Pneumatosis Cystoides Intestinalis with Intestinal Volvulus

Pneumatosis cystoides intestinalis is an uncommon condition characterized by the presence of multiple gas-filled cysts within the wall of the gastrointestinal tract. It is still a poorly understood phenomenon, considered to result from primary mucosal insult from varying causes. However, it is associated with various diseases, including gastroenteral obstructive and connective vascular diseases and even pulmonary or endocrine diseases. Authors report a case of pneumatosis cystoides intestinalis with volvulus in the small intestine that developed in a 44-year-old man without history of any special underlying diseases.

Correlation of Vascular Endothelial Growth Factor-D Expression and VEGFR-3-Positive Vessel Density with Lymph Node Metastasis in Gastric Carcinoma

Lymph node metastasis is an important prognostic factor in gastric cancer. Vascular endothelial growth factor-D (VEGF-D) is a lymphangiogenic growth factor that activates VEGF receptor (VEGFR)-3, a receptor expressed in the lymphatic endothelium. We investigated the clinical value of VEGF-D expression and VEGFR-3 positive vessel density in gastric carcinoma with regard to lymphangiogenesis. Immunohistochemical staining was used to determine the expression of VEGF-D and VEGFR- 3 in specimens from 104 cases of resected gastric cancer. VEGF-D expression was observed in 62.5% of the gastric cancers and in 9.6% of the non-neoplastic gastric tissue. The VEGFR-3-positive vessel density was significantly greater in the VEGFD positive group than the negative group. VEGF-D expression was significantly associated with lymph node metastasis, increased serum CEA levels, and the nonsignet ring cell type. The VEGFR-3-positive vessel density was correlated with tumor size, lymphatic invasion, and lymph node metastasis. The VEGF-D expression and high VEGFR-3-positive vessel density were significant poor prognostic factors for relapse-free survival. These results suggest that VEGF-D and VEGFR-3-positive vessel density are potential molecular markers that predict lymphatic involvement in gastric carcinoma.

Appendico-colonic Fistula

Perforation of the appendix into the neighboring viscera is an uncommon sequel to acute appendicitis, and the persistence of the fistula between the appendix and a viscus is even rarer. Although a variety of causes such as foreign body ingestion and regional enteritis may be responsible for persistent appendiceal enteric fistula, the cause for these unusual lesions in our experience appeared to be antecedent appendicitis. Generally, the incidence of persistent appendiceal enteric fistula is very rare and the progress of disease is quite different from the so-called 'usual' acute appendicitis. The diagnosis might lean the wrong way such as towards colitis or cystitis, and so surgical intervention is delayed. Treatments of perforation are diversion (colostomy), as is shown above or conservative treatment such as drainage only.

Laparoscopic Management of Primary Omental Torsion in 11-year-old Boy

Primary torsion of the greater omentum is a rare cause of an acute abdomen in children, which often mimic other acute abdominal conditions. Resection of the infarcted segment is the treatment of choice. Here, a case of torsion of the greater omentum, diagnosed with preoperative computed tomography and subsequently managed by laparoscopic surgery, is reported. The patient was discharged three day after surgery without any complication. Omental torsion can be accurately diagnosed and safely treated with a laparoscopy.

Comparative Study of Delayed Gastric Emptying between Manual and Stapled Anastomosis in Patients Undergoing Subtotal Gastrectomy with Billroth I Gastroduodenostomy for Early Gastric Cancer

PURPOSE: Many surgeons are using stapled anastomosis in Billroth I gastroduodenostomy after subtotal gastrectomy because of the shorter operation time and simpler handling. However, many patients complain delayed gastric emptying after using EEA stapler. The delayed gastric emptying was compared between manual and stapled anastomosis in Billroth I gastroduodenostomy for stomach cancer. METHODS: 92 patients who performed Billroth I gastroduodenostomy after subtotal gastrectomy due to early gastric cancer at the Hanyang University Guri Hospital between January 2001 to December 2003 were reviewed. Delayed gastric emptying was diagnosed by patients' symptoms and upper gastrointestinal roentgenogram. Manual anastomosis was using the Albert-Lambert suturing and stapled procedure with EEA stapler (auto suture(R)). RESULTS: Of the 92 patients, 22 were in the stapled anastomosis group (a mean age of 61.58 years, M:16, F:6) and 70 in the manually anastomosis group(a mean age of 61.12 years, M: 44, F: 26). The incidence of delayed Gastric emptying were significantly lower in the manual than the stapler group (P=0.035), but the operation times and the hospitas stay were significantly shorter in stapler group (P=0.001 and 0.07, respectively). CONCLUSION: The manual group had better outcomes with regard to gastric emptying despite of the many advantages of stapled anastomosis in the filedld of intraabdominal operations. Various stapled anastomosis instruments and methods have been tried, but further studies are necessary if stapled anastomosis is to be the perfect substitute for manual anastomosis.

