopathological features of the patients who underwent surgery for cHCC-CC at our center during the period of 2001-2010 were retrospectively analyzed and compared with those of stage-matched HCC and CC patients. Cancer staging was performed according to the AJCC Cancer Staging Manual (6th ed.). Overall survival and disease-free survival were compared among the groups and prognostic factors of cHCC-CC were evaluated. RESULTS: Significant differences were observed in clinicopathological features among 42 patients with cHCC-CC, 90 patients with HCC and 45 patients with CC. Similar to HCC patients, cHCC-CC patients had frequent hepatitis B virus antigen positivity, microscopic vessel invasion, cirrhosis and high level of serum alpha-fetoprotein. Similar to CC patients, cHCC-CC patients showed increased bile duct invasion and decreased capsule. The 1-, 3-, and 5-year overall survival and disease-free survival of patients with cHCC-CC were not significantly different from those with stage-matched patients with CC; but significantly poorer than those with HCC. In subanalysis of patients with stage II, the overall survival in patients with cHCC-CC or CC was significantly poorer than that in patients with HCC. We did not find the difference in patients with other stages. Univariate analysis of overall and disease-free survival of patients with cHCC-CC showed that the vascular invasion and intrahepatic metastasis were the significant predictive factors. CONCLUSION: Patients with cHCC-CC showed similar clinicopathological features as those with HCC or CC, and patients with cHCC-CC or CC had a poorer prognosis compared with those with HCC, especially at matched stage II.

Pretransplant absolute monocyte count in peripheral blood predicts posttransplant tumor prognosis in patients undergoing liver transplantation for hepatocellular carcinoma.

BACKGROUND: Preoperative absolute monocyte count in peripheral blood (AMCPB) is closely associated with prognoses in not only various malignancies but also hepatocellular carcinoma (HCC). The purpose of this study was to evaluate whether pretransplant AMCPB predicts posttransplant outcomes in patients with HCC undergoing liver transplantation (LT). METHOD: We retrospectively analyzed relationships between clinicopathologic factors involving pretransplant AMCPB and tumor recurrence or survival in 256 patients who had undergone LT for HCC between January 2005 and April 2012. RESULTS: ROC curve analysis showed that AMCPB >200/mm(3) was a risk factor for tumor recurrence; 43 patients showed higher AMCPB (>200/mm(3)), whereas 213 showed lower AMCPB (≤200/mm(3)) at the time of LT. On multivariate analysis, pretransplant high AMCPB, positive findings in pretransplant (18)F-FDG PET/CT, pathological maximal tumor size >5 cm, intrahepatic metastasis, moderately or poorly differentiated tumor and microvascular invasion were independent factors affecting recurrence-free survival. When we performed subgroup analysis based on the Milan criteria, high AMCPB was an independent factor for predicting HCC recurrence in patients with tumor beyond the Milan criteria (P=0.004), and not for patients within the criteria. CONCLUSION: This study demonstrated that pretransplant AMCPB could predict tumor recurrence after LT for HCC, especially in patients with tumor beyond the Milan criteria.

Prognostic significance of preoperative peripheral blood monocyte ratio in patients with hepatocellular carcinoma.

BACKGROUND: Leukocyte subsets in peripheral blood, which include neutrophils, lymphocytes, and monocytes, have not been well established as prognostic factors in patients with hepatocellular carcinoma (HCC). METHODS: Consecutive patients who underwent curative hepatic resection for HCC at the National Cancer Center, Republic of Korea, from 2001 to 2008 were enrolled in this retrospective study. Clinicopathologic factors, cancer-specific survival (CSS), and disease-free survival (DFS) were analyzed with respect to preoperative lymphocyte subsets, especially monocyte ratio. RESULTS: The 603 patients had a median follow-up of 40.0 months and a 5-year overall survival rate of 67.7 %. In univariate analysis of survivals, preoperative lymphocyte ratio ≤35 % and monocyte ratio >7 % were significantly poor prognostic factors. In multivariate analysis, preoperative monocyte ratio >7 %, satellite nodule, and microvascular invasion were independent risk factors for CSS and DFS (hazard ratio of monocyte ratio >7 % = 1.77, p = 0.02 and 1.57, p = 0.006, respectively). Considering monocyte ratio with preoperative α-fetoprotein level, patients with both abnormal α-fetoprotein levels (>12 ng/mL) and monocyte ratio >7 % showed significantly worse CSS and DFS than other groups (p < 0.001). Cirrhotic patients with monocyte ratio >7 % showed significantly poor CSS and DFS compared with non-cirrhotic patients (p = 0.033 and <0.001, respectively). CONCLUSIONS: A preoperative monocyte ratio >7 % of peripheral blood is an independent risk factor for CSS and DFS after hepatic resection for HCC. Preoperative monocyte ratio might be considered as a novel biomarker for HCC.

