Chang Ryul Park

Experience without using venoveno bypass in adult orthotopic liver transplantation

Background Venoveno bypass (VVB) has been used to achieve hemodynamic stability and decrease the incidence of renal dysfunction. However, VVB has many complications. The purpose of this study is to verify the safety of total clamping of the suprahepatic inferior vena cava (IVC) without VVB during orthotropic liver transplantation (OLT) in terms of anesthetic management. Methods Twenty-five patients without preoperative renal dysfunction who underwent primary OLT were enrolled in this study. Hemodynamic data and blood gas measurements were collected 1 hour after incision, 30 minutes after IVC total clamping and 30 minutes after reperfusion. Postoperative laboratory data, including blood urea nitrogen (BUN), creatinine (Cr) and glomerular filtration rate (GFR), were assessed at postoperative day (POD) 0-7, 30, 90, 180 and 1 year. Results Mean blood pressure was well maintained during IVC total clamping with infusion of inotropics. There was no case of severe acidosis (pH < 7.2) during the anhepatic period. The immediate postoperative Cr and GFR were not significantly different from those of the preoperative values. BUN increased from POD 1 and decreased after POD 6, while Cr increased at POD 90 only. Conclusions In patients without preoperative renal dysfunction, when IVC was totally clamped, VVB does not need to be routinely performed to maintain hemodynamics during the anhepatic phase and renal function after OLT.

Hemothorax caused by spontaneous rupture of a metastatic mediastinal lymph node in hepatocellular carcinoma: a case report.

