Unfavorable effect of high postoperative fluid balance on outcome of pancreaticoduodenectomy

Purpose@#Despite the many efforts to overcome postoperative complications, pancreaticoduodenectomy (PD) is still accompanied with considerable concerns of lethal complications. The clinical factors are known to affect postoperative outcomes such as diameter of pancreatic duct, texture of pancreas, and comorbidity of the patients are mostly uncorrectable. Thus, investigation for correctable risk factors is required. Recently, perioperative fluid volume was reported to be associated with complications after PD. This study aims to determine the relationship between postoperative fluid balance and surgical outcome after open PD. @*Methods@#We reviewed, retrospectively, 172 consecutive patients who underwent open PD in a single institution between 2015 and 2019. The status of perioperative fluid balance 2 days after surgery and clinical factors were investigated to determine the association with postoperative outcome including postoperative pancreatic fistula (POPF). According to postoperative fluid balance, patients were divided into high- and low-balance groups, and clinical features and surgical outcomes were compared between both groups. Multivariate analysis were performed to identify risk factors for POPF. @*Results@#The percentage of morbidity and the incidence of POPF were higher in the high-balance group compared to the low-balance group (61.6% vs. 37.2%, P = 0.001; 15.1% vs. 3.5%, P = 0.009). High postoperative fluid balance and the presence cardiovascular disease were correlated with POPF on multivariate analysis (odds ratio [OR], 4.574; 95% confidence interval [CI], 1.229–17.029; P = 0.023 and OR, 3.517; 95% CI, 1.209–12.017; P = 0.045). @*Conclusion@#Higher amount of postoperative fluid balance and the presence of cardiovascular disease are associated with POPF after PD.

Various types of reconstruction after pancreaticoduodenectomy for the patients who underwent all types of gastrectomy: a single-center experience

Purpose@#The incidence of patients requiring pancreaticoduodenectomy (PD) following any type of gastrectomy is increasing as the population of elderly patients is increasing, especially in endemic areas of gastric cancer such as Korea. All types of gastrectomy can be categorized as subtotal gastrectomy with Billroth I (BI), Billroth II (BII), and total gastrectomy with Roux-en-Y anastomosis. In this paper, we reviewed our experiences of PD for patients who previously underwent gastrectomy. @*Methods@#We reviewed the medical records of the patients who underwent PD following any type of gastrectomy among 505 consecutive patients who underwent PD in a single institution between 2011 and 2020 retrospectively. @*Results@#There were 13 patients who had undergone gastrectomy including 7 patients of BI, 1 patient of BII, and 5 patients of total gastrectomy. For all 7 patients of BI, the reconstruction was not different from conventional PD. For the 1 patient of BII, previous gastrojejunal anastomosis was preserved and reconstruction was performed in Roux-en-Y method. For the 5 patients with total gastrectomy, 2 different types of reconstruction were performed. In one patient, we removed the remaining jejunum with the specimen, and reconstruction was performed. For the other 4 patients, the remaining jejunum, distal to the Treitz ligament, was preserved and was utilized for anastomosis. Surgeries for all patients were uneventful. @*Conclusion@#PD following any type of gastrectomy can be safe. Especially, if the length of remained jejunum is long enough, its utilization for the reconstruction can be an appropriate option.

Outcomes and recurrence pattern after non-anatomic liver resection for solitary hepatocellular carcinomas

