Overexpression of PD-L1 and PD-L2 Is Associated with Poor Prognosis in Patients with Hepatocellular Carcinoma / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Hepatocellular carcinoma (HCC) is one of the most aggressive malignancies. Recently, the overexpression of programmed cell death 1 (PD-1) and PD-1 ligand 1 (PD-L1) has been shown to correlate with poor prognosis in many cancers. However, the expression of PD-L1 or PD-1 ligand 2 (PD-L2) and clinical outcomes have not been fully investigated in HCC. MATERIALS AND METHODS: Formalin-fixed paraffin-embedded samples were obtained from 85 patients with HCC who underwent surgery. The expression of PD-Ls (PD-L1, PD-L2) was evaluated by immunohistochemical analysis. RESULTS: The proportion of high expression groups of PD-L1 and PD-L2 was 27.1% and 23.5%, respectively. Univariate analysis revealed that tumor size (p < 0.001), histological differentiation (p=0.010), PD-L1 expression (p < 0.001), and PD-L2 expression (p=0.039) were significant prognostic factors of overall survival in patients with HCC. Multivariate analysis revealed that overall tumor size (hazard ratio [HR], 4.131; 95% confidence interval [CI], 2.233 to 7.643; p < 0.001 and HR, 3.455; 95% CI, 1.967 to 6.067; p < 0.001) and PD-L1 expression (HR, 5.172; 95% CI, 2.661 to 10.054; p < 0.001 and HR, 3.730; 95% CI, 1.453 to 9.574; p=0.006) were independent prognostic values for overall and disease-free survival. Patients with high expression of PD-Ls had a significantly poorer survival than those with low expression (p < 0.001, p=0.034). CONCLUSION: The overexpression of PD-Ls in HCC patients is correlated with survival and tumor recurrence. Further evaluation of PD-1 and PD-Ls as therapeutic targets and predictive biomarkers for HCC is warranted.

Long-term results of oncoplastic breast surgery with latissimus dorsi flap reconstruction: a pilot study of the objective cosmetic results and patient reported outcome

PURPOSE: The goal of oncoplastic breast surgery is to restore the appearance of the breast and improve patient satisfaction. Thus, the assessment of cosmetic results and patient-reported outcomes (PROs) using appropriately constructed and validated instruments is essential. The aim of the present study was to assess the long-term objective cosmetic results and corresponding PROs after oncoplastic breast surgery. METHODS: Cosmetic results were assessed by the patients, a medical panel, and a computer program (BCCT.core). PROs were assessed using BREAST-Q, a questionnaire that measures the perception of patients having breast surgery. The cosmetic results and PROs were analyzed in patients who underwent quadrantectomy and partial breast reconstruction utilizing the latissimus dorsi flap. RESULTS: The mean duration of the follow-up period was 91.6 months (range, 33.3-171.0 months), and mean age of the patients was 51 years old (range, 33-72 years). The mean tumor size was 2.1 cm (range, 0.9-5.5 cm). There was fair agreement between the medical panel and BCCT.core score (K = 0.32, P < 0.001), and a statistically significant correlation between the BCCT.core score and medical panel cosmetic results was identified (r = 0.606, P < 0.001). A better BCCT.core result was related to a higher PRO of each BREAST-Q domain-satisfaction with breasts (R2 = 0.070, P = 0.039), satisfaction with outcome (R2 = 0.087, P = 0.021), psychosocial well-being (R2 = 0.085, P = 0.023), sexual well-being (R2 = 0.082, P = 0.029), and satisfaction with information (R2 = 0.064, P = 0.049). CONCLUSION: Our long-term results of oncoplastic surgery achieved a high level of patient satisfaction with good cosmetic results. The medical panel and BCCT.core results correlated well with the PROs of the patients using valid, reliable, and procedure-specific measures.

Spontaneous Rupture of Multiple Intrahepatic Cholangiocarcinoma in a Pregnant Patient

Spontaneous rupture of intrahepatic cholangiocarcinoma is rare due to its abundant fibrous stroma. We report our experience in a case of spontaneous rupture of intrahepatic cholangiocarcinoma in a pregnant patient. In our case, multiple hepatic masses with intratumoral hemorrhage were noted on post-delivery computed tomography and magnetic resonance imaging and they caused hemoperitoneum. A right hemi-hepatectomy was carried out to control the bleeding and the diagnosis of intrahepatic cholangiocarcinoma with metastasis was performed.