To the Editor, The frequency of massive hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma (HCC) has been reported to be 10% to 18% because of the extensive vascular structure and relatively small amount of fibrous tissue in these tumors [1]. Hemothorax caused by rupture of a lung or pleural metastasis of HCC occurs less frequently. Although one case of cardiac tamponade caused by spontaneous rupture of a metastatic mediastinal lymph node (MLN) has been described [2], to our knowledge, no case of hemothorax due to spontaneous rupture of a metastatic MLN of HCC has been reported in the Korean- or English-language literature. We describe here a case of massive hemothorax due to spontaneous rupture of a metastatic MLN in HCC. A 60-year-old male Korean farmer was brought to the Department of Emergency, Ulsan University Hospital with dyspnea and left pleuritic chest pain within 6 hours after symptom onset. Six years earlier, he was diagnosed with chronic hepatitis B-related cirrhosis and 4 years earlier he had been diagnosed with HCC (Fig. 1A) and underwent a right hepatic lobectomy. Multiple metastatic pulmonary nodules were detected 3 months after the surgery and the patient received six cycles of a cisplatin-based chemotherapy regimen over 6 months. Contrast-enhanced computed tomography (CT) scanning showed complete disappearance of the multiple metastatic lung nodules after chemotherapy. At 8 months after finishing the chemotherapy, however, he was readmitted to our hospital due to a single metastatic nodule in the left lower lobe of the lung and underwent metastasectomy with video-assisted thoracoscopic surgery (VATS). Pathological examination of the lung nodule removed showed results consistent with metastatic HCC. Figure 1 Chest computed tomography scans showing (A) a 10-cm sized intrahepatic peripheral capsular enhanced mass, (B) a single enlarged lymph node (white arrow) in the left inferior pulmonary ligament, and (C) a 73 × 84-mm ruptured low-attenuated central ... At 1 year before admission, CT images of the chest showed a single enlarged lymph node (LN) in the left inferior pulmonary ligament, regarded as a metastatic MLN of HCC (Fig. 1B). Two weeks before this admission, follow-up CT images showed enlargement of the metastatic MLN, and the patient was scheduled for additional chemotherapy. On the day of admission, the patient experienced an abrupt onset of dyspnea and left pleuritic chest pain. Physical examination on admission revealed an acutely ill-looking man with body temperature of 36.5℃, pulse rate of 130 beats per minute, blood pressure of 100/70 mmHg, and a respiration rate of 32 breaths per minute. Laboratory test results included hemoglobin 12.3 g/dL, hematocrit 33.4%, white blood cell count 4.37 × 103/µL, platelet count 9.9 × 104/µL, aspartate aminotransferase 47 IU/L, alanine aminotransferase 60 IU/L, total bilirubin 2.0 mg/dL, albumin 3.2 mg/dL, and α-fetoprotein 819.2 ng/mL. Chest X-rays showed a massive left-sided pleural effusion, with the trachea deviated to the right side. Massive hemothorax was diagnosed by thoracentesis. CT images of the chest revealed a 73 × 84 mm-sized ruptured low-attenuated central necrotic mass with massive left side hemothorax (Fig. 1C). A chest tube was inserted and approximately 1,200 mL of bloody fluid was drained. Arteriography of the bronchial arteries revealed a massive ruptured LN in the left inferior pulmonary ligament, to which blood was supplied by an accessory bronchial artery originating 10 cm beneath the left bronchial artery. These findings indicated that the massive hemothorax was caused by a spontaneous rupture of a metastatic MLN of HCC into the intrapleural space. Transcatheter arterial embolization (TAE) of the left bronchial artery was performed successfully, injecting 13 mL of lipiodol ultraf luide (Guerbet, Aulnay-sous-Bois, France) and 30 mg of adriamycin (doxorubicin hydrochloride) with polyvinyl alcohol particles (contour emboli, Interventional Therapeutics Corp., Fremont, CA, USA) (Fig. 1D). No complication was observed and the pleural effusion gradually disappeared thereafter. The patients dyspnea improved, as did his physical condition. Following removal of the chest tube, he was discharged after 15 days in the hospital and was followed monthly as an outpatient at the department of oncology for 3 months. Serial chest X-rays revealed a decrease in the size of the MLN with lipiodol embolization. Four months later, however, the patient died at home. Due to its vascular structure and relatively small amount of fibrous tissue, spontaneous rupture of HCC is not uncommon [1]. Rupture of HCC is considered a medical emergency and is associated with high mortality. HCC frequently metastasizes, most often to the lungs, LNs, bones, and adrenal glands. Moreover, HCC metastases, like the primary tumors, may rupture spontaneously. Sohara et al. [3] reviewed 10 cases with HCC complicated by hemothorax, including four case reports in Japanese, describing patients with metastasis to the chest wall and rib, lung, pleura, diaphragm, and MLN [4]. Those reports included the first case of hemothorax from spontaneous rupture of a mediastinal metastasis [4]. Common clinical presentations are chest pain and dyspnea initially [3]. Other signs are palpitations and hypotension, consistent with hypovolemic shock. Reported rare signs included massive hemoptysis and respiratory failure. Our patient also developed hemothorax with sudden-onset chest pain, dyspnea, and tachycardia. Ruptured HCC can be treated surgically or by TAE, with the latter now used widely for HCC ruptured into the peritoneal cavity. Masumoto et al. [5] first reported hemothorax due to HCC rupture successfully controlled by TAE and our case was also successfully controlled using TAE. On the other hand, surgically treated and untreated failures have been reported and drainage-only cases do allow complete control [3]. Our patient had been diagnosed with HCC 4 years earlier and had undergone various treatments, including right hepatic lobectomy, six cycles of chemotherapy for multiple lung metastases, VATS metastasectomy for a single metastasis in the lung, and TAE for rupture of metastatic MLN causing massive hemothorax. TAE was effective, in that bleeding was successfully controlled and pleural effusion did not recur. Our findings suggest that patients with HCC should be closely monitored and suitably managed to improve survival. In conclusion, this is the first report of hemothorax secondary to spontaneous rupture of metastatic MLN of HCC in the Korean- or English-language literature. The hemothorax was successfully treated with TAE. The various manifestations observed in patients with HCC suggest the need for careful monitoring and suitable management.

