Cheng-Chung Tsai

Risk factors of mortality in perforated peptic ulcer

OBJECTIVE To assess the risk factors that influence mortality from perforated peptic ulcer. DESIGN Retrospective study. SETTING General hospital, Taiwan. SUBJECTS 179 patients who had their perforated peptic ulcers operated on and who had minimum follow-up of one year. MAIN OUTCOME MEASURES Mortality. RESULTS The overall mortality was 15% (26/179). Of the 26 patients who died, the cause of death was uncontrolled systemic infection in 21 (81%), hypovolaemic shock in 2, and fatal arrhythmia and heart failure in 1 each. 15 of the patients who died of sepsis did not have fulminant abdominal sepsis. Most deaths occurred early after operation, (range 1-96 days). Old age, preoperative shock, and type of operation seemed to be related to these deaths on univariate analysis, but multivariate analysis showed that coexisting medical illness, delayed treatment, and low albumin concentration were independent risk factors for mortality. CONCLUSIONS To improve the result of treatment of perforated peptic ulcer, the diagnosis and treatment should not be delayed, the associated medical illnesses should be treated, and nutritional support should be given.

Is Hepatectomy Beneficial in the Treatment of Multinodular Hepatocellular Carcinoma

BACKGROUND/PURPOSE Hepatectomy remains the standard treatment for primary hepatocellular carcinoma (HCC). However, its role in the treatment of multinodular HCC (MNHCC) is unknown. METHODS The study consisted of 599 patients undergoing curative hepatic resection for HCC between October 1990 and June 2006, in which 112 patients had MNHCC (tumor number > or = 2). The type of MNHCC was classified into: A, nodules involving one or two adjoining segments; B, large tumor with satellite nodules involving three or more segments; C, three or fewer nodules that are scattered in remote segments; and D, more than three separate tumors. Univariate and multivariate analyses were used to identify the prognostic factors related to postoperative survival. During the same period of time, and from our database of 178 patients with pathologically proven MNHCC who were undergoing nonsurgical multidisciplinary therapy, 48 patients with serum albumin level > or = 3.5 g/dL, total bilirubin < 2 mg/dL, tumor number < or = 3, and tumor size < or = 5 cm were compared with 38 patients with the same condition treated with hepatectomy, in which 16 received one-block resection and 22 underwent multiple-site resection. RESULTS The overall 1-, 3- and 5-year survival rates for patients with single-tumor HCC and MNHCC were 88.0%, 69.2% and 58.4%, and 86.1%, 55.5% and 29.9%, respectively (p < 0.001). Alpha-fetoprotein > 400 ng/mL, total tumor size > 5 cm, largest tumor size > 5 cm, total tumor number > 3, microvascular invasion, non-A type MNHCC and multiple-site resection were poor prognostic factors for MNHCC in the hepatectomy group. Multivariate analysis revealed that only multiple-site hepatic resection was an independent adverse factor related to postoperative survival. In addition, patients who underwent one-block resection had significantly better survival compared with the nonsurgical group (p = 0.0016), but the multiple-site resection subgroup did not. CONCLUSION The prognosis of MNHCC is poor in comparison with that of single-nodular HCC. Hepatectomy is the treatment of choice if the tumors can be removed by one-block resection and liver function reserve is acceptable.

APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer

BACKGROUND Operating for bleeding gastric ulcer remains controversial. Gastric resection bears a higher surgical risk while limited operation may result in more postoperative hemorrhage. There has been little discussion of effective risk assessment of patients. The aim of this study is to define surgical risk by using the APACHE II scoring system, and to determine optimal management. STUDY DESIGN Records from October 1990 to December 1996 were retrospectively reviewed for patients (n=101) with bleeding gastric ulcer who had undergone emergency operation after failed endoscopic therapy. Mortality rates were examined according to different APACHE II scores, and the surgical risk was defined. From January 1997 to December 1997, 35 consecutive patients were enrolled for prospective study. Partial gastric resection (PGR) was performed for patients with huge ulcers (>2 cm) and for low-risk patients with ulcers at the antrum or angularis, while limited operation (oversewing or excision of bleeding ulcer) was reserved for others. The results were compared with the retrospective study. RESULTS In the retrospective study, the mortality rates for the group with a score < 15 and > or = 15 were 5% (3 of 63) and 58% (22 of 38), respectively (p < 0.05). In the group with a score < 15, PGR was performed on 27 patients, and one died. For those patients with a score > or = 15, PGR carried a lower mortality than limited operation, although this was not statistically significant (47% vs 65%). Limited operation resulted in an overall rate of 22% postoperative hemorrhage and 12% reoperation rate, in which all patients with a score > or = 15 died. In the prospective study, the mortality rates in those scoring <15 and > or = 15 were 6% and 50%, respectively. This is not significantly different than the retrospective study. However, the rate of postoperative hemorrhage was diminished (5%). CONCLUSIONS APACHE II score is a useful tool for assessing risk in patients with bleeding gastric ulcer. The mortality is minimal in those with a score <15, and PGR can be performed with low risk. Although high-risk patients have dreadful outcomes, limited operation cannot improve them if postoperative hemorrhage occurs. Decision making in emergency operation for such patients should be based on the ulcer conditions and the patients hemodynamic status.

