The outcome of endoscopic management of bile leakage after hepatobiliary surgery

BACKGROUND/AIMS: Despite improvements in surgical techniques and postoperative patient care, bile leakage can occur after hepatobiliary surgery and may lead to serious complications. The aim of this retrospective study was to evaluate the efficacy of endoscopic treatment of bile leakage after hepatobiliary surgery. METHODS: The medical records of 20 patients who underwent endoscopic retrograde cholangiopancreatography because of bile leakage after hepatobiliary surgery from August 2009 to September 2014 were reviewed retrospectively. Endoscopic treatment included insertion of an endoscopic retrograde biliary drainage stent after endoscopic sphincterotomy. RESULTS: Most cases of bile leakage presented as percutaneous bile drainage through a Jackson-Pratt bag (75%), followed by abdominal pain (20%). The sites of bile leaks were the cystic duct stump in 10 patients, intrahepatic ducts in five, liver beds in three, common hepatic duct in one, and common bile duct in one. Of the three cases of bile leakage combined with bile duct stricture, one patient had severe bile duct obstruction, and the others had mild strictures. Five cases of bile leakage also exhibited common bile duct stones. Concerning endoscopic modalities, endoscopic therapy for bile leakage was successful in 19 patients (95%). One patient experienced endoscopic failure because of an operation-induced bile duct deformity. One patient developed guidewire-induced microperforation during cannulation, which recovered with conservative treatment. One patient developed recurrent bile leakage, which required additional biliary stenting with sphincterotomy. CONCLUSIONS: The endoscopic approach should be considered a first-line modality for the diagnosis and treatment of bile leakage after hepatobiliary surgery.

Complete Response of Single Nodular Large Hepatocellular Carcinoma with Pulmonary Metastasis by Sequential Transarterial Chemoembolization and Sorafenib: A Case Report

Current guidelines recommend sorafenib as the first-line molecular target agent for advanced hepatocellular carcinoma (HCC) with extrahepatic metastasis and unresectable HCC. Sorafenib was reported to show survival benefit for patients with advanced HCC. However, complete response is extremely rare in patients treated with sorafenib. Here, we report a 52-year-old man with advanced HCC and pulmonary metastasis who showed complete response by sequential transarterial chemoembolization and continuous sorafenib. Complete response was sustained for 53-month until now.

Long Term Survival in Patient with Hepatocellular Carcinoma after Surgical Resection of Brain Metastasis: A Case Report

Brain metastasis is a rare condition of extraheptaic metastases in hepatocellular carcinoma (HCC). Patients with hepatocellular carcinoma and brain metastasis have rapidly worsened neurologic signs and symptoms, therefore it is regarded to oncologic emergency. Current recommended treatments for brain metastasis are surgical resection or gamma-knife surgery with/without whole brain radiation therapy (RT). However, patients with brain metastasis have a very poor prognosis after adequate treatment. Here, we report a 62-year-old man with HCC and brain metastasis who had long term survival after surgical resection and whole brain RT.

Survival Benefit of Antiviral Agents for Hepatocellular Carcinoma Patients Treated with Sorafenib

BACKGROUND/AIMS: Nucleos(t)ide analogues (NAs) help reduce the recurrence rate after the curative treatment of hepatitis B related hepatocellular carcinoma (HCC). Sorafenib has been shown to improve survival of advanced HCC patients. Whether antiviral therapy with NAs could help such patients is unknown. Our aim is to investigate the usefulness of antiviral therapy for advanced-stage HCC treated with sorafenib. METHODS: We performed a retrospective cohort study in advanced-stage HCC patients treated with sorafenib between June 2007 and December 2013. Patients in group A (the non-antiviral therapy group) were treated with sorafenib alone. Those in group B (the antiviral therapy group) were treated with sorafenib and NAs. Progression-free survival (PS) and overall survival (OS) were compared between these two groups. RESULTS: Finally, 23 patients in group A and 40 patients in group B were enrolled in the study. The mean number of days of treatment with sorafenib was 79 (34-231) days and 96 (33-449) days for group A and B, respectively (P=0.286). The mean PS of group A and B was 97 (14-449) days and 51 (0-461) days, respectively (P=0.068). The OS was 154 (44-741) days in group A and 138 (30-1,025) days in group B (P=0.665). PS and OS showed no significant difference between the two groups. CONCLUSIONS: This study shows that there was no significant survival gain of using antiviral therapy in patients with advanced-stage HCC treated with sorafenib. In consideration of cost-effectiveness, antiviral therapy may be not mandatory.