BACKGROUNDS/AIMS: Anatomic resection (AR) is preferred for eradicating portal tributaries in patients with hepatocellular carcinoma (HCC). However, the extent of resection is influenced by underlying liver disease and tumor location. We compared the surgical outcomes and recurrence pattern between non-anatomic resection (NR) and AR. METHODS: From March 2009 to February 2012, 184 patients underwent surgical resection for HCC. Among these, 79 patients who were primarily treated for a single tumor without rupture or macroscopic vascular invasion were enrolled. The patients were divided into 2 groups based on the extent of resection: AR (n=31) or NR (n=48). We compared the clinical characteristics, overall survival, disease-free survival, pattern of recurrence, and biochemical liver functions during the perioperative period between the two groups. RESULTS: The extent of resection had no significant effect on overall or disease-free survival rates. The overall 1- and 3-year survival rates were 97% and 82% in the AR group, and 96% and 89% in the NR group, respectively (p=0.49). In addition, the respective 1- and 3-year disease-free survival rates for the AR and NR groups were 84% and 63%, and 85% and 65%, respectively (p=0.94). On the other hand, the presence of hepatic cirrhosis and a tumor size of >5 cm were significant risk factors for recurrence according to multivariate analysis (p<0.001 and p=0.003, respectively). The frequency of early recurrence, the first site of recurrence, and the pattern of intrahepatic recurrence were similar between the 2 groups (p=0.419, p=0.210, and p=0.734, respectively); in addition, the frequency of marginal recurrence did not differ between the 2 groups (1 patient in the AR group and 2 in the NR group). The NR group showed better postoperative liver function than the AR group. CONCLUSIONS: Non-anatomic liver resection can be a safe and efficient treatment for patients with a solitary HCC without rupture or gross vascular invasion.

Late Hepatic Venous Outflow Obstruction Following Inferior Vena Cava Stenting in Patient with Deceased Donor Liver Transplantation Using Modified Piggyback Technique / 대한이식학회지

Following liver transplantation, a few reports have documented hepatic venous outflow obstruction (HVOO) after inferior vena cava (IVC) stenting for the treatment of IVC stenosis. However, HVOO occurred early after IVC stenting and was mostly associated with living donor liver transplantation. Here, we report a case of HVOO that occurred 31 months after IVC stenting in a man who received deceased donor liver transplantation (DDLT) using a modified piggyback (PB) technique. The cause of HVOO was unclear, but one possible explanation is that the balloon-expandable IVC stent might have compressed the IVC chamber on the donor liver side, which would have changed the outflow hemodynamics, resulting in intimal hyperplasia. Therefore, simultaneous hepatic venous stenting with IVC stent placement could help prevent HVOO in patients receiving DDLT with the modified PB technique.

Major Hepatectomy in the HCC Patient with an Indocyanine Green Retention Rate at 15 Minutes of 10% or Higher: Predictive Values of Postoperative Hepatic Failure

PURPOSE: Major hepatic resection is sometimes inevitable in patients with impaired liver function. We evaluated risk factors that cause postoperative liver failure after major hepatic resection in patients with over a 10% Indocyanine Green Retention rate at 15 minutes (ICGR15). METHODS: From Apr. 2002 to Aug. 2009, 32 patients who had over a 10% rate of ICGR15 underwent major hepatic resection (> or =4 Couinaud segments). Among the 32, 9 patients showed postoperative liver failure (less than 50% prothrombine time and/or 5 mg/dl or higher of total bilirubin). This high-risk group was compared to the rest who constituted a low-risk group. RESULTS: Patients with esophageal varix were more common in the high risk group (4 versus 2, p=0.043). Other clinicopathologic features showed no difference between the two groups. We had 2 in-hospital deaths in the high risk group. CONCLUSION: Great care is needed in patients with esophageal varix and limited liver function during major hepatic resection.

Atypical Hepatocellular Carcinoma Mimicking Abscess on Multiphasic CT Images and Comparison between Imaging Finding and Gross Specimen

Although multiphasic CT is an efficient technique for determination of hepatocellular carcinoma (HCC), occasionally, diagnosis of HCC using multiphasic CT can be difficult. Herein we present a case of HCC that was indicative of a typical abscess on CT imaging and compared the image findings with the gross specimen. The patient's body temperature and laboratory results indicated that inflammation were in the normal range. This case emphasizes that not only imaging findings but also clinical presentation should be considered to achieve a correct diagnosis in clinical practice.