Delayed Superficial Transposition of Cephalic Vein for Salvage of Brachiocephalic FIstula

The small diameter and sclerosis of the veins are the main causes of failure of autogenous arterio-venous fistula(AVF) for hemodialysis. In addition, the deep location of veins prevents adequate access postoperatively, as exemplified by the frequent requirement of transposition of basilic veins either primarily or delayed. As for the cephalic veins, superficial transposition was not emphasized. We report a case of brachiocephalic AVF which required delayed superficial transposition for access. We emphasize that the depth of veins should be considered for adequate creation of AVF.

Migration Pattern of UV-B Irradiated Leukocyte in a Rat Kidney Transplantation Model

PURPOSE: This project is designed to investigate the immune response of a rat transplantation model to donor specific allogeneic blood transfusion (DST) prior to kidney transplantation. It has been hypothesized that partial activation of the immune system due to allogeneic antigen presentation, followed by immune unresponsiveness. In addition, previous models have shown prolonged donor cell microchimerism can be established following organ transplantation. Mixed chimerism has been demonstrated in organ transplant recipients surviving over a long period. Attempts were made to assess the fate and movements of donor cells following organ transplantation. METHODS: Rat male-to-female renal transplantation and microchimerism was assessed by semiquantitative PCR. A PCR specific for the Y-chromosome (sex-determining region Y[Sry]) allowed the distinction of small amounts of male cells in a large excess of female cells. The study group was divided into four according to the donor specific transfusion (DST) and cyclosporin (CsA) Group 1 are recipients without DST or CsA administration, Group 2 are recipient with CsA, Group 3 with DSILT and Group 4 with full immunosuppresive agent (CsA & DSILT). The samples were obtained at thymus, lymph node, spleen and sternum following transplantation day 1, 7, 21. Donor cell microchimerism were detected by donor Y chromosome in female recipients using PCR RESULTS: The Y-chromosome was detected at high levels in group 4, 21 days after transplantation. The detection ratio in the lymph node was higher than in the other organs. CONCLUSION: The fate of donor cell were closely related to he additional supporting immunosuppressive agent.

A Clinical Review of Initial 20 Cases of Laparoscopic Adrenalectomy / 대한내분비외과학회지

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors due to many advantages; a more rapid and comfortable recovery, shortened hospitalization period, and fewer complications. This study reports on an initial 4 year period of experience with LA and describes various unusual findings encountered during the treatment. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Of the several LA techniques previously described we prefer the transabdominal approach in the lateral decubitus position utilizing 3 or 4 trocars, and this method was employed in all the cases presented here. RESULTS: All 20 patients had a unilateral tumor. The pathological findings consisted of 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. Of the 20 patients, 18 were successfully operated with the laparoscopic procedure and the remaining 2 cases were converted to open adrenalectomy. The reasons for conversion were sudden cardiac arrest of unknown origin in one and intraoperative bleeding due to periadrenal massive fat in the other. During LA, 2 patients with non-catecholaminesecreting cortical adenomas pathologies displayed abnormal EKG findings, which reverted to normal after the operation. The average complete LA operation times was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There were no postoperative complications, operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: LA is a relatively fast and safe method and has become is accepted as the preferred procedure for adrenal tumors but it requires good perioperative preparation. Surgeons and anesthesiologists need to be aware of the possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.