Graft-to-recipient weight ratio lower to 0.7% is safe without portal pressure modulation in right-lobe living donor liver transplantation with favorable conditions.

BACKGROUND: The low graft-to-recipient weight ratio (GRWR) in adult-to-adult living donor liver transplantation (LDLT) is one of the major risk factors affecting graft survival. The goal of this study was to evaluate whether the lower limit of the GRWR can be safely reduced without portal pressure modulation in right-lobe LDLT. METHODS: From 2005 to 2011, 317 consecutive patients from a single institute underwent LDLT with right-lobe grafts without portal pressure modulation. Of these, 23 had a GRWR of less than 0.7% (group A), 27 had a GRWR of ≥0.7%, <0.8% (group B), and 267 had a GRWR of more than and equal to 0.8% (group C). Medical records, including recipient, donor, operation factors, laboratory findings and complications were reviewed retrospectively. RESULTS: The baseline demographics showed low model for end-stage liver disease score (mean 16.3+/-8.9) and high percentage of hepatocellular carcinoma (231 patients, 72.9%). Three groups by GRWR demonstrated similar characteristics except recipient body mass index and donor gender. For small-for-size syndrome, there were 3 (13.0%) in group A, 1 (3.7%) in group B, and 2 patients (0.7%) in group C (P<0.001). Hepatic artery thrombosis was more frequently observed in group A than in groups B and C (8.7% vs 3.7% vs 1.9%, P=0.047). However, among the three groups, graft survival rates at 1 year (100% vs 96.3% vs 93.6%) and 3 years (91.7% vs 73.2% vs 88.1%) were not different (P=0.539). In laboratory measurements, there was no group difference in total bilirubin and albumin. However, prothrombin time was longer in group A within postoperative 1 week and platelet count was lower in groups A and B within postoperative 1 month. CONCLUSION: A GRWR lower to 0.7% is safe and does not need to modulate portal pressure in adult-to-adult LDLT using the right-lobe in favorable conditions including low model for end-stage liver disease score.

ABO-incompatible living donor liver transplantation without graft local infusion and splenectomy.

BACKGROUND: Graft local infusion and splenectomy in ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) are associated with high rates of operative complications. METHODS: Consecutive ABO-I LDLT patients treated at the National Cancer Centre between January 2012 and February 2013 were identified. The protocol for ABO-I LDLT at the study centre included the administration of rituximab (300 mg/m(2)) at 2 weeks preoperatively, followed by plasma exchanges (target isoagglutinin titre: ≤ 1:8), basiliximab (20 mg on the day of surgery and on postoperative day 4), and i.v. immunoglobulin (0.8 g/kg on postoperative days 1 and 4) without graft local infusion or splenectomy. RESULTS: Fifteen patients (11 men and four women) who underwent transplantation for liver cirrhosis (n = 3) or hepatocellular carcinoma (n = 12) were identified. These included 13 patients with hepatitis B virus infection, one with hepatitis C virus infection and one with alcoholic cirrhosis. The mean age, mean Model for End-stage Liver Disease (MELD) score and mean graft-to-recipient weight ratio (GRWR) of these patients was 51.8 years, 11.5 and 0.84, respectively. The median isoagglutinin titre before plasma exchange was 1:32 (range: 1:4 to 1:256). There were no hyperacute or antibody-mediated rejections. No bacterial or fungal infections were observed. Complications included herpes zoster viral infection in one patient, postoperative bleeding in one patient and extrahepatic biliary stricture in three patients. CONCLUSIONS: This simplified ABO-I LDLT protocol showed good graft outcomes without immunologic failure or serious infections.

Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases.

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.

Clinical significance of portal-superior mesenteric vein resection in pancreatoduodenectomy for pancreatic head cancer.