Astrocyte elevated gene-1 overexpression in hepatocellular carcinoma: an independent prognostic factor

PURPOSE: Astrocyte elevated gene-1 (AEG-1) plays important roles in tumorigenesis such as proliferation, invasion, metastasis, angiogenesis, and chemoresistance. We examined the expression of AEG-1 in patients with hepatocellular carcinoma (HCC). METHODS: Eighty-five samples were collected from patients with HCC who underwent surgery and were histopathologically confirmed to have HCC. Two independent pathologists, experienced in evaluating immunohistochemistry and blinded to the clinical outcomes of the patients, reviewed all samples. They determined AEG-1 expression semiquantitatively by assessing the percentage of positively stained immunoreactive cells and staining intensity. Clinicopathological data were analyzed in association with prognosis. RESULTS: The association was estimated by univariate and multivariate analyses with Cox regression. Tumor size (hazard ratio [HR], 2.285; 95% confidence interval [CI], 1.175-4.447; P = 0.015), microvascular invasion (HR, 6.754; 95% CI, 1.631-27.965; P = 0.008), and AEG-1 expression (HR, 4.756; 95% CI, 1.697-13.329; P = 0.003) were independent prognostic factors for overall survival. Those for disease-free survival rate were tumor size (HR, 2.245; 95% CI, 1.282-3.933; P = 0.005) and AEG-1 expression (HR, 1.916; 95% CI, 1.035-3.545; P = 0.038). The cumulative 5-year survival and recurrence rates were 89.2% and 50.0% in the low-expressing group and 24.5% and 82.4% in the high-expressing group, respectively. CONCLUSION: The results suggest that AEG-1 overexpression could serve as a valuable prognostic marker in patients with HCC.

Feasibility and outcomes of laparoscopic enucleation for pancreatic neoplasms

PURPOSE: With the advancement of laparoscopic techniques and instruments, laparoscopic approach for pancreatic lesions has become an increasingly used procedure. But, there are few and limited studies about laparoscopic enuleation (LE) for pancreatic lesions. Therefore, the purpose of this study was to present our experience and to evaluate the clinical outcome of LE for pancreatic benign or borderline malignant tumors. METHODS: Between May 2005 and December 2011, 11 patients who underwent LE were analyzed. Candidates for LE met the following criteria: benign or borderline malignant pancreatic tumor, no involvement of main pancreatic duct, and outwardly growing tumor with small tumor bed. RESULTS: All 11 patients (10 women and 1 man with a mean age of 43.1 +/- 11.9 years) who underwent LE were completed laparoscopically without conversion. The mean diameter of tumor was 4.0 +/- 3.3 cm and all cases had benign tumors at the final pathologic diagnosis. One patient (9%) developed pancreatic fistula and mean postoperative hospital stay was 5.5 +/- 1.7 days. During follow-up period (mean, 44.3 +/- 23.9 months), all patients were alive with no recurrence or new onset of diabetes. CONCLUSION: LE is a safe and effective procedure, and should be considered as a treatment option for pancreatic lesions that do not involve the main pancratic duct and have an outgrowing aspect with small tumor bed.

Segmental duodenectomy with duodenojejunostomy of gastrointestinal stromal tumor involving the duodenum / 대한외과학회지

Duodenal gastrointestinal stromal tumors (GISTs) are uncommon and a relatively small subset of GISTs whose optimal surgical procedure has not been well defined. Because submucosal spread and local lymph node involvement is infrequent in GISTs, wide margins with routine lymph node dissection may not be required. Various techniques of limited resection for duodenal GISTs have been described depending on the site and the size of the tumors. In this study, we report two cases of GIST involving the third and fourth portion of the duodenum successfully treated by segmental duodenectomy with end-to-end duodenojejunostomy. This technique should be considered as a treatment option for GIST located at the third and fourth portion of the duodenum.

