Transilluminated Powered Phlebectomy under Local Anesthesia

PURPOSE: Transilluminated powered phlebectomy (TIPP) has emerged as a very attractive surgical procedure for varicose vein because of it's many advantages. However, it also has some problems such as hematoma, and skin perforation, and needs general or spinal anesthesia and hospitalization. To overcome these shortcomings, we performed TIPP under only local anesthesia using the tumescent method. METHOD: Eleven (12 limbs) patients were operated and we prospectively estimated the operative complication, pain, duration of hospital stay, side effects and amounts of lidocaine. Lidocaine was infiltrated for groin dissection, and tumescent anesthesia was used on the calf area for TIPP. Great saphenous veins were stripped in 9 limbs, and closed suction drains were inserted in the calf area in 11 limbs. We calculated the amounts of lidocaine, according to the unit area of TIPP, body weight, and body surface area. RESULT: The mean age of the 11 patients was 55.4+/-10.7 years, and 3 patients (27.3%) had risk factors for general anesthesia. Mean operation time was 54.9+/-9.2 minutes, the number of incisions including groin was 4.7+/-0.6, and the area of TIPP was 272.6+/-85.3 cm2. The total lidocaine used was 495.4+/-167.5 mg (1.45 mg/cm2, 8.3 mg/kg, 302.1 mg/BSA m2). Except 2 patients (16.6%) who complained of mild pain and 2 of hematoma (16.6%), there were no side effects of lidocaine or operative complication. Mean hospital stay was 5.8+/-1.4 hours. CONCLUSION: TIPP under local anesthesia might be a relative safe method, and it could reduce the risks and complications of general or spinal anesthesia, hospital stay, and hesitancy to operation.

Massive Subcutaneous Emphysema and Hypercarbia during Endoscopic Thyroidectomy: A case report / 대한마취과학회지

Endoscopic thyroidectomy is being performed increasingly, because it is less invasive and more cosmetically advantageous, and thus improves the postoperative quality of life. However, the technical aspects of this procedure can increase the risk of certain complications, which include subcutaneous emphysema, hypercarbia, pneumothorax, and pneumomediastinum. This report describes the case of a 37-year-old female patient who had subcutaneous emphysema and hypercarbia due to increased carbon dioxide absorption during endoscopic thyroidectomy. After increasing minute ventilation, paying cautious attention to signs of other complications, the operation proceeded and blood gas findings improved. The operation ended successfully and she showed no further problems.

Preoperative Chemoradiation and Pancreaticoduodenectomy with Portal Vein Resection for Localized Advanced Pancreatic Cancer

Pancreatic adenocarcinoma is a common disease that is rarely cured. Surgical resection remains the only treatment modality that has a curative potential, although the majority of patients are unsuitable for resection at the time of diagnosis. Chemoradiation therapy prior to a pancreaticoduodenectomy ensures that a patient who undergoes a complete resection multimodality therapy, avoids a resection in patients who have a rapidly progressive disease, and allows radiation therapy to be given to well oxygenated cells before, surgical devasculation. This permits the chance of resection of an unresectable pancreatic cancer by downstaging. A patient with cytologic proof of localized adenocarcinoma of the pancreatic head received an intravenously chemoradiation (Taxol, 50 mg/m2 intravenously for 3 hours week on 5 cycles, of Gemcytabine 1000 mg/m2/day intravenously for 3 days week on 2 cycles, of 4500 cGy) with the intention of proceeding to a resection operation, restaging was performed by computed tomography, magnetic resonance imaging from 5 weeks every months due to ongoing decreasing of tumor size after the chemoradiation. At laparotomy, the patient didn't have suspected metastatic disease, the tumor size was 2 x 3 cm on the pancreas head and was infiltrating into the portal vein for about 3 cm length on right side. A pancreaticoduodenectomy along with a portal vein and superior mesenteric vein resection was done and then reconstruction of a vascular anastomosis by using the right side of the internal jugular vein. Perioperative complications didn't occur. In conclusion, preoperative chemoradiation of a localized advanced pancreatic tumor has no added risk to the operative complications and the prospects for resectability are enhanced.