Chemical Pleurodesis Using Mistletoe Extraction (ABNOVAviscum® Injection) for Malignant Pleural Effusion

PURPOSE Malignant pleural effusion (MPE) is common in patients with advanced cancer. Chemical pleurodesis can be considered for MPE that do not respond to chemotherapy, radiotherapy, or therapeutic thoracentesis. However, it is not yet clear which agent is more effective and safer in chemical pleurodesis. METHODS This study was designed as a single arm, multicenter, and open-label phase III clinical trial to evaluate efficacy and safety of chemical pleurodesis using mistletoe extraction (ABNOVAviscum(®) Injection). References of other agents in chemical pleurodesis were investigated to compare efficacy and safety. Efficacy was evaluated by followed up chest X-ray and changes of clinical symptoms and Karnofsky performance scale. Safety was evaluated by serious adverse event (SAE) and changes of laboratory findings. A follow-up period was 4 weeks after last pleurodesis. RESULTS Of 62 patients, 49 (79.0%) had complete response, 11 (17.7%) had partial response, and two had no response. Mean response rate was significantly different in this study comparing with reference response rate which was 64% (p <0.0001). There were two SAEs, but all were recovered without sequelas. CONCLUSION The results of this study suggest that mistletoe extraction (ABNOVAviscum(®) Injection) could be an effective and safe agent of chemical pleurodesis in patients with MPE.

Extraskeletal osteosarcoma arising from the pleura.

A 37-year-old woman was referred to our institution for further management of a mass lesion located in the thoracic cavity. The mass had grown by more than 10 cm over the course of a year and was initially considered to be a scar from previous pulmonary tuberculosis at another hospital. The patient had complained of left-sided flank pain for a year and experienced dyspnea for one month. Chest radiography and chest computed tomography revealed an irregular-shaped mass in the left mid to lower pleural cavity. The mass was widely excised through left thoracotomy. Pathologic examination of the biopsy specimen revealed a malignant spindle cell tumor, which consisted of components of osteosarcoma, pleomorphic sarcoma, and leiomyosarcoma. The patient underwent adjuvant chemotherapy and has been doing well without any evidence of recurrence for 14 months.

Prospective phase II trial of a combination of gemcitabine and UFT as first-line treatment in elderly patients with advanced non-small cell lung cancer.

BACKGROUND The standard regimen in elderly patients with non-small-cell lung cancer (NSCLC) is still uncertain. Gemcitabine is one of the most widely used drugs for the treatment of NSCLC, and several phase II trials specifically designed for elderly patients with advanced NSCLC have confirmed the role of gemcitabine in this setting. In addition, oral uracil-tegafur (UFT) was associated with a survival advantage in the adjuvant setting. Therefore, we performed a phase II study using the combination of gemcitabine and UFT as first-line therapy in elderly patients with advanced NSCLC. METHODS Chemotherapy-naïve, elderly (≥ 70 years) patients who had histologically or cytologically confirmed with stage IIIB or IV NSCLC with a performance status of 1-2 were enrolled. Patients received gemcitabine (1250 mg/m(2) on days 1 and 8, respectively) and UFT (400mg/day on days 1-14) every 3 weeks for up to four cycles. Patients who had not progressed after four cycles continued UFT monotherapy until progression. Primary endpoint was overall response rate and secondary endpoints were overall survival, time to progression and safety profiles. RESULTS Between March 2008 and November 2010, 48 patients were enrolled. The median age was 74.5 years (range: 70-84 years), and there were 29 males. The performance status was 1 in 41 and 2 in 7 patients. Thirty-one (64.6%) patients were stage IV and seventeen (35.4%) patients were stage IIIB. Thirty patients (62.5%) completed four cycles of chemotherapy. Response was evaluated in 44 patients. Partial response was achieved in twelve (25.0%) patients and stable disease in 23 (47.9%) patients. Disease control rate was 72.9%. The median survival time was 6.1 months (95% confidence interval [CI]; 5.1-7.0 months), the 1-year survival rate was 29.1% and the median time to progression was 4.6 months (95% CI; 3.7-5.5 months). Toxicities were mild and mostly hematological adverse events. Grade 3/4 neutropenia occurred in 8.3% of patients and one patients experienced febrile neutropenia. Grade 3/4 anemia and thrombocytopenia occurred in 2.1% and 2.1% of patients, respectively. Non-hematological toxicities were tolerable. CONCLUSIONS The combination of gemcitabine and UFT was effective in disease control and well tolerated first-line regimen in elderly patients with advanced NSCLC.