Predictive factors for invasive intraductal papillary mucinous neoplasm of the pancreas

BACKGROUNDS/AIMS: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has malignant potential. Predicting invasive IPMN has proven difficult and controversial. We tried to identify predictive factors for invasive IPMN. METHODS: Thirty six patients underwent resection for IPMN from February 2001 to July 2011. Clinicopathological features including demographic, imaging, microscopic, and serological findings were retrospectively reviewed. Receiver operating characteristic (ROC) curve analysis was used to analyze sensitivity and specificity of all possible cut-off values for the diameter of the main pancreatic duct and mass size predicting invasive IPMN. Student t-test, chi-square test, and logistic regression were used for univariate and multivariate analysis. RESULTS: The mean age was 63.5+/-8.4 years. Males were more commonly affected (58.3% vs 41.7%). Pancreaticoduodenectomy was performed in 55.6% of patients, distal pancreatectomy in 36.1%, and central pancreatic resection in 8.3%. Non-invasive IPMNs were present in 80.6% (n=29), whereas invasive IPMNs were present in 19.4% (n=7). In univariate analysis, tumor location (p=0.036), Kuroda classification (p=0.048), mural nodule (p=0.016), and main duct dilatation (> or =8 mm) (p=0.006) were statistically significant variables. ROC curve analysis showed that a value of 8 mm for the main duct dilatation and a value of 35 mm for the size of the mass lesion have 80% sensitivity and 75% specificity and 100% sensitivity and 82.6% specificity, respectively. However, in multivariate analysis, main ductal dilatation (> or =8 mm) was identified to be the only independent factor for invasive IPMN (p=0.049). CONCLUSIONS: Main duct dilatation appears to be a useful indicator for predicting invasive IPMN.

Clinical Features and Long Term Survival of Pancreatic Neuroendocrine Tumors According to the WHO Classification

PURPOSE: Clinical features of Pancreatic Neuroendocrine Tumors (PETs) vary according to the hormone secreted and to the heredity of the tumors. Malignant PETs are common among nonfunctioning PETs (NFTs) whereas the majority of functioning PETs (FTs) are benign. Our goal was to determine the clinical features and prognosis of PETs stratified by the WHO classification scheme and AJCC-UICC 7TH TNM staging. METHODS: We selected for study 30 patients with PETs, including one case of nesidiolastosis, who presented at our clinic between April 1992 and June 2010. Clinicopathological features were studied retrospectively. PETs were classified as benign, uncertain malignant, well differentiated carcinoma, or poorly differentiated carcinomas by the WHO classification. For statistical analysis, Student's t-test, the Chi-square test, and the Kaplan-Meier method were utilized. RESULTS: Nine cases were FTs and twenty one cases were NFTs. The average size of the FTs was smaller than that of the NFTs (1.71 vs 4.33, p=0.04). The head of the pancreas was most commonly involved (33.3% of FTs; 47.6% of NFTs) but the locations of the tumors were not different. Insulinoma was the most common (66.7%, 6/9) among FTs. The incidence of malignant tumors was 33.3% and 55.0% among, respectively, FTs and NFTs. The 5-year disease-free survival rate of patients with benign PETs (FTs and NFTs), and of patients with functioning well-differentiated carcinomas was 100%. However, the 5-year disease-free survival rates of patients with nonfunctioning well- and poorly-differentiated carcinomas were 66.7% and 0%. CONCLUSION: Among patients with Pancreatic Neuroendocrine Tumors, malignant tumors are more common among NFTs than FTs. Poorly-differentiated carcinomas have a worse prognosis while all FTs regardless of their WHO classification fail to show any disease recurrence.

Is Laparoscopic Cholecystectomy Safe in Octogenarians?