A Clinical Review of Initial 20 Cases of Laparoscopic Adrenalectomy / 대한내분비외과학회지

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors due to many advantages; a more rapid and comfortable recovery, shortened hospitalization period, and fewer complications. This study reports on an initial 4 year period of experience with LA and describes various unusual findings encountered during the treatment. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Of the several LA techniques previously described we prefer the transabdominal approach in the lateral decubitus position utilizing 3 or 4 trocars, and this method was employed in all the cases presented here. RESULTS: All 20 patients had a unilateral tumor. The pathological findings consisted of 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. Of the 20 patients, 18 were successfully operated with the laparoscopic procedure and the remaining 2 cases were converted to open adrenalectomy. The reasons for conversion were sudden cardiac arrest of unknown origin in one and intraoperative bleeding due to periadrenal massive fat in the other. During LA, 2 patients with non-catecholaminesecreting cortical adenomas pathologies displayed abnormal EKG findings, which reverted to normal after the operation. The average complete LA operation times was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There were no postoperative complications, operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: LA is a relatively fast and safe method and has become is accepted as the preferred procedure for adrenal tumors but it requires good perioperative preparation. Surgeons and anesthesiologists need to be aware of the possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.

Penetrating Injury of Inferior Vena Cava by Abdominal Stab Wound

Injuries of the inferior vena cava (IVC) might be caused by a blunt trauma, which usually affects the retrohepatic portion. Injuries of the infrahepatic IVC are usually caused by penetrating injuries and rarely occur in Korea. We report a case of a penetrating injury of the IVC at the infrahepatic suprarenal portion with a review of other reported cases.

Temporal Morphologic Changes in the Mouse Liver after Common Bile Duct Ligation

PURPOSE: Cholestasis is a common manifestation of biliary obstructive diseases. This study was designed to verify histopathologic manifestations of cholestatic liver injury after bile duct ligation in a murine model. METHODS: Eight-week-old female CB6 F1 mice underwent common bile duct ligation and sacrificed at various intervals after surgery. Serum samples were used for the levels of ALT, gamma-GT, total bilirubin. Liver tissues were used for H&E stain for histopathologic examination, Masson's trichrome to assess fibrosis, and reticulin for evaluation of hepatic lobular framework and cell loss. Data were analyzed using the Students' t-test. RESULTS: In mid-duct ligated animals, marked microvesicular fatty change was noted between 1 to 2 days, which completely subsided after 3 days. Scattered variable-sized foci of hepatic cell loss were noted also, beginning at 12 hours, but becoming more prominent at 1 to 3 days. Fibrosis in larger portal tracts near the hilum was first noted through day 3, and remained at days 7 and 28. This was accompanied by marked branching and/or epithelial proliferation in the large bile ducts. Peripheral hepatic fibrosis was evident at day 5 and continued postoperatively. Liver function tests on serums showed an obstructive jaundice pattern during the first week. These values normalized by week 4. Choledochoduodenal fistulae were formed in mice surviving 4 weeks after ligation. CONCLUSION: This study provides a temporally reproducible pattern of biochemical and histopathological changes in the liver, providing a useful model for studying the pathobiology of cholestatic liver diseases secondary to extrahepatic bile duct obstruction.

Analytical and Clinical Evaluation of Lana(TM), the Reagent Measuring 1,5-Anhydroglucitol / 대한임상병리학회지

BACKGROUND: There have been many reports that 1,5-Anhydroglucitol (1,5-AG) was a better marker than the hemoglobin A1c (HbA1c) or fructosamine for monitoring the control of glucose in patients with Diabetes Mellitus (DM). However, there was difficulty in performing the tests on the patient's samples in the hospital laboratory because the measurement was possible only with gas chromatog-raphy or high performance chromatography. Recently, a reagent that can measure 1,5-AG on the automatic chemistry analyzer was introduced. We evaluated the analytical and clinical characteris-tics of the reagent. METHODS: We measured the 1,5-AG with the Lana(TM) (Japan Chemistry Medicine, Tokyo, Japan) on the automatic chemistry analyzer, TBA-30FR (Toshiba, Otawara, Japan). We evaluated the pre-cision, the recovery rate, the lower detection limit, the reference value, and the correlation with other clinical markers for glucose control of the DM patient. RESULTS: The within-run precisions of abnormal and normal samples were 1.27% and 1.41%. The between-day precisions were 2.34% and 4.56%, respectively. The recovery rate was 100.1% and 100.7% in abnormal and normal samples, respectively. The lower detection limit was 0.05 mg/L. The reference value from the healthy people was from 12.7 to 50.9 mg/L. The correlation coefficients of the 1,5-AG with glucose and HbA1c were -0.45 and -0.63, respectively. CONCLUSIONS: The newly introduced reagent for 1,5-AG that could be applied with the automatic chemistry analyzer was enough to satisfy the analytical features and it showed better correlation with HbA1c than with the fasting blood glucose. We expect that the Lana(TM) can be used in hospital lab-oratories to monitor the blood glucose control of DM patients and more studies on the clinical value of the 1,5-AG can be done with the convenient reagent such as this.

