Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

Early Experience of Laparoscopic Management of Choledochal Cyst

PURPOSE: The total excision of choledochal cyst with gallbladder is a treatment of choice due to the high risk of the development of cancer in a biliary tree. The cosmetic result as well as cure of disease is important in the management of this disease. Here we report the early experience of totally laparoscopic excision of a choledochal cyst and hepaticojejunostomy using 4 holes methods. METHODS: Between October 2003 and May 2005, we performed totally laparoscopic choledochal cyst excision in twelve patients. All were female except one male with a mean age 37.3 (range: 17~62) years. According to the Todani classification, five were type Ia, four type Ic and three type IV. Choledochal cyst excision and Roux-en-Y hepaticojejunostomy was entirely performed laparoscopically using 4 port technique. RESULTS: The mean operation time was 228 (150~330) minutes. There was no operative or postoperative transfusion. An oral diet was started on the 3rd operative day. The average length of hospital stay was 5.8 days. There was no major complication associated with anastomosis leakage or obstruction. All patients have showed no specific symptoms or laboratory abnormalities during 2~19 months follow-up periods. CONCLUSION: Considering that choledochal cyst is common in young ages and females, who are especially interested in cosmetic results as well as cure of disease, laparoscopic management of choledochal cyst can be an attractive treatment option.

Clinical Outcome and Predictive Factor of Splenectomy in Patients with Idiopathic Thrombocytopenic Purpura

PURPOSE: Splenectomy is an important treatment modality for the patients with idiopathic thrombocytopenic purpura (ITP), but the response rate of splenectomy for ITP patients is variable and the predictive factors of the postoperative response are uncertain. The purpose of this study is to investigate the response rate of splenectomy and find the predictive factors of splenectomy in ITP patients. METHODS: We reviewed the medical records of 54 consecutive patients who underwent splenectomy and were followed up. A positive response to splenectomy was defined as a postoperative platelet count greater than 50, 000/microliter without medication. We analyzed the following variables to find the predictive factors for splenectomy; age, gender, disease duration, platelet count at diagnosis, preoperative platelet count, early response to steroid, IVIG response, operative method, accessory spleen and postoperative platelet count. RESULTS: The response rate of splenectomy was 60% at the 1st postoperative month, 46% at the 3rd postoperative month and 37% at the 6th postoperative month. The age of the splenectomy responders at the 6th postoperative month was significantly lower than that of the non-responder (33.4+/-14.5 years versus 48.7+/-17.1 years, p< 0.05). The platelet count at the time of discharge of the splenectomy responders was significantly greater than that of the non-responders (378, 429+/-272, 399/microliter versus 191, 731+/-151, 435/microliter, p< 0.05). These results were significant on multivariate analysis. CONCLUSION: The response rate of splenectomy is decreased according to the passage of time during the early postoperative period, so long term follow up is important to investigate the predictive factors. Young age for the patients and high platelet count at discharge can be used as the predictive factors for splenectomy in ITP.