PURPOSE: Biliary tract disease is one of the most common causes of acute abdominal pain in elderly patients, but there is still some debate over treatment. The aim of this study is to determine the safety and surgical outcomes of laparoscopic cholecystectomy (LC) for benign gallbladder disease in octogenarian patients. METHODS: We selected 42 patients of 80 years or older who underwent LC or open-converted cholecystectomy (OC) from February 1992 to November 2006. We evaluated clinicopathological features, treatment modalities, and surgical outcomes retrospectively. RESULTS: The patients included 17 males and 25 females. The mean age of the patients was 83.3 and 83.7, respectively. Right upper quadrant pain was the most common symptom, present in 85.7% of the patients. Gallstones were present in 85.7%. ASA class II and III comprised 92.9% of the patients. Comorbidities included hypertension, cardiac disease, pulmonary disease, and diabetes mellitus. Preoperatively biliary drainage was performed in 12 cases (endoscopic drainage in 8, percutaneous drainage in 4 cases). Preoperative cholecystostomy was performed in 5 cases. Emergency operations were more frequent than elective surgery (25 vs. 17). Mean hospital stay of LC patients was 5 days, whereas that of OC patients was 13 days. Open conversion rate was 16.7%. No surgical mortality was present and postoperative morbidity included acute myocardial infarction in one patient and wound infection in one patient. CONCLUSION: LC in octogenarian patients was safe. However, since the incidence of comorbidities is high in these patients, great care should be taken to evaluate and manage the comorbidities before surgery.

The Impact of Concomitant Splenectomy on the Portal Pressure in Patients with Liver Cirrhosis

PURPOSE: Concomitant splenectomy in cirrhotic patients is known to ameliorate the tendency to bleed and it decreases the portal venous pressure (PVP). However, the direct measurement of the change in the PVP after concomitant splenectomy has not yet been reported. We tried to measure the change of the PVP before and after splenectomy. METHODS: From March 2000 to May 2006, 18 patients underwent anatomical liver resection with concomitant splenectomy. All the patients had liver cirrhosis, thrombocytopenia and/or esophageal varix. Through the 5 French feeding tube, which was inserted into the right gastroepiploic vein after laparotomy, we directly measured the PVP before and after splenectomy, and also under portal triad clamping (PTC). RESULTS: After splenectomy, the PVP decreased significantly from 261.11+/-45.87 mmH2O to 221.11+/-38.48 mmH2O (p<0.05). Under PTC, the PVP decreased significantly from 605.00+/-116.48 mmH2O to 513.89+/-70.56 mmH2O (p<0.05). CONCLUSION: Concomitant splenectomy in patients with liver cirrhosis resulted in a significant reduction of the PVP.

Clinical Features and Prognostic Factors Influencing Long-term Survival in pT2 Gallbladder Carcinoma Patients

PURPOSE: The prognosis of gallbladder carcinoma is unfavorable, and the depth of invasion, the T-factor, is the most important prognostic factor. T2 tumors are not easily diagnosed preoperatively, and they have unpredictable behavior. In this study, we reviewed the clinicopathologic features of pT2 gallbladder carcinoma and identified prognostic factors. METHODS: We enrolled 64 pT2 gallbladder carcinoma patients who underwent surgery in Kyungpook National University Hospital between January 1992 and July 2006. The clinicopathologic features were retrospectively reviewed, and univariate and multivariate analyses were performed using the Kaplan-Meyer method and Cox regression hazard model to identify factors influencing long-term survival. RESULTS: Twenty-one patients (32.8%) were asymptomatic, with seven tumors (10.9%) found incidentally. The gallbladder body was the most commonly involved site (45.3%, 29/64). Although CA19-9 was not sensitive, it was helpful for predicting recurrence. The 5-year diseasespecific survival rate in R0 resection was 75.9%, whereas no patients in the R1 or R2 resection groups survived more than 18 months.ANone of the clinicopathologic factors was prognostic. The unfavorable prognostic effect associated with lymph node involvement highlights the importance of complete lymph node dissection. Partial liver resection favorably affected survival, but not to a statistically significant degree. CONCLUSION: Absence of symptoms and specific imaging findings in patients with considerable pT2 gallbladder carcinoma warrants high disease suspicion, and every effort should be taken to achieve R0 resection with extensive lymph node dissection, since it may improve long-term survival in pT2 carcinoma patients.