Laparoscopic versus Open Appendectomy in Pregnancy / 대한내시경복강경외과학회지

PURPOSE: Although laparoscopic appendectomy is a safe and effective procedure for the management of acute appendicitis, laparoscopic appendectomy in pregnancy has not been considered the preferred procedure until recently. The aim of this study was to evaluate the safety of laparoscopic appendectomy (LA) during pregnancy as compared with the control group that underwent open appendectomy (OA) during pregnancy. METHODS: The clinical data of all the patients who underwent appendectomy during pregnancy at our hospital between 2006 and 2009 was collected and retrospectively analyzed. Nineteen patients underwent LA and 11 patients underwent OA. The general features of the cases, the outcomes and the fetal status were evaluated. RESULTS: There were no significant differences in the length of the procedure, the hospital stay and the complication rate between the LA and OA groups. All the laparoscopic procedures were completed without conversion to an open operation. There were no significant differences between the two groups for premature delivery, the delivery type and the birth weight. There were no fetal losses or abortions. CONCLUSION: Our results demonstrate that LA was not inferior to OA in terms of the operative outcomes, the complication and both the fetal and maternal safety during 1st and 2nd trimesters of pregnancy. LA could be safely performed even in the 1st and 2nd trimesters of pregnancy using careful patient selection, safe operative techniques and the appropriate application of instruments.

Steatotic Graft for Liver Transplantation / 대한이식학회지

It is common practice to reject potential grafts with fatty change over 30%. We report a case of successful liver transplant using a graft with 70% fatty liver. The patient was a 53 year old male with alcoholic liver cirrhosis who had received endoscopic varix ligation (EVL) for esophageal varix bleeding 4 months ago. He presented with esophageal varix bleeding and drowsy mentality, and was admitted to the ICU via the emergency room. He received EVL again. Preoperative total bilirubin was 11.4 mg/dl, prothrombin time was 40%. The donor was a 50 year old male with diabetes. Liver biopsy showed 70% fatty liver. The operation took 10 hours, and there was no intraoperative complication. Sixteen days after the operation, liver enzymes were normal but total bilirubin was elevated up to 10.26 mg/dl. Liver biopsy was done. Biopsy showed almost no fatty liver but it showed moderate rejection, so steroid recycling was done. Total bilirubin decreased steadily. But 38 days after the operation, ascites increased, and follow-up liver biopsy again showed almost no fatty change but showed severe rejection. Steroid pulse therapy was done, and after pulse therapy the amount of ascites decreased, and the patient was discharged 56 days after the transplantation in tolerable condition. Brain death donor liver grafts with severe fatty liver increase the risk of post transplant complications such as renal failure. But since severe fatty liver does not always cause primary nonfunction, it may be considered as transplant grafts in selected cases.

Gemcitabine-based Chemotherapy for Gallbladder Cancer

PURPOSE: Patients with gallbladder cancer tend to have advanced, unresectable tumor at the time of presentation and they face a dismal prognosis in the absence of a standard chemotherapy regimen. This study was performed to evaluate the outcomes of patients with gallbladder cancer and who underwent postoperative gemcitabine-based chemotherapy. METHODS: From March of 2001 to February of 2008, a total of 27 patients underwent operation for gallbladder cancer. They underwent two types of gemcitabine-based chemotherapy. One type of regimen was the combined administration of gemcitabine 1,000 mg/m2 and 5-fluorouracil 200 mg/m2. The other one was combined administration of gemcitabine 1,000 mg/m2 and cisplatin 70 mg/m2. RESULTS: Among the 27 patients, 15 patients were treated with gemcitabine-based chemotherapy and 12 patients were treated with many kinds of the best supportive care without chemotherapy. The median survival was 29.1+/-2.7 months and 15.7+/-2.8 months, respectively. The median survival and disease free survival for the gemcitabine based chemotherapy group who received curative resection was 31.6+/-2.5 and 15.7+/-3.2 months, respectively. The median survival and disease free survival for the patients without chemotherapy after curative resection was 16.3+/-2.9 and 15.7+/-3.2 months, respectively. CONCLUSION: Patients with gallbladder cancer and who received adjuvant gemcitabine-based chemotherapy had a relatively favorable prognosis. Especially, gemcitabine-based combination chemotherapy could be effective and acceptable for the treatment of gallbladder cancer patients who have undergone curative resection.