Incidence of and risk factors for thyroid dysfunction during peginterferon alpha and ribavirin treatment in patients with chronic hepatitis C

BACKGROUND/AIMS: Thyroid dysfunction (TD) is more likely to occur in patients with chronic hepatitis C (CHC) and is particularly associated with interferon (IFN) treatment. The purpose of this study was to investigate the incidence, outcomes, and risk factors for TD during pegylated interferon (PEG-IFN) and ribavirin (RBV) combined therapy in patients with CHC. METHODS: A total of 242 euthyroid patients with CHC treated with PEG-IFN/RBV were included. Thyroid function and autoantibodies were measured at baseline, and virologic response and thyroid function were assessed every 3 months during therapy. RESULTS: TD developed in 67 patients (27.7%) during the PEG-IFN/RBV treatment. The types of TD were subclinical hypothyroidism (50.7%), hypothyroidism (14.9%), thyroiditis (11.9%), subclinical hyperthyroidism (10.4%), and hyperthyroidism (10.4%). Most of the patients with TD recovered spontaneously; however, seven patients (10.4%) needed thyroid treatment. The sustained virological response rate was higher in patients with TD than those without (65.7% vs. 49.1%, p = 0.02). Baseline thyroid stimulating hormone (TSH) concentrations (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.96 to 8.77; p < 0.001), presence of the thyroid peroxidase antibody (OR, 8.81; 95% CI, 1.74 to 44.6; p = 0.009), and PEG-IFNalpha-2b (OR, 3.01; 95% CI, 1.43 to 6.39; p = 0.004) were independent risk factors for the development of TD. CONCLUSIONS: TD developed in 27.7% of patients with CHC during PEG-IFN/RBV treatment, and 10.4% of these patients needed thyroid treatment. TD is associated with a favorable virologic response to PEG-IFN/RBV. Assessment of TSH and thyroid autoantibodies at baseline and close monitoring of thyroid function during PEG-IFN/RBV therapy are necessary for early detection and management of IFN-induced TD.

Pulmonary Cryptococcosis in a Patient with Ankylosing Spondylitis treated with Etanercept

Ankylosing spondylitis (AS) is a chronic inflammatory disorder, commonly characterized by inflammation of axial skeleton and development of enthesopathies. Tumor necrosis factor inhibitors (TNFi) shows good therapeutic responses in AS patients without good response to non-steroidal anti-inflammatory drugs. Although TNFi are relatively safe for AS patients, serious opportunistic infections, including tuberculosis and fungal infection, could develop. Here, according to our knowledge, we report a first Korean case of pulmonary cryptococcosis in a patient with AS treated with etanercept. A 64 year-old man with AS visited due to a newly appeared pulmonary nodule on a routine chest radiography. He had been administered etanercept for 5 months. Histologic findings of the lung nodule showed characteristic features of cryptococcosis. Etanercept was discontinued and oral fluconazole was administrated, as there was no evidence of central nervous system involvement. After 7 months of treatment, chest CT showed an improvement of the pulmonary lesion.

Spontaneous abdominal intramuscular hematoma in a non-dialysis chronic kidney disease patient under cilostazol therapy / 영남의대학술지

Spontaneous intramuscular hematoma of the abdominal wall is a rare condition characterized by acute abdominal pain. It is often misdiagnosed as a surgical condition. It used to be associated with risk factors such as coughing, pregnancy, and anticoagulant therapy. Most cases of abdominal wall hematomas were rectus sheath hematomas caused by the rupture of either the superior or inferior epigastric artery, but spontaneous internal oblique hematoma was extremely rare. In this report, we present a case of spontaneous internal oblique hematoma in a 69-year-old man with non-dialysis chronic kidney disease who was taking cilostazol. The patient complained of abrupt abdominal pain with a painful palpable lateral abdominal mass while sleeping. The abdominal computed tomography showed an 8 cm-sized mass in the patient's left internal oblique muscle. The administration of cilostazol was immediately stopped, and the intramuscular hematoma of the lateral oblique muscle disappeared with conservative management.