Bioartificial Liver System using a Fluidized-Bed Bioreactor

PURPOSE: Acute fulminant hepatic failure (FHF) is associated with high mortality. Recent studies have shown that a liver support system based on viable hepatocytes can prolong life in animal models of FHF and also in some FHF patients who were successfully bridged to liver transplantation. To be applied in humans, the bioartificial liver (BAL) system should have sufficient liver cell mass to provide adequate bioactive support. The most widely investigated bioreactor at present is based on hollow fiber membrane. However, it is difficult to build a scaledup module of this model. We devised a fluidized-bed bioreactor that is packed with isolated porcine hepatocytes, and these hepatcytes are immobilized in Ca-alginate hydrogel. METHODS: We isolated fresh porcine hepatocytes using a 2-step collagenase perfusion method, and they were suspended in 1.5% alginate solution. Through a drop-generator, this mixture was gelled in 135mM Cacl2. The resulting spherical beads (mean size: 500 micrometer) were embedded in a module. An average of 2x10(10) hepatocytes were present in the module. The efficacy of our design was tested in pigs that had undergone total hepatic devascularization and portocaval shunt. RESULTS: The BAL-treated group showed a significantly lower ammonium build-up rate compared to the control group (598.6+/-344.2 microgram/dl vs 1937.6+/-744.1 microgram/dl, respectively, at 8 hours after connecting to BAL). In addition, the intracranial pressure was well controlled in the BAL-treated group, whereas the control group showed a progressive increase of the intracranial pressure (16.9+/-1mmH2O vs 21.9+/-2.6mmH2O, respectively, at 8 hours after connecting to BAL). CONCLUSION: Our bioartificial liver system is a fluidized-bed bioreactor packed with immobilized porcine hepatocytes, and it seems to be a more effective scaled-up module.

Surgical Management of Liver Trauma

The management of blunt injuries to the liver still remains a significant challenge. The therapeutic options for liver trauma ranges from non-surgical management, surgical management and even to liver transplantation. Although a significant number of patients are treated non-surgically, most unstable patients require an immediate laparotomy. The preferred surgical techniques include resectional debridement, hepatotomy with direct suture ligation and perihepatic packing. In addition, an anatomical resection, hepatic artery ligation and various bypass techniques have a more defined role in selected injuries. This review discusses the various surgical options for unstable liver trauma patients.

The Comparative Results of Radiofrequency Ablation versus Surgical Resection for the Treatment of Hepatocellular Carcinoma / 대한간학회지

BACKGROUND/AIMS: Although surgical resection remains the gold standard of therapy for hepatocellular carcinoma (HCC), only selected patients can undergo resection because of the severity of the underlying cirrhosis or due to the diffuse distribution of the tumor. Radiofrequency ablation (RFA) has recently shown comparable results to surgical resection for the treatment of HCC. We compared the results of RF ablation and surgical resection for the treatment of HCC. METHODS: From January 2000 to December 2002, one hundred-sixty patients who had undergone surgical resection or RFA were analyzed retrospectively. The patients with a tumor size less than 5 cm in diameter, with less than 3 tumors in number, with tumor having a Child-Pugh class A classification and no evidence of extrahepatic metastasis were enrolled in the study. The recurrence pattern was classified into local and distant recurrence. We compared the recurrence patterns, the survival rates, the recurrence rates and the complications between the two groups. RESULTS: 1) The local recurrence rate was 9.8% for surgical resection and 18.2% for RFA and the distant recurrence rate were 32.8% and 28.3%, respectively. 2) The 1-, 2- and 3-year overall cumulative survival rates after RFA and surgery were 95.8%, 86.8%, 80.0%, 98.3%, 87.0% and 77.4%, respectively. 3) The incidence of complication was similar between the two groups. CONCLUSIONS: Radiofrequency ablation shows comparable results to surgical resection for the treatment of HCC. Therefore, RFA should be considered as the treatment of choice those patients who are not candidates for resection. However, intrahepatic recurrence of tumor after RFA was as frequent as that seen after surgical resection. Further investigation is warranted to clarify whether the current RFA technology could offer improved long-term results.