Extra-Gastrointestinal stromal tumor of the pancreas with c-KIT gene mutation: Report of a case

Mesenchymal tumors of the pancreas are quite rare, accounting for less than 1% of all pancreatic tumors. Mesenchymal tumors in the gastrointestinal tract are mainly gastrointestinal stromal tumors (GISTs). GISTs are defined as KIT-positive mesenchymal spindle cells or epithelioid neoplasms originating from the interstitial cell of Cajal. GISTs occur mainly in the stomach, small intestine, colorectum and esophagus. However, extra-gastrointestinal stromal tumors in the bladder, gallbladder, omentum, and mesentery are rare. We report a case of GIST in the pancreas head. A 55-year-old female patient was referred to our hospital for a pancreas head mass detected by a CT scan checked for a fever with an unknown origin. She underwent Whipple's operation for the 5.5x4.4cm-sized mass located in the pancreas head. A microscopic examination revealed GIST showing positive c-KIT protein expression with <5/50 HPF mitosis. C-KIT gene analysis revealed a mutation in exon 9. To the best of our knowledge, this is the first case of extra-gastrointestinal stromal tumor of the pancreas demonstrated by histology, immunohistochemistry and genetic analysis in Korea.

Surgical Management for Intraductal Papillary Mucinous Tumor (IPMT) of the Pancreas Confined to Branch Duct

PURPOSE: Intraductal papillary mucinous tumor (IPMT) of the branch duct type has been reported that it is associated with less aggressive histologic features than the main duct type. The purpose of this study was to evaluate the clinicopathologic features and the optimal management of branch duct type IPMT. METHODS: From October 1994 to November 2004, 30 cases who underwent operations with branch duct type IPMT were reviewed retrospectively. Clinicopathologic findings and late results of treatment were studied in 20 cases of the benign (adenoma, borderline malignancy) group and in 10 cases of the malignant (carcinoma in situ, invasive carcinoma) group. RESULTS: There were statistically significant difference in the 3 factors (mural nodule (P=0.030), diameter of the main pancreatic duct (P=0.036), main location of the tumor (P= 0.031)). There was no statistically significant difference in th survival analysis between the main duct type IPMT including combined type IPMT and the branch duct type IPMT (P=0.572), but there was significant difference between the benign group and the malignant group of the branch duct type IPMT (P=0.049). CONCLUSION: The long-term follow up result of the branch duct type IPMT is similar to that of the main and combined duct type IPMT. Therefore, it is not safe just to monitor the branch duct type IPMT. Our results suggest that surgery is certainly the gold standard treatment for the branch duct type IPMT. And after operation, close long term follow up with appropriate treatment is necessary due to tumor recurrence.

Prognostic Factors after Major Resection for Distal Extrahepatic Cholangiocarcinoma / 대한소화기학회지

BACKGROUND/AIMS: Although diagnosis and surgical treatment for distal common bile duct cancer have enormously advanced, survival is not satisfactory and its prognostic factors are still being debated. Thus, we evaluated the outcomes and prognostic factors after major resection for distal extrahepatic cholangiocarcinoma (dCC). METHODS: One hundred and fifty-four patients who underwent major resection such as pancreaticoduodenectomy for dCC were retrospectively analyzed. We investigated clinical features, postoperative complications, survival, and prognostic factors of dCC. CONCLUSIONS: One hundred and three (66.9%) male and 51 (33.1%) female patients were enrolled and their mean age was 59.6 (31-78) years. Among them, 97 patients (63.0%) underwent Whipple's procedure, 45 (29.2%) pylorus-preserving pancreaticoduodenectomy, 7 (4.5%) total pancreatectomy, and 5 (3.3%) hepatopancreaticoduodenectomy, respectively. Mean follow-up duration was 26.6 (0.4-108.5) months. The postoperative morbidity and mortality were 42.2% and 1.3%, respectively. Five-year survival rate was 32.8% and mean survival duration was 47.2 (39.1-55.3) months. Type of biliary drainage (percutaneous transhepatic biliary drainage), lymph node status (positive), and cellular differentiation (moderate or poor) were significant indicators for death in multivariate analysis of resectable dCC. CONCLUSIONS: Moderate or poor cellular differentiation and lymph node metastasis may be independent poor prognostic factors for resectable dCC.