The Effect of Cholestasis on Hepatitis B Virus Replications

PURPOSE: HBV infection acquired later in life elicits an inflammatory response. The quality and intensity of the response determines whether virus clears or persists. Clearance is mediated through antigen-specific cytotoxic T-cells. The immune response often precipitates cholestasis while releasing a number of inflammatory cytokines, such as tumor necrosis factor-alpha and interferon-gamma, which are known to inhibit HBV replication in vivo. Transgenic mice which replicate HBV provide a useful model for studying viral pathogenesis. We try to determine whether cholestasis, apart from inflammation, modulates HBV replication. Method: HBV-expressing female 9-wk old BALD/B6 mice matched for HBeAg titer were utilized. Cholestasis was achieved by mid-length ligation and transection of the common bile duct in anesthesized animals. Sham and ligated animals were sacrificed over at 4 h, 12 h, 24 h, 48 h, and 72 h after operation (4 animals/interval). Sera were assayed for ALT, GGT, and direct bilirubin. Histopathology was obtained. Cytokine profiles for interferons, interleukins and tumor necrosis factor were monitored by RNase protection assay. HBV replication was quantitated by measurement of HBV DNA and RNA using Southern and Northern blotting. RESULTS: Sham-operated animals remained without biochemical, pathological or serological changes. Operated animals demonstrated markedly elevated total bilirubin, ALT and GGT levels. Histologic examination showed marked periductular fibrosis and ductular proliferation and area of focal hepato cellular necrosis. Ribonuclease protection assays demon strated minimal infiltration of CD3 cells, and minimal to no migration of CD4 and CD8 cells. Interferon-gamma mRNA was not detected. TNF-alpha peaked between 1 and 3 days post surgery, but to a much lesser extent than that found in naive virus-challenged animals. Both major HBV RNA species remained unchanged during the experiment. HBV DNA production demonstrated no changes in the quantity of the relaxed circular or single-stranded intermediates for the first 2 days. However, by days 5 and 7, reduction in the quantity of viral intermediates were seen. This diminution did not appear to be due to the presence of inflammatory cytokines or CTLs (cytotoxic T lymphocytes) previously implicated in viral clearance. CONCLUSION: Whereas inflammatory cytokines and cellular immunity are essential for viral attenuation and clearance, Acute cholestasis does not appear to contribute independently to biological modulation of HBV replication.

Paraplegia with Rapid Deterioration in a Thrombocytopenic Patient: A Case Report of Acute Aortic Thrombosis

Acute aortic occlusion is rare but poses a high mortality and morbidity. Prompt diagnosis and treatment is essential. Typical presentation is rest pain with bilateral absent femoral pulse. When the non-typical symptoms predominate such as paraplegia, acute abdomen or sudden-onset hypertension, diagnosis may be difficult. We experienced a case of acute aortic thrombosis who suddenly developed paraplegia and rapidly deteriorated within several hours. When the paraplegia developed, he was under treatment with heparin and urokinase, was thrombocytopenic, and the femoral arteries were pulsatile. Spinal cord compression due to bleeding complication had to be ruled out. Duplex sonography and lumbar CT scan were not diagnostic. Aortic thrombosis was diagnosed by abdominal CT scan. This case illustrates the need for high suspicion of acute aortic occlusion presenting with paraplegia especially in patients with associated atherosclerotic disease.