Hemodynamic Changes during Isolated Liver Hemoperfusion of Hepatoma / 대한구급학회지

BACKGROUND: To analyze hemodynamic changes during single catheter technique of hepatic venous isolation and extracorporeal charcoal hemoperfusion for malignant liver tumor. METHODS: Drugs for chemotherapy were infused to the liver through hepatic artery. With 4-lumen- 2-balloon (4L-2B) catheter, hepatic venous blood was circulated to the extracorporeal charcoal system. During extracorporeal charcoal system circulation, drugs were eliminated and the blood was reinfused to supra-hepatic vein-IVC. At the same time, IVC was clamped. Systemic vascular resistance index (SVRI), cardiac index (CI), stroke volume index (SVI), mean arterial pressure (MAP), heart rate (HR) and arterial blood gas were measured after 4L-2B catheter insertion (T1), during test circulation (T2), after 20min chemotherapy (T3) and after 10min reperfusion (T4). RESULTS: MAP was decreased at T3 compared to T1 and increased at T4 compared to T3. CI was decreased at T3 and increased at T4 compared to T1. SVRI was decreased at T4 compared to T1. HR was increased at T2 and T3 compared to T1. SVI was decreased at T2 and T3 compared to T1. CONCLUSIONS: During clamping of IVC, MAP is decreased by decreased SVI in spite of increased HR. After IVC is released and the stagnated blood of lower extremity is recirculated, the MAP is returned to the value of after catheter insertion by increased SVI in spite of decreased SVRI.

A Comparison of the Clinicopathologic and Prognostic Differences in Patients Who Underwent Hepatic Resection with Hepatitis B- versus Hepatitis C-related Hepatocellular Carcinoma / 한국간담췌외과학회지

BACKGROUND/AIMS: The surgical outcomes for patients with HCC according to different hepatitis viral status have been inconsistently reported. This study evaluated the clinico-pathological and prognostic differences in patients with HBV- and HCV-related HCC. METHODS: Two hundred and eleven patients with HCC who underwent curative hepatic resection were categorized into three groups according to viral status: Group I (Hbs Ag (+) HCV Ab (-), n=116); Group II (Hbs Ag (-) HCV Ab (+), n=74); Group III (Hbs Ag (-) HCV Ab (-), n=17). The clinical manifestations, pathologic features, and treatment outcomes were compared. RESULTS: The average age at onset of HCV-related HCC is older than that of HBV-related HCC. Most HCV-related HCC is associated with liver cirrhosis as reflected by lower albumin level, platelet count, higher ICG R15 value, ALT levels. and frequency of minor resection (P<0.05). The incidence of portal vein invasion or intrahepatic metastasis did not differ among groups. In addition, HCV Ab (+) group had significantly lower disease free survival rates (P<0.05). CONCLUSION: This study suggests that the patients with HCV- related HCC have poorer liver function with more frequent recurrence.