Correlation of Ki-67, nm23-H1 and the VEGF Expression with the Clinicopathological Variables for Distant Recurrence after Curative Surgery for Carcinoma of the Ampulla of Vater

PURPOSE: Not a few patients show early distant recurrence after curative resection for carcinoma of the ampulla of Vater, and this recurrence is not just related to the clinicopathological factors. This study was performed to determine the correlation of the clinicopathological and biological characteristics with early distant recurrence after surgery for carcinoma of the ampulla of Vater. METHODS: Of the 158 patients who underwent curative resection for carcinoma of the ampulla of Vater at the Samsung Medical Center between December 1994 and August 2004, 38 patients (the recurrence group) with distant recurrence within a year after surgery and 32 patients (the non-recurrence group) without recurrence for more than 3 years after surgery were retrospectively analyzed. Evaluation of their clinicopathological characteristics and their immunohistochemical staining for Ki-67 antigen, nm23-H1 protein and vascular endothelial growth factor (VEGF) were carried out. RESULTS: Of the recurrence group, 24 patients (63.2%) had multiple recurrence sites and 10 (26.3%) were TNM stage I after surgery. The TNM stage was significantly advanced in the recurrence group. Both the Ki-67 labeling index (LI) (10.2% vs. 5.8%, respectively) and positive rate (50.0% vs.18.8%, respectively) according to the cut-off value of Ki-67 LI (i.e. 9%) were significantly higher in the recurrence group. The immunoreactivity for nm23-H1 protein and VEGF was not different between the two groups. Only lymph node metastasis was statistically significant on the multivariate analysis for early distant recurrence after surgery. CONCLUSION: The recurrence group showed an advanced TNM stage and increased Ki-67 LI. Lymph node metastasis was the single independent poor indicator for early distant recurrence after curative resection for carcinoma of the ampulla of Vater.

Clinicopathological Analysis of Solid Pseudopapillary Tumor (SPT) of the Pancreas

PURPOSE: Solid pseudopapillary tumor (SPT) of the pancreas is a rare benign or low-grade pancreatic neoplasm with distinct clinicopathologic features. The purpose of this study was to evaluate the clinical presentation of SPT and to examine the etiology of this tumor by performing immunohistochemical staining. METHODS: From October 1994 to March 2005, 35 cases of SPT who underwent operations were retrospectively reviewed. The clinicopathologic findings and late results of treatment were studied in 7 cases of borderline malignant SPT and in 28 cases of the benign SPT. Immunohistochemical staining was performed for alpha1-antitrypsin, alpha1-antichymotrypsin, neuron specific enolase, chromogranin, synaptophysin, vimentin and cytokeratin. RESULTS: The mean age of the patients was 31.8 years. SPT's were more common in women (77.1%) and the tumors were usually located in the body and the tail of the pancreas (68.6%). There were statistically significant differences in the men (P=0.016), for the masses with calcification (P=0.029), and for the solid masses (P=0.018) between the malignant SPT (including the borderline malignant SPT) and the benign SPT (P=0.014). The SPTs stained positive for alpha1-antitrypsin, neuron specific enolase, and vimentin in all cases, and they were alpha1-antichymotrypsin positive in 94.1% (16/17), chromogranin positive in 18.8% (3/16), synaptophysin positive in 12.5% (2/16), and cytokeratin positive in 18.2% (2/11). All 35 patients underwent curative resection and they are all alive without any evidence of recurrence at a mean follow-up of 44.2 months. CONCLUSION: SPT is a rare tumor that behaves less aggressively than other pancreatic tumors, and surgical resection can result in cure. This tumor thought to originate from a stem cell capable of differentiating into endocrine cells or exocrine cells.

Adenosquamous Carcinoma of the Pancreas

Adenosquamous carcinoma of the pancreas is a rare tumor; its clinical features and radiologic findings are not well known, so the definite preoperative diagnosis of this tumor is quite difficult. We report a case of adenosquamous carcinoma of the pancreas. A 47-year-old woman was admitted on April 2005 to our hospital with a complaint of left upper quadrant pain. The serum CA 19-9 and CEA level were increased up to 4019.08 U/ml and 13.13 ng/ml, respectively. An abdominal computed tomographic (CT) revealed a 10x9 cm sized well-defined homogenous lobulated mass in the pancreas tail. Under the impression of solid-pseudopapillary neoplasm (SPN) or nonfunctioning islet cell tumor, distal pancreatectomy and splenectomy with wedge resection of stomach were performed. The specimen consisted of a huge pancreatic mass that was attached to the posterior wall of stomach. The cut surface of pancreatic mass revealed a huge whitish infiltrative mass. Microscopically, glandular elements of ductal adenocarcinoma were admixed with solid squamoid complexes or squamous cell carcinoma components. Although the origin of the adenosquamous carcinoma has not been well proven, the histopathological findings of our case support the theory of squamous metaplasia.