Immediate Free TRAM Flap Reconstruction after Mastectomy in Breast Cancer Patients

PURPOSE: Despite the advocation of a breast conserving approach to the treatment of breast cancer, many women continue to surgically require or choose mastectomy for the treatment of breast cancer. In many cases, breast reconstruction after mastectomy is being performed using tissue expander, implants or a myocutaneous flap. In recent years, immediate free transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction has become an cosmetically and economically attractive alternative, compared to other types of reconstruction, although the technique is not easy. The author's experience with 25 successful immediate free TRAM flap reconstructions is reviewed. METHODS: We analyzed 25 cases of immediate free TRAM reconstruction that were performed at the Department of Surgery, Hanyang University Hospital, from August 1995 to June 2000, for age, histologic type, stage and estimated degree of patient satisfaction. RESULTS: The patient age distribution ranged from 26 to 58 years old, the mean age was 38.3, and the majority of tumors were invasive ductal carcinoma (13 cases) and intraductal carcinoma (8 cases). All tumor sizes were less than 3 cm (Tis: 8 cases, T1: 8 cases, T2: 7 cases) with the exception of the phyllodes tumors (8 cm and 6 cm). The stage was from 0 to IIB (0: 7 cases, I: 7 cases, IIA: 8 cases, IIB: 1 case, phyllodes tumor: 2 cases). Immediate postoperative complications included 3 cases of bleeding and 1 case of wound infection at the donor site. According to the patients' expressed opinions, almost all patients werepleased with the result. There was no local recurrence during the follow-up period except for one case of bone metastasis that developed. CONCLUSION: This technique undoubtedly can play a major role in the so called "onco-plastic" surgical management of breast cancer.

Cystic Neoplasms and Intraductal Papillary Mucinous Neoplasms of the Pancreas

PURPOSE: Cystic neoplasms of the pancreas are rare tumors that occurs in approximately 10~15% of all cystic lesions of the pancreas. A recent trend has been to resect all cystic neoplasms, without any attempt to preoperatively determine the exact histologic subtype. METHODS: We retrospectively reviewed the clinical records of fifteen patients with cystic neoplasms and intraductal papillary mucinous neoplasms of the pancreas who were treated surgically between January, 1991 and May, 2001. RESULTS: Patient ages ranged from 14 to 69 years with a mean of 53.4. Sixty percent of patients were women. There were 4 cases of mucinous cystic neoplasms, 7 solid pseudopapillary tumors, 3 intraductal papillary mucinous neoplasms, and 1 serous cystadenoma. The most prominant symptom was an abdominal mass. Pancreaticoduodenectomy was performed in six cases, distal pancreatectomy in five cases, excision of cyst in three cases and median segmental pancreatectomy in one case. The mortality rate from surgery was 0%, and the overall perioperative complication rate was 40%. The mean follow-up was 24 months (range from 2 months to 63 months). Two patients, both displaying intraductal papillary mucinous neoplasms, died at 9 and 14 months postoperatively. CONCLUSION: We suggest that cystic neoplasms of the pancreas including intraductal papillary mucinous neoplasm should be resected because they are malignant or pre-malignant. Endoscopic retrograde cholangiopancreatography is the imaging modality of choice for the diagnosis of intraductal papillary mucinous neoplasm. We conclude that the prognosis for resected cystic neoplasms of the pancreas is good.

A Clinical Review of 20 Initial Cases of Laparoscopic Adrenalectomy

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors due to many advantages; a more rapid and comfortable recovery, shortened hospitalization period, and fewer complications. This study reports on an initial 4 year period of experience with LA and describes various unusual findings encountered during the treatment. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Of the several LA techniques previously described we prefer the transabdominal approach in the lateral decubitus position utilizing 3 or 4 trocars, and this method was employed in all the cases presented here. RESULTS: All 20 patients had a unilateral tumor. The pathological findings consisted of 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. Of the 20 patients, 18 were successfully operated with the laparoscopic procedure and the remaining 2 cases were converted to open adrenalectomy. The reasons for conversion were sudden cardiac arrest of unknown origin in one and intraoperative bleeding due to periadrenal massive fat in the other. During LA, 2 patients with non-catecholamine-secreting cortical adenomas pathologies displayed abnormal EKG findings, which reverted to normal after the operation. The average complete LA operation times was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There were no postoperative complications, operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: LA is a relatively fast and safe method and has become is accepted as the preferred procedure for adrenal tumors but it requires good perioperative preparation. Surgeons and anesthesiologists need to be aware of the possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.