Case of bronchoesophageal fistula with gastric perforation due to multidrug-resistant tuberculosis.

Gastric perforation and tuberculous bronchoesophageal fistula (TBEF) are very rare complications of extrapulmonary tuberculosis (TB). We present a case of pulmonary TB with TBEF and gastric perforation caused by a multidrug-resistant tuberculosis strain in a non-acquired immune deficiency syndrome male patient. The patient underwent total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy and feeding jejunostomy during intravenous treatment with anti-TB medication, and esophageal reconstruction with colonic interposition and jejunocolostomy were performed successfully after a full course of anti-TB medication. Though recent therapies for TBEF have favored medication, patients with severe stenosis or perforation require surgery and medication with anti-TB drugs based upon adequate culture and drug susceptibility testing.

Non-infected and Infected Bronchogenic Cyst: The Correlation of Image Findings with Cyst Content.

We hereby report a case on bronchogenic cyst which is initially non-infected, then becomes infected after bronchoscopic ultrasound (US)-guided transesophageal fine-needle aspiration (FNA). The non-infected bronchogenic cyst appears to be filled with relatively echogenic materials on US, and the aspirate is a whitish jelly-like fluid. Upon contrast-enhanced MRI of the infected bronchogenic cyst, a T1-weighted image shows low signal intensity and a T2-weighted image shows high signal intensity, with no enhancements of the cyst contents, but enhancements of the thickened cystic wall. The patient then undergo video-assisted thoracic surgery 14 days after the FNA. The cystic mass is known to be completely removed, and the aspirate is yellowish and purulent. To understand the image findings that pertain to the gross appearance of the cyst contents will help to diagnose bronchogenic cysts in the future.

Foregut duplication cyst: a novel computed tomography finding mimicking a small bowel hernia

Rationale: A foregut duplication cyst (FDC) is an uncommon congenital disease. This report presents a case of mediastinal foregut duplication cyst that mimicked a diaphragmatic small bowel hernia. Patient concern: A 27-month-old girl was first referred for a mediastinal lesion found incidentally on a chest radiograph. At that time, our impression was cystic lung lesion such as congenital pulmonary airway malformation or pulmonary sequestration. At the age 6 years, she presented with recurrent vomiting. The physical examination and laboratory studies were within normal limits. Diagnoses: Chest CT revealed a thin- and smooth-walled cystic mass containing an air-fluid level in the left paravertebral space. It had several inner circular folds and characteristic double-layer enhancement and inner circular fold. Our radiological impression was a type I congenital cystic adenomatoid malformation. Interventions: The patients undergone video-assisted thoracoscopic surgery for excision. The operative finding was the cystic mass with smooth bowel-like outer surface and located between the aorta and heart. The cyst was excised and confirmed to be a foregut duplication cyst pathologically. Outcomes: The patient was doing well with no postoperative complications during follow-up. Recurrent vomiting was improved. This is the first case report describing foregut duplication cyst mimicking a small bowel hernia. Lessons: Foregut duplication cysts are rare congenital anomalies of primitive foregut origin. They can occur at any level of the alimentary track and comprise approximately 10% of all mediastinal tumors. Its characteristic double-layered histopathological nature, an FDC can show a double-layered enhancement pattern, which is typical in the alimentary tract.