Clinical Analysis for Mucinous Cystic Neoplasms of the Pancreas

PURPOSE: Mucinous cystic neoplasms are at best potentially malignant and present a spectrum of neoplasia ranging from benign neoplasms to invasive carcinoma. The purpose of this study was to investigate the clinicopathologic characteristics relevant to the specific diagnosis of mucinous cystic neoplasms of the pancreas. METHODS: We retrospectively reviewe the clinical features and histopathologic findings of 34 cases who underwent op-erations with mucinous cystic neoplasms of the pancreas from October 1994 to March 2005. RESULTS: There were 25 mucinous cystadenoma (73.5%), 6 mucinous cystic tumor of borderline malignant potential (17.6%), 1 in situ mucinous cystadenocarcinoma (2.9%), 2 invasive mucinous cystadenocarcinoma (5.9%). Their ages ranged from 23 to 76 years with a mean of 44.2. The 88.2% of the patients were women. The 94.1 % of the tumors were located in the body or tail of the pancreas. The tumor size ranged from 2 to 17 cm, especially the mean size of invasive mucinous cystadenocarcinoma was 13.5 cm. The accuracy of CT for diagnosing was 81.8% and that of US was 53.3%. After a follow-up duration from 5 to 103 months, all patients are still alive. However, recurrent disease developed in all of the 2 patients with invasion. CONCLUSION: Our results suggest that complete surgical resection is certainly the gold standard treatment for mucinous cystic neoplasms. A histologic diagnosis of invasive cysta-denocarcinoma portends a dismal prognosis, so close long term follow up is necessary due to tumor recurrence.

Clinical Results of Transanal Endoscopic Microsurgery (TEM)

PURPOSE: Local treatment of rectal tumors have become an alternative to the classic radical operation. However, conventional transanal procedures are limited to tumors located in the lower rectum and the precision of the excision is restricted by the limitation of the surgeon's visualization during the procedure. This report will present our surgical management and functional results after TEM, a new minimally invasive technique for the treatment of rectal tumors. METHODS: From December 1994 to January 2000, 136 patients underwent TEM. All patients were evaluated preoperatively with sigmoidoscopy or colonoscopy with biopsy. The indications for TEM were benign rectal tumors and T1 and T2 malignant rectal tumors with well or moderately differentiation. All patients were followed up 1 month postoperatively and every 3 months thereafter. RESULTS: The mean operation time was 56.5 minutes (25~150 minutes) and the mean postoperative hospital stay was 3.6 days (2~10 days). On the basis of the postoperative evaluations, 56 of the 136 patients proved to have benign tumors while the remaining 80 patients had malignant tumors. One hundred thirty five patients were removed with adequate resection margins. One patient had cancer cell involvement at the resection margin. There were no serious complications. After a mean observation time of 29 months (12~42 months), there were five noted recurrences. Functional results were excellent; 24 of the 136 patients complained of impaired continence or defecation disorders in a review one month postoperatively. These problems improved during the first 6 months after the surgery. CONCLUSIONS: We feel that TEM is an adequate method for removal of benign rectal tumors, and properly selected early rectal cancers.

Clinical Analysis of Urachal Anomalies

PURPOSE: Although urachal anomalies are rarely observed clinically, they often give rise to a number of problems, such as infection and late malignant changes. Because of variable clinical presentations, uniform guidlines for evaluation and treatment are lacking. The authors discuss the problems involved in both the diagnosis and the treatment of these anomalies. METHODS: We retrospectively analyzed 15 patients (9 males and 6 females) who had undergone surgery for urachal anomalies from July 1995 to December 1999. RESULTS: The age distribution ranged from 14 days to 38 years old, and the male to female ratio was 1.5:1. The 4 variants of urachal anomalies included a urachal sinus in 7 patients (47%), a urachal cyst in 4 (27%), a patent urachus in 3 (20%), and a bladder diverticulum in 1 (6%). The presenting complaint was periumbilical discharge in 6 patients, fever in 5, umbilical granuloma in 4, low abdominal mass in 3, and low abdominal pain in 1. Eight combined anomalies were seen in 7 patients; 2 umbilical hernias, 1 inguinal hernia, 1 hydrocele, 1 urachal vessel anomaly, 1 vesicoureteral reflux, 1 hydronephrosis, 1 Hirschsprung's disease, and 1 hypertrophic pyloric stenosis. Ultrasound examination disclosed a cyst or a sinus in 5 patients, and CT was performed in 1 case. Excision was performed in all patients, and there was no postoperative complication or recurrence. CONCLUSION: Urachal anomalies most frequently present in infancy or childhood, and the initial presentation is umbilical discharge with infection. Furthermore, the large number of associated genitourinary and gastrointestinal anomalies suggests that a complete work-up for these conditions should be performed. Definitive surgical excision appears to be appropriate for most patients.