Percutaneous Cholecystostomy Using Central Venous Catheterization Set with Blue FlexTip Catheter / 한국간담췌외과학회지

PURPOSE: Percutaneous cholecystostomy (PC) using a pig-tail catheter is indicated for high risk acute cholecystitis. However, this procedure is time consuming, expensive and requires radiological equipment. This study compared PC using a pig-tail catheter with central venous catheterization set. METHODS: From January 1992 to June 2003, 44 patients underwent PC without a malignancy or a combined hepato- biliary-pancreatic disease were selected. A retrospective study was performed on the time interval to procedure, cost, complications and therapeutic results of the central venous catheter group (A, 15) and the pig-tail catheter group (B, 29) RESULTS: The time interval was 1.8 days in group A, 3.52 in group B (p=0.002). The cost was 188,684 won in group A, 327,814 won in group B. There were 4 complications in group A (2 leakage, 1 dislodgment, 1 malfunction) while 5 in group B (2 dislodgement, 1 sepsis, 2 malfunction). Although PC, 2 in group A and 5 in group B were discharged hopelessly or died due to the progression of the underlying disease. Twenty-two patients underwent a delayed cholecystectomy with 7 patients in group A (3 laparoscopy, 4 open) and 15 in group B (6 laparoscopy, 8 open, 1 conversion to open). The complication rate was slightly high in group A but there were no statistical significance, no clinical problems and no difference in the mortality rate and surgical method. CONCLUSION: In high risk acute cholecystitis, PC using central venous catheter is easy, economic, effective and performed at early stage in the emergency room by medical doctors or surgeons.

Metastatic Renal Cell Carcinoma of the Gallbladder

Metastatic renal cell carcinoma is renowned for its potency to spread to almost any organ of the body; however metastasis to the gall bladder is very rare. We present a case of a 48 year old man who initially demonstrated renal cell carcinoma, and in who gallbladder metastasis was later detected. A review of the literature revealed only a small number of cases of renal cell carcinoma metastasizing to the gallbladder, and these were primary found upon necropsy. Gall-bladder metastasis in this case was detected clinically.

Clinical Analysis of CA19-9 Positive Rate of Hepatobiliary Pancreas Disease

PURPOSE: CA19-9 is the most widely used pancreatic-tumor marker, and has become the standard against which other makers. However, the CA19-9 level is increased in conditions such as gallbladder cancer, cholangiocarcinoma, hepatocellular carcinoma, gallbladder polyp, acute cholangitis, and chronic pancreatitis. Therefore, this study aimed to determine the CA19-9 positive rate of the above diseases in Korea. METHODS: A positive result was considered if the upper limit of normal was 37~40 U/ml. The CA19-9 level was measured in 53 patients with pancreatic cancer, 72 with cholangiocarcinoma, 41 with common bile duct cancer, 27 with gallbladder cancer, 35 with hepatocellular cancer, 70 with acute pancreatitis, 93 with chronic pancreatitis, and 30 with a gallbladder polyp from September 1998 to December 2000 in the Severance hospital. RESULTS: When the cut-off value was >40 U/ml, a positive result was found in 79.2% (42/53) of pancreatic cancer patients, 58.3% (42/72) of cholangiocarcinoma patients, 37% (10/27) of gallbladder cancer patients, 31.7% (13/41) of common bile duct cancer patients, 19.7% (14/70) of acute pancreatitis patients, 14.2% (5/35) of hepatocellular cancer patients, 16% (5/93) of chronic pancreatitis patients, and the 3.3% (1/30) of patients with a gallbladder polyp. CONCLUSION: The highest positive rate was 79.2% in the pancreatic cancer patients. We confirmed that the Lewis phenotype distribution indieates that pancreatic cancer, cholangiocarcinoma, and chronic pancreatitis show high frequency in Le(a-b-) group when they were statistically compared with a healthy control group, but that acute pancreatitis showed a stastically higher frequency in the Le(a-b-) group than chronic pancreatitis.

Thoracoscopic Splanchnicectomy for the Relief of Intractable Upper Abdominal Cancer Pain

PURPOSE: Pain is the most distressing feature of cancer patients. Thoracoscopic splanchnicectomy, first performed in 1993, has caused a resurgence of interest in surgical treatment of such excruciating pain. We wish to introduce a method of splanchnicectomy. METHODS: Five patients underwent a splanchnicectomy for intractable cancer pain, over a period of 11 months. We evaluated the type of splanchnicectomy performed and the results. The procedure was done using a double lumen catheter to deflate the lung at the operation side under general anesthesia with the patient in the lateral decubitus position. A small opening was made with scissors in the pleura of the 5th intercostal space to expose the terminal branch of the greater splanchnic nerve. Six-Seven branches of splanchnic nerve were cut downward until the splanchnic nerve trunk and then cut. A left thoracoscopic splanchnicectomy was done in one case, and a bilateral thoracoscopic splanchnicectomy in four cases. RESULTS: The splanchicectomy appears to result in significant reduction of abdominal pain in all cases. There were no postoperative complications. CONCLUSION: As a conclusion, thoracoscopic splanchnicectomy is the treatment of choice for intractable intraabdominal cancer pain, affording drug cessation and recovery of daily activity in most patients.