Polycythemia Vera Presenting with Generalized Chorea: A Case Report and Review of the Literature / 대한내과학회지

Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by erythrocytosis. Clinical symptoms can range in severity from headache and tinnitus to thrombohemorrhagic complications. Neurologic symptoms are common at the onset of polycythemia; however, chorea due to PV is a rare complication. We present the case of a 77-year-old female who was referred to our hospital because of choreic movement of the limbs, head and face. She was diagnosed with JAK2V617F mutation-positive PV. Her chorea was completely resolved by phlebotomy combined with hydroxyurea and aspirin.

Polycythemia Vera Presenting with Generalized Chorea: A Case Report and Review of the Literature / 대한내과학회지

Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by erythrocytosis. Clinical symptoms can range in severity from headache and tinnitus to thrombohemorrhagic complications. Neurologic symptoms are common at the onset of polycythemia; however, chorea due to PV is a rare complication. We present the case of a 77-year-old female who was referred to our hospital because of choreic movement of the limbs, head and face. She was diagnosed with JAK2V617F mutation-positive PV. Her chorea was completely resolved by phlebotomy combined with hydroxyurea and aspirin.

Hodgkin's Lymphoma after Autologous Hematopoietic Stem Cell Transplantation for Angioimmunoblastic T-cell Lymphoma / 대한내과학회지

Post-transplantation lymphoproliferative disorder (PTLD) is a serious complication that can develop after either solid organ or hematopoietic stem cell transplantation (HSCT). The incidence of Hodgkin's lymphoma (HL) ranges from 0.5-1.0% of PTLD after HSCT without T-cell depletion. Here, we report a case of HL-PTLD that occurred after autologous peripheral blood stem cell transplantation for an angioimmunoblastic T-cell lymphoma (AITL). A 36-year-old patient developed fever and chills with multiple lymphadenopathies at day 673 after auto-HSCT for AITL. Three months after the transplant, the patient developed fever with elevated plasma Epstein-Barr virus (EBV)-PCR values. The excisional biopsy revealed HL at Ann Arbor stage IIIB. A total of 8 cycles of chemotherapy with ABVD please define were performed, and the patient has remained disease-free. To our knowledge, this is first case report of HL-PTLD after auto-PBSCT in Korea.

Muscle Weakness in a Patient with History of Poliomyelitis: A Differential Diagnosis for Post-polio Syndrome (PPS) and Dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory myopathy, characterized by inflammation of the proximal skeletal muscles and typical skin manifestations, which results in symmetric muscle weakness. A 43-year-old man was presented with skin rash and left leg weakness, and he had a history of poliomyelitis. Initially, he was diagnosed as having post-polio syndrome (PPS) due to unilateral muscle weakness and a result of an the electromyography (EMG), which had shown patterns of PPS. After 4 months with conservative therapy for PPS, weakness of bilateral upper arms had developed and skin rashes on his entire body had aggravated and progressed. He was diagnosed as having dermatomyositis, based on elevated muscle enzyme levels, typical skin rashes, and typical EMG findings, which indicated muscle disease. When a patient with previous poliomyelitis has a newly developed muscle weakness or pain, we should consider various possible causes other than PPS.

Mushroom Poisoning by Podostroma cornu-damae: A Case Report and Review of the Literature

Podostroma cornu-damae is a rare species of fungus belonging to the Hyocreaceae family. Its fruit body is highly toxic, as it contains trichothecene mycotoxins. Unfortunately, it highly resembles Ganoderma lucidum and Cordyceps, well-known health foods; this can lead to poisoning. We experienced such a case of a 42-year old man who received mushroom poisoning by injesting Podostroma cornu-damae. The patient was presented with severe pancytopenia and infection. The patient recovered without any complications after conservative care, antibiotics therapy, and granulocyte colony stimulating factor administration. The most common complications of podostroma cornu-damae intoxication were reported pancytopenia, infection, disseminated intravascular coagulation, acute renal failure, etc. It is important to provide enough fluid therapy, use of antibiotics to infection and granulocyte colony stimulating factor administration.