OBJECTIVES: The purpose of this study was to determine the significance of portal vein-superior mesenteric vein (PV-SMV) invasion on survival in patients who underwent margin-negative pancreatoduodenectomy (PD) with PV-SMV resection for pancreatic adenocarcinoma. METHODS: We retrospectively reviewed the records of 60 patients who underwent margin-negative PD with or without PV-SMV resection for pancreatic adenocarcinoma between August 2001 and December 2007. The depth of vessel invasion was investigated and was categorized into 3 groups: tunica adventitia, media, and intima. Clinicopathologic factors and survival were analyzed. RESULTS: Portal vein-superior mesenteric vein resection was performed on 19 patients, but only 15 patients (78.9%) had histologically true invasion and showed poorer survival (median survival, 14 vs 9 months; P < 0.05). Univariate analysis revealed that poorly differentiated tumor, lymphatic invasion, endovascular invasion, PV-SMV invasion, and invasion into the intima of PV-SMV were statistically significant. Poorly differentiated tumor and invasion into the intima of PV-SMV were significant in multivariate analysis. CONCLUSIONS: Aggressive surgical resection should be attempted in cases with suspected PV-SMV invasion because 21.1% of patients had no true invasion and showed better survival than those with true invasion. However, invasion into the tunica intima may be a poor prognostic factor for survival even after margin-negative PD for pancreatic adenocarcinoma.

Failure of uterine artery embolization for controlling postpartum hemorrhage.

AIM: We evaluated the efficacy of uterine artery embolization (UAE) for controlling postpartum hemorrhage (PPH). MATERIALS AND METHODS: Between January 2008 and December 2009, 23 women with intractable PPH underwent UAE. Specific diagnoses included uterine atony (n = 10), placenta accreta (n = 8), puerperal hematoma (n = 2) and placental polyp (n = 3). RESULTS: Of 10 patients with uterine atony, treatment with UAE failed in two women with severe vasoconstriction. One patient developed lumbosacral plexopathy. All eight patients with placenta accreta were treated successfully with the placement of multiple sutures in the placental bed and UAE. Two of the three women with placental polyps were treated successfully with UAE and packing of the uterus. CONCLUSIONS: Embolization should follow resuscitation for vascular collapse. In the case of an adherent placenta, embolization is more effective with the placement of multiple sutures in the placental bed or compression of the placental bed.

Survival analysis of intrahepatic cholangiocarcinoma after resection.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy, but the studies for the outcome after resection of ICC are rare. The aim of this study was to elucidate outcomes and prognostic factors of ICC in patients undergoing hepatic resection. METHODS: A retrospective study was conducted with a total of 63 patients who underwent surgical resection with curative intent for ICC. We performed the survival analysis with preoperative and postoperative clinicopathologic factors according to the clinical outcome. RESULTS: The cumulative 1-, 3-, and 5-year survival rates were 68.2, 50.5, and 31.8%, respectively. Univariate analysis revealed that patient's old age, high preoperative carbohydrate antigen 19-9 (CA19-9) level, major vessel invasion, T classification, lymph node metastasis, lymphatic invasion, perineural invasion, intrahepatic metastasis, and narrow resection margin were statistically significant. By multivariate analysis, patient's old age, high preoperative CA19-9 level, lymphatic invasion, and narrow resection margin were independent dismal prognostic factors. The preoperative CA19-9 level shows a significant correlation with some histopathologic factors including major vessel invasion, bile duct invasion, and perineural invasion. CONCLUSIONS: Preoperative CA19-9 level was a valuable clinical factor for predicting histopathologic invasiveness as well as clinical outcome. An adequate resection margin was the only modifiable factor by a surgeon during hepatic resection for ICC.

Learning curve for living-donor liver transplantation in a fledgling cancer center.

Hepatocellular carcinoma (HCC) has become one of the main indications for liver transplantation. To keep abreast of the times, a comprehensive cancer center may have to perform liver transplantation as a treatment option for HCC. We introduce a learning curve for living-donor liver transplantation(LDLT) and present our initial experience in a new cancer center as an example to any center considering LDLT. A total of 51 consecutive adult right liver LDLTs performed from January 2005 to January 2008 were analyzed by comparing the first 17 transplants performed with the help of an outside experienced team (group 1) with the middle 17 (group 2) and the last 17 cases(group 3) performed in our center independently. There was no hospital mortality in donors and recipients. In a mean follow-up of 34 months (range: 12-48 months), there was only one case of late mortality in donor and recipient,respectively. A total of four donors and 12 recipients underwent re-operations.The warm ischemic time was significantly longer in group 2 than that in groups 1 and 3. Otherwise, there was no significant difference in the operative outcomes among the three groups. Thorough preparation and the assistance of an experienced liver transplantation team at the beginning can facilitate a more rapid learning curve and bring about a good outcome even in a small, newly established institution.