Preoperative Chemoradiation and Pancreaticoduodenectomy with Portal Vein Resection for Localized Advanced Pancreatic Cancer

PURPOSE: Chemoradiation therapy prior to pancreaticoduodenectomy has several effects. First, it ensures that patient who undergo resection subsequently complete multimodality therapy and helps to avoid resection in patients with rapid progressive disease. Second, it allows radiation therapy to be delivered to well oxygenated cells before surgical devasculation. Finally, in such cases there is a chance of resection of unresectable pancreatic cancer by downstaging. METHODS: A patient with cytologic proof of localized adenocarcinoma of the pancreatic head recieved preoperative chemoradiation (Taxol, 50 mg/m2 IV for 3 hours weekly 3 cycles, Gemcytabine 1,000 mg/m2/day IV for 3 days weekly 2 cycles, 4,500 cGy) with the intent of proceeding to resection, Restaging was performed by computed tomography and magnetic resonance imaging every months from 5 weeks due to the ongoing decreasing of tumor size following the completion of chemoradiation. Upon laparotomy, the patient was found to not have any suspected metastatic disease and the tumor size was 2 3 cm on the pancreas head infiltrating to the portal vein approximately 3 cm in length along right side. Pancreaticoduodenectomy was performed with partial portal vein and superior mesenteric vein resection followed by reconstruction of the vascular anastomosis by using the right side internal jugular vein. Perioperative complication did not occur. RESULTS AND CONCLUSION: Preoperative chemoradiation of localized advanced pancreatic has a low incidence of operative complication and enhanced resectability.

Hepatocellular Carcinoma Metastatic to Brain

The most common metastatic site of a hepatocellular carcinoma is the lung, followed by the adrenal gland, inferior vena cava, bone, diaphragm in that order. However hepatocellular carcinoma metastasizing to the brain is rare. Only 7 cases has been reported in Taiwan. A metastatic brain tumor was excised and a hepatocellular carcinoma was treated by a left lateral segmentectomy. Adjuvant chemotherapy (5-FU, adriamycin) was added, and carcinoma was followed up for 10 months without recurrence. Here report a case of hepatocellular carcinoma metastasizing to the brain. with a review of the relevant literature.

Stability and Safety of Laploop under the Endoscopic Surgery of Rabbits / 한국간담췌외과학회지

BACKGROUND/AIMS: Along with the expansion of the field of laparoscopic surgery, many laparoscopic instruments have been developed and these all together made laparoscopic surgery possible in many operative procedures which used to be considered impossible to be done using a laparoscope. Suturing is a technique quite often required during laparoscopic surgery and so far we have used imported suture material. In this article, we have compared the safety and harmfulness of suture material developed domestically in Korea with those imported using house rabbits. METHODS: A total of 40 white house rabbits from New Zealand weighing 3.0-3.4 Kg were used from July 1, 2000 until April 30, 2001. Under general anesthesia, we created a pneumoperitoneum using a veress needle with a pressure of 10 mmHg followed by insertion of a 5mm laparoscope right above the umbilicus and two 5mm trocars were inserted in the right and left midclavicular lines 5cm below the costal margin. After perforating the pylorus of the stomach using laparoscopic scissors, we sutured two sites using Laploop and then perforated the body of the stomach and again sutured two sites but this time using Vicryl #3-0 for comparison with Laploop. 10 house rabbits were sacrificed each on post operation days 10, 20, 30 and 40 and tissues obtained from those house rabbits were compared using the Sewell method. RESULTS: Suturing and ties were done without any problems and there were no postoperative complications or deaths. On postoperation days 10 and 20, Laploop showed a moderate degree of tissue reaction proved by a Sewell score of 57 and 48 respectively and on postoperation days 30 and 40, a mild to moderate degree of tissue reaction occurred with a S score of 36 and 33 respectively. In models using Vicryl, the S scores were 67 an 62 on postoperation days 10 and 20 respectively showing a moderate degree of tissue reaction and on postoperation days 30 and 40, it showed a mild to moderate degree of tissue reaction with a S score of 52 and 44 respectively which is similar to the results obtained by Laploop. CONCLUSION: Imported Vicryl and Laploop were both applicable in terms of biologic compatibility but Laploop was easier to apply, more cost effective compared to Vicryl but most of all, there were no complications such as a loosening of a knot or a knot being undone. Therefore it could be concluded that Laploop shows a promising future as a suture material in laparoscopic surgery.