Hemosuccus Pancreaticus (Hemoductal Pancreatitis, Gastrointestinal Hemorrhage Due to Rupture of a Splenic Artery Aneurysm into the Pancreatic Duct)

Hemorrhage through the pancreatic duct into the duodenum is rare presentation of upper gastrointestinal bleeding. This condition is most commonly associated with inflammatory disorders of the pancrease with the bleeding originating from an area of hemorrhagic pancreatitis, abscess, or pseudocyst. A pseudoaneurysm of the splenic artery be can form as a result of erosion and autodigestion by the inflammatory process of this major blood vessel. More frequently, splenic artery aneurysms rupture into the greater or lesser peritoneal sacs, stomach, retroperitoneum, colon, or splenic vein. We experienced a patient with a prolonged history of upper gastrointestinal bleeding in which the diagnosis of hemosuccus pancreaticus secondary to a ruptured splenic artery aneurysm was diagnosed preoperatively. We report our experience with a review of the related literature.

Immediate Free TRAM Flap Reconstruction after Mastectomy in Breast Cancer Patients / 한국유방암학회지

PURPOSE: Despite the advocation of a breast conserving approach to the treatment of breast cancer, many women continue to surgically require or choose mastectomy for the treatment of breast cancer. In many cases, breast reconstruction after mastectomy is being performed using tissue expander, implants or a myocutaneous flap. In recent years, immediate free transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction has become an cosmetically and economically attractive alternative, compared to other types of reconstruction, although the technique is not easy. The author's experience with 25 successful immediate free TRAM flap reconstructions is reviewed. METHODS: We analyzed 25 cases of immediate free TRAM reconstruction that were performed at the Department of Surgery, Hanyang University Hospital, from August 1995 to June 2000, for age, histologic type, stage and estimated degree of patient satisfaction. RESULTS: The patient age distribution ranged from 26 to 58 years old, the mean age was 38.3, and the majority of tumors were invasive ductal carcinoma (13 cases) and intraductal carcinoma (8 cases). All tumor sizes were less than 3 cm (Tis: 8 cases, T1: 8 cases, T2: 7 cases) with the exception of the phyllodes tumors (8 cm and 6 cm). The stage was from 0 to IIB (0: 7 cases, I: 7 cases, IIA: 8 cases, IIB: 1 case, phyllodes tumor: 2 cases). Immediate posto-perative complications included 3 cases of bleeding and 1 case of wound infection at the donor site. According to the patients' expressed opinions, almost all patients were pleased with the result. There was no local recurrence during the follow-up period except for one case of bone metastasis that developed. CONCLUSION:This technique undoubtedly can play a major role in the so called "onco-plastic" surgical management of breast cancer.

Mirizzi Syndrome with Cholecystobiliary Fistula

BACKGROUND: Mirizzi syndrome is a rare presentation of long-standing cholelithiasis. It occurs when gallstones become impacted in either the gallbladder neck or the cystic duct, causing an obstruction of the common hepatic duct by extrinsic compression. Furthermore, impacted stones may cause pressure necrosis of the adjacent bile duct and produce a cholecystobiliary fistula. Although the definition of this syndrome varies somewhat among authors, Csendes et al. defined four evolving stages of patients with Mirizzi syndrome and cholecystobiliary fistulas. The aim of this study was to observe the clinical characteristics and to review the literature for better management in this clinical situation. METHODS: We retrospectively observed 7 patients who had been diagnosed with Mirizzi syndrome and cholecystobiliary fistulas perioperatively at Hanyang University Hospital. RESULTS: The 6 male patients and the one female patient had an average age of 58 years (range, 39 to 74 years). Jaundice was present in all patients. Six patients complained of abdominal pain, and two patients had acute inflammatory signs, such as fever/chill. Preoperative evaluations suggested Mirizzi syndrome in only two patients. A cholecystectomy was performed in all patients, followed by repair of the common hepatic duct and T-tube choledochostomy in three patients. A hepaticojejunostomy was required for the three difficult patients. The Csendes et al. classification was type I in one patient, type II in four, and type III in two. CONCLUSIONS: Since preoperative diagnosis of Mirizzi syndrome remains difficult, a high index of suspicion is required to diagnosis the condition, and awareness of the cholecystobiliary fistula condition is of the utmost importance for safe and optimal management.