The Hepatitis Viral Status in Patients With Hepatocellular Carcinoma: a Study of 3843 Patients From Taiwan Liver Cancer Network.

AbstractHepatocellular carcinoma (HCC) is the leading cancer death in Taiwan. Chronic viral hepatitis infections have long been considered as the most important risk factors for HCC in Taiwan. The previously published reports were either carried out by individual investigators with small patient numbers or by large endemic studies with limited viral marker data. Through collaboration with 5 medical centers across Taiwan, Taiwan liver cancer network (TLCN) was established in 2005. All participating centers followed a standard protocol to recruit liver cancer patients along with their biosamples and clinical data. In addition, detailed viral marker analysis for hepatitis B virus (HBV) and hepatitis C virus (HCV) were also performed. This study included 3843 HCC patients with available blood samples in TLCN (recruited from November 2005 to April 2011). There were 2153 (56.02%) patients associated with HBV (HBV group); 969 (25.21%) with HCV (HCV group); 310 (8.07%) with both HBV and HCV (HBV+HCV group); and 411 (10.69%) were negative for both HBV and HCV (non-B non-C group). Two hundred two of the 2463 HBV patients (8.20%) were HBsAg(-), but HBV DNA (+). The age, gender, cirrhosis, viral titers, and viral genotypes were all significantly different between the above 4 groups of patients. The median age of the HBV group was the youngest, and the cirrhotic rate was lowest in the non-B non-C group (only 25%). This is the largest detailed viral hepatitis marker study for HCC patients in the English literatures. Our study provided novel data on the interaction of HBV and HCV in the HCC patients and also confirmed that the HCC database of TLCN is highly representative for Taiwan and an important resource for HCC research.

Hepatitis B Genotype C Correlated with Poor Surgical Outcomes for Hepatocellular Carcinoma

BACKGROUND Genotype B and C are the predominant hepatitis B virus (HBV) strains in Taiwan. We aimed to investigate the role of genotype in HBV-related hepatocellular carcinoma (HCC) after resection. STUDY DESIGN From October 2005 to November 2008, 64 patients who underwent liver resection for HBV-related HCC were enrolled. HBV genotypes were determined by molecular method. Patient characteristics, biochemical, tumor, and viral factors were evaluated for their prognostic significance. RESULTS During a mean follow-up of 26.6 ± 13.2 months, patients infected with genotype C had higher HBV viral load (p = 0.007) and worse disease-free survival rate (p = 0.028) than patients with genotype B. By univariate analysis, genotype C, alanine transaminase >50 U/L, tumor size ≥5 cm, and microvascular invasion were associated with tumor recurrence. Further multivariate analysis demonstrated genotype C remained a significant risk factor (p = 0.034). CONCLUSIONS Genotype C is a strong risk factor for HCC recurrence after resection. More intensive monitoring for recurrence should be considered in patients with genotype C.

An unusual cause of haematemesis: Left-sided portal hypertension due to a large pancreatic tumour

A 28 year-old woman presented to our hospital after several pisodes of bloody vomitus for 1 day. The physical examinaions showed pale conjuctiva and a palpable mass over left upper uadrant of abdomen without tenderness. The laboratory tests evealed white-cell count of 11,980/Cumm with 80% neutrophils nd haemoglobin of 6.6 g/dL. An upper gastrointestinal panenoscopy showed isolated gastric varices and external compression f stomach from posterior wall of body (Fig. 1). A contrast enhanced omputed tomographic scan of the abdomen revealed a huge cystic ass, 18 cm × 11 cm × 12 cm, over the pancreatic tail and budding he splenic hilum. The splenic vein was anteriorly displaced and ompressed (Fig. 2A, arrow). Distal pancreatectomy and splenecomy were performed (Fig. 2B). The pathological diagnosis was onfirmed with mucinous cystadenoma of pancreas. The patient ecovered well and discharged in good health 5 days after the opertion. She received an upper gastrointestinal panendoscopy 1 year ater for regular follow-up and no gastric varices were presented. Left-sided portal hypertension (LSPH) is a rare clinical syndrome hich may lead to bleeding from isolated gastric varices [1]. Panreatic disease is the most common aetiology. LSPH is also one of he rare curable syndromes causing portal hypertension. Since haeatemesis is a life-threatening condition, as early to diagnose and reat as possible may result in better prognosis.

Intestinal Obstruction in Patients with Previous Laparotomy for Non-Malignancy

Background: Intestinal obstruction is one of the most common surgical emergencies. The aim of this study was to identify important management information from the evaluation of patients with intestinal obstruction who had undergone previous laparotomy for non‐malignancy. Methods: Data from 176 patients with previous laparotomy for non‐malignancy, and who were operated on for intestinal obstruction, were collected and analyzed retrospectively. Results: Gastroduodenal operations, appendectomy, and obstetric/gynecologic procedures were the 3 most common previous abdominal surgeries. More than half of all bowel obstructions developed within 10 years after previous laparotomy, and particularly within the first 5 years. Most obstructions were related to adhesion, although their etiologies were diverse. The rate of bowel strangulation was much higher in patients with internal herniation, volvulus, intussusception, closed loop, and diaphragmatic hernia than in patients with simple adhesion, bezoar, tumor, and inflammation (48.3% vs 12.2%). The surgical mortality rate correlated significantly with bowel strangulation: the overall rate was 6.8%, that in patients with strangulation was 18.8%, and that in patients without strangulation was 4.2%. Conclusion: The etiologies of intestinal obstruction were not only significantly related to bowel strangulation, but were also an important determinant of therapeutic strategy.