The Effect of Preoperative Transcatheter Arterial Chemoembolization in Hepatocellular Carcinoma (prospective study) / 한국간담췌외과학회지

BACKGROUND/AIMS: The effect of preoperative Transcatheter Arterial Chemoembolization (TACE) in the management of Hepatocellular carcinoma (HCC) has remained controversial and lack of prospective study. To investigate the impact of preoperative TACE, we have performed a prospective study in HCC patients with tumor size below 5 cm. METHODS: From November 1998 through March 2002, 126 patients with HCC who had been referred for surgical resection were prospectively allocated to Group I (preoperative TACE, n=42) and Group II (simple hepatic angiography only, n=38). Patients who were underwent noncurative hepatic resection (n=4) were excluded and the groups with large tumor mass (above 5 cm) with or without TACE (n=64) were excluded from this analysis due to insufficient number. The impact of preoperative TACE on incidence of complication as well as long term overall and disease free survival rate were analyzed. RESULTS: Preoperative demographics and intraoperative data were compatible between two groups. There were no difference in complication rates between two groups. The 3 year survival rate of Group I and Group II were 88.10% and 58.32% respectively. The 3 year disease-free survival rate of Group I and Group II were 40.14% and 34.89% respectively. The 3 year overall rate was significantly high in Group I (p=0.0348), disease-free survival rate did not show difference between two groups (p=0.6132). CONCLUSION: Preoperative TACE can be done safely and showed improved overall survival rate in this prospective study, however fruther prospective study with longer period of follow up will be necessary to prove the effect of preoperative TACE.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.

Heterotopic Mesenteric Ossification Following Intraabdominal Surgery

Heterotopic mesenteric ossification is a very uncommon disorder that is characterized by new bone formation in the mesentery, which does not normally undergo ossification. A 52-year-old female experienced a small bowel obstruction 12 days after a segmental resection of the small bowel following a trauma. A laparotomy was performed 16 days after the initial operation, and a 2 cm hard mass was detected in the small bowel mesentery, with severe fibrous adhesions around the mass, involving the jejunum, which required resection. Postoperatively, the patient developed an intraabdominal abscess, followed by intestinal fistulation. The patient gradually recovered by conservative management, and left hospital 70 days after the first operation. Microscopic examination of the mass showed well oriented trabeculae of the osseous tissue, osteoid formation, with fine calcification and osteoblastic activity, but there was no formation of mature lamellar bone or clear evidence of the "zone phenomenon" that is classically described in heterotopic ossification. These findings appeared consistent with an early stage of heterotopic ossification. The etiology and pathogenesis are unknown; the heterotopic mesenteric ossification was thought to be associated with the trauma (intraabdominal surgery). The previous literature on heterotopic mesenteric ossification is reviewed, and a new case reported.

Outcome of the Liver Resection of the Hepatocellular Carcinoma under Milan Criteria

PURPOSE: Liver resection (LR) has been the treatment of choice for hepatocellular carcinoma (HCC), but resection and survival rates remain low, and recurrence is common in cirrhotic patients. This study was designed to evaluate the outcome after resection of potentially transplantable early HCCs and compare it with that for liver transplantation (LT) as reported in the literature. METHODS: We studied 109 patients with HCC under the Milan criteria who underwent LR at Kyungpook National University Hospital from September 1997 to May 2002. The patients were divided into two groups: group A had a single tumor and group B had two or three tumors. RESULTS: The mean age was 56.1+/-8.1 years and the male-to-female ratio was 4.7: 1. Most of the patients had chronic liver disease due to viral hepatitis, but had preserved hepatic function. Overall survival rates (SR) at 1, 2, 3, and 4 years were 86.7, 69.4, 44.8, and 13.3%, respectively, and the corresponding disease-free survival rates (DFSR) were 74.2, 53.8, 41.6, and 23.7%. SR and DFSR were not significantly different between the two groups, although group B tended to have lower SR and DFSR. At a median follow-up of 25.3 months, 52 patients experienced recurrence, most of whom had intrahepatic recurrence within 2 years after resection. At the time of the diagnosis of recurrence, 34 patients were considered eligible for LT. CONCLUSION: Although most of the patients had preserved hepatic function, LR of early HCC showed low survival rates and high recurrence rates compared with those after LT reported in the literature and in our experiences. Therefore, in the absence of limiting factors, LT may be the better option for surgical treatment of patients with early HCC, even when preserved hepatic function is maintained.