Clinical Analysis of Urachal Anomalies

PURPOSE: Although urachal anomalies are rarely observed clinically, they often give rise to a number of problems, such as infection and late malignant changes. Because of variable clinical presentations, uniform guidlines for evaluation and treatment are lacking. The authors discuss the problems involved in both the diagnosis and the treatment of these anomalies. METHODS: We retrospectively analyzed 15 patients (9 males and 6 females) who had undergone surgery for urachal anomalies from July 1995 to December 1999. RESULTS: The age distribution ranged from 14 days to 38 years old, and the male to female ratio was 1.5:1. The 4 variants of urachal anomalies included a urachal sinus in 7 patients (47%), a urachal cyst in 4 (27%), a patent urachus in 3 (20%), and a bladder diverticulum in 1 (6%). The presenting complaint was periumbilical discharge in 6 patients, fever in 5, umbilical granuloma in 4, low abdominal mass in 3, and low abdominal pain in 1. Eight combined anomalies were seen in 7 patients; 2 umbilical hernias, 1 inguinal hernia, 1 hydrocele, 1 urachal vessel anomaly, 1 vesicoureteral reflux, 1 hydronephrosis, 1 Hirschsprung's disease, and 1 hypertrophic pyloric stenosis. Ultrasound examination disclosed a cyst or a sinus in 5 patients, and CT was performed in 1 case. Excision was performed in all patients, and there was no postoperative complication or recurrence. CONCLUSION: Urachal anomalies most frequently present in infancy or childhood, and the initial presentation is umbilical discharge with infection. Furthermore, the large number of associated genitourinary and gastrointestinal anomalies suggests that a complete work-up for these conditions should be performed. Definitive surgical excision appears to be appropriate for most patients.

Analysis of the Venous Hemodynamic Changes in the Primary Varicose Vein of the Lower Limbs

PURPOSE: To evaluate the changes of venous hemodynamics after the treatment of the primary varicose vein of the lower limbs. METHODS: We retrospectively analyzed 493 lower limbs (221 right and 272 left, 157 male and 336 female) who underwent surgery for the primary varicose veins from September 1994 to May 1999. All patients were evaluated using air-plethysmography (APG) pre-and post-operatively. RESULTS: The prevalent age was 40 to 49-year-old and the male to female ratio was 1:2. Presumed etiological factors included occupations requiring long periods of standing in 94 cases, and pregnancy in 188 female cases. The average duration of illness was 12.9+/-8.2 years. 232 limbs were treated with a method of the greater saphenous vein high ligation (GSV HL) and above knee (AK) stripping with varicosectomy (VS), 38 limbs with GSV HL and total stripping and VS, 101 with short saphenous vein HL and VS, 100 with external banding valvuloplasty of GSV and VS, 5 with external banding valvuloplasty of GSV only, 10 with Linton's operation, 6 with GSV branch ligation and VS, and sclerotherapy in 9. The reduction rate of venous volume (VV) were 13.9+/-6.6 % in GSV stripping group and 20.4+/-18.2% in GSV valvuloplasty group. The reduction rate of venous filling index (VFI) were 53.6+/-31.0% in GSV stripping group and 58.9+/-33.7% in GSV valvuloplasty group. The increasing rate of ejection fraction (EF) were 26.9+/-41.1% in GSV stripping group and 21.1+/- 32.2% in GSV valvuloplasty group. The reduction rate of ambulatory venous pressure (AVP) were 4.4+/-128% in GSV stripping group and 22.7+/-73.3% in GSV valvuloplasty group. CONCLUSION: In patients with primary varicose vein of the lower limbs, APG could be a useful method for the documentation of hemodynamic improvement by showing decrease in VV, VFI, AVP and increase in EF.