Metabolic risk factors are associated with non‐hepatitis B non‐hepatitis C hepatocellular carcinoma in Taiwan, an endemic area of chronic hepatitis B

Metabolic risk factors, such as obesity, fatty liver, high lipidemia, and diabetes mellitus are associated with increased risk for nonviral hepatocellular carcinoma (HCC); however, few nonviral HCC studies have stratified patients according to underlying etiologies. From 2005 to 2011, 3,843 patients with HCC were recruited into the Taiwan Liver Cancer Network. Of these patients, 411 (10.69%) who were negative for hepatitis B virus (HBV), surface antigen, HBV DNA, and anti‐hepatitis C virus (HCV) antibody were classified as non‐HBV non‐HCV (NBNC)‐HCC. Detailed clinical analyses of these patients were compared with age‐ and sex‐matched patients with HBV‐HCC or HCV‐HCC for the associated metabolic risk factors. For this comparison, 420 patients with HBV‐HCC and 420 patients with HCV‐HCC were selected from the 3,843 patients with HCC. Multivariate analyses showed fatty liver (by echography), high triglyceride levels (>160 mg/dL), and diabetes mellitus history to be significantly associated only with NBNC‐HCC and not with the matched patients with HBV‐ or HCV‐HCC. When the patients with HCC were further divided into four groups based on history of alcoholism and cirrhotic status, the group without alcoholism and without cirrhosis exhibited the strongest association with the metabolic risk factors. Based on trend analyses, patients with NBNC‐HCC with or without alcoholism were significantly different from the matched patients with HBV‐ or HCV‐HCC, except for patients with alcoholism and cirrhosis, in having more than two of the above three risk factors. Conclusion: Metabolic risk factors are significantly associated with nonviral HCC, especially for patients without alcoholism in Taiwan. Because the prevalence of viral HCC is decreasing due to the success of universal vaccination and antiviral therapy, strategies for cancer prevention, prediction, and surveillance for HCC will require modification. (Hepatology Communications 2018;2:747‐759)

Hepatobiliary Cystadenoma: Report of a Case

Hepatobiliary cystadenoma is a rare tumor and has malignant potential. Owing to its neoplastic nature, this tumor must be distinguished from simple hepatic cysts. Complete surgical resection is the recommended treatment. We report a 67-year-old woman presenting with right flank pain on urination for 4 months. Preoperative evaluation failed to provide definitive diagnosis. Enucleation of the tumor was done, and the pathologic report disclosed hepatobiliary cystadenoma of the liver. The patient was discharged 8 days after the operation and was followed up at our hospital for 22 months without evidence of recurrence. The literature concerning the entity is reviewed.

Management of Difficult Duodenal Stump: VGH-Kaohsiung Experience

Purpose: Although most peptic ulcers are currently treated successfully with medical treatment, some still need surgical intervention because of the complications caused by peptic ulcer disease, such as bleeding, perforation and obstruction. Partial gastrectomy with Billroth Ⅱ reconstruction is one of the commonly performed procedures. However, in those patients with a difficult duodenal stump, which is usually caused by chronic ulcer in the posterior wall of the duodenal bulb, the duodenal stump leakage rate is high if it is closed by a traditional method. Hence, alternative methods to the conventional duodenal closure have been reported for the management of the so-called ”difficult duodenal stump”, including Nissens closure, Bancrofts closure and tube duodenostomy, etc. We report our experience in the management of the difficult duodenal stump and present our modified method of Nissens closure. Methods: A retrospective study was performed in reviewing patients with duodenal ulcers who underwent partial gastrectomy with Billroth Ⅱ reconstruction. Patient profile, incidence of difficult stumps, method for duodenal stump closure, post-operative morbidity and mortality were collected and analyzed. We modified Nissens closure with an interrupted far-near whole layer suture for duodenal stump closure as an easier method. Results: From November 1990 to July 2002, 242 patients underwent partial gastrectomy with Billroth Ⅱ reconstruction due to complications of duodenal ulcer. The overall duodenal stump leakage rate was 13.6% (n=33). Eighty-five patients were considered to have a difficult duodenal stump and had significantly higher leakage, complication and mortality rates. No stump leakage was noted in either Nissens or our modified Nissens closure. Conclusions: Gastric resection is usually unavoidable at the management of complications of duodenal ulcer. Facing the difficult duodenal stump after gastric resection, especially in chronic and large-sized duodenal ulcers at the posterior wall of the duodenal bulb, our modified Nissens closure is a good and safe alternative method for easy duodenal stump closure.