Clinical Efficacy and Safety of Intravenous levofloxacin in Patients of Abdominal Operati / 한국간담췌외과학회지

BACKGROUND/AIMS: For the investigation of the efficacy and safety of intravenous levofloxacin, The clinical study was carrried out in 30 patients with abdominal operation, especially in hepatobiliary and pancreatic division. METHODS: Randomly chosen patients received intravenous levofloxacin (250mg bid) for only 7 days. Clinical and microbiological evaluation were conducted on the day of starting and finishing levofloxacin treatmeat except for the case of combined use of antibiotics. RESULTS: The most commonly isolated organism was staphylococcus aureus(33%, 3/9). The overall bacteriologic eradication rate was 67%, (6/9) with clinical success rate was 96%(29/30), There were no significant dverse effects to stop the administration of the drug. CONCLUSION: These results suggest that intravenous levofloxacin is effective and safe antibiotics in the fields management of abdominal operation especially in hepatobiliary and pancreas surgery.

The Effect of Lipo-PGE1 in Canine Partial Liver Allograft Model / 대한이식학회지

PURPOSE: Hepatoprotective effect of prostaglandin E1 (PGE1) has been verified in numerous animal experiments but not so apparent in clinical trials. Although the reason for this discrepancy in clinical results is still unknown, one possible explanation is the instability of PGE1. In this study, the hepatoprotective effect of lipo-PGE1, which is known to be stable during pulmonary circulation and have more targeting effect, was investigated in canine partial liver allotansplantation. In order to reckon in the possible injury during harvest of partial liver, lipo-PGE1 was infused from the start of living graft harvest procedure. METHODS: Mongrel dogs weighing about 25 kg were divided into control (n=6) and lipo-PGE1 (n=6) group. Partial liver allotransplantation was performed. In lipo-PGE1 group, lipo-PGE1 was slowly infused through splenic venous cannulation during the donor liver harvesting procedure (50 mg) and continuously infused (60 mg/day) for 48 hrs after reperfusion. The aspartate aminotransferase (AST), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH) were monitored. RESULTS: The AST and ALP levels of the lipo-PGE1 group were significantly lower than that of the control group at both 1 hour and 48 hours after reperfusion. The LDH level in lipo-PGE1 group was lower at 1 hour and 48 hours after reperfusion, but no significant differences were shown between two groups. CONCLUSION: This study demonstrated the hepatoprotective effect of the lipo-PGE1 against ischemia-reperfusion injury in canine partial liver allotransplantation.

Liver Pathology after Transplantation of Short-Term Preserved Canine Liver with Euro-Collins or UW Solution / 대한이식학회지

PURPOSE: In living donor partial liver transplantation, the organ cold preservation time is relatively short, thereby, Euro-Collins (EC) solution could be used with comparable result to University of Wisconsin (UW) solution. METHODS: About 70% partial liver was harvested and reimplanted after 3.5 hours of cold preservation with EC or UW solution in same mongrel dog weighing about 25 kg. In 5 cases EC solutions were used, and UW solutions were used in another 5 cases. Blood sample and liver biopsy specimens were taken just before donor hepatectomy, postreperfusion 1 hour, 7 days and 14 days after operation. Serum aspartate aminotransferase (AST), alkaline phosphatase (ALP), and lactate dehydrogenase (LDH) were monitored, and morphologic grading of liver injury was performed as Spiegel et al. reported in 1999. RESULTS: Total ischemic time was 4 hours and 27 minutes in average. At 1 hour after reperfusion, there were no significant differences in liver enzyme and morphological score between the UW solution group and the EC group. Survival rate was similar in two groups; 2 dongs were alive at postoperative 7th day, and 1 dog was alive at postoperative 14th day in each group. CONCLUSION: In living donor partial liver transplantation where both operations could be performed simultaneously with relatively short graft preservation time, EC solution could be used with comparable results to UW solution.

A Case Report of Agenesis of Gallbladder which was Diagnosed after an Emergent operation Due to Ostructive Jundice with Impacted CBD Stones

A case of Agenesis of gallbladder in 73-year old female patient who had an emergent operation due to obstructive jaundice with impacted CBD stones is reported. The patient suffered from icteric sclera and abdominal pain which waxed and waned for three days. Impacted CBD stones and an agenesis of the gallbladder was suggested by a computed tomogram of the abdomen. In the operating field, multiple adhesions around the biliary tree was noticed, but we could not find the gallbladder and cystic duct. She underwent choledocholithotomy, T-tube choledochostomy, operative cholangiography, and drainage. Operative cholangiogaphy showed no remained stones, and there was no structures suggesting gallbladder and cystic duct. The authors described the case with a recent review from the literature.