Chi-Min Park

Pathology of cholangiocarcinoma

Different classifications using various terminologies have been used to describe the gross appearances and radiologic findings of intraand extrahepatic cholangiocarcinomas. Eggel [1] classified intrahepatic cholangiocarcinomas as nodular, massive, and diffuse. Rosai [2] classified extrahepatic cholangiocarcinomas into three types: nodular, sclerosing, and polypoid. Weinbren and Mutum [3] classified these as nodular, sclerosing, and papillary. In the radiologic literature, hilar and extrahepatic cholangiocarcinomas are classified as exophytic, infiltrating, and polypoid or papillary [4–6]. The terms sclerosing and infiltrative refer to the same type. However, terminologies such as nodular, massive, exophytic, polypoid, and papillary are ambiguous and confusing. The Liver Cancer Study Group of Japan has proposed a new classification for intrahepatic cholangiocarcinoma as mass-forming, periductal-infiltrating, and intraductal-growing based on their growth characteristics [7]. According to this new classification, the nodular or exophytic type of extrahepatic cholangiocarcinomas matches the mass-forming type, the infiltrating or sclerosing type matches the periductal-infiltrating type, and the polypoid or papillary type matches the intraductal-growing type [8]. The Japanese Society of Biliary Surgery has proposed that extrahepatic cholangiocarcinoma be classified into six types: papillary-expanding, papillary-infiltrating, nodularexpanding, nodular-infiltrating, flat-expanding, and flat-infiltrating [9]. However, this classification is redundant because it can be simplified further. Klatskin [10] recognized three main types of hilar cholangiocarcinoma as seen on laparotomy: a small fibrous nodule, a segmental stenosis, and a papillary growth. In other classifications, extrahepatic cholangiocarcinomas have been categorized as nodular, sclerosing, and papillary by macroscopic appearance [3, 11]. These classifications are based on the gross morphology of extrahepatic cholangiocarcinoma and refer to mass-forming (nodular or small fibrous nodule), periductal-infiltrating (flat, sclerosing or segmental stenosis), and intraductal-growing (papillary or papillary growth).

Completely isolated enteric duplication cyst: case report

AbstractWe present a case of a completely isolated enteric duplication cyst in a 28-year-old man. Computed tomography showed a large complex cystic mass with curvilinear and nodular calcifications near the anterior aspect of the left kidney. It had no connection to the pancreas, stomach, small bowel, or large bowel. We found no report describing computed tomographic findings of completely isolated enteric duplication cyst in the English-language literature.

Clinical Usefulness of Procalcitonin and C-Reactive Protein as Outcome Predictors in Critically Ill Patients with Severe Sepsis and Septic Shock

Sepsis is a major cause of mortality and morbidity in critically ill patients. Procalcitonin (PCT) and C-reactive protein (CRP) are the most frequently used biomarkers in sepsis. We investigated changes in PCT and CRP concentrations in critically ill patients with sepsis to determine which biochemical marker better predicts outcome. We retrospectively analyzed 171 episodes in 157 patients with severe sepsis and septic shock who were admitted to the Samsung Medical Center intensive care unit from March 2013 to February 2014. The primary endpoint was patient outcome within 7 days from ICU admission (treatment failure). The secondary endpoint was 28-day mortality. Severe sepsis was observed in 42 (25%) episodes from 41 patients, and septic shock was observed in 129 (75%) episodes from 120 patients. Fifty-five (32%) episodes from 42 patients had clinically-documented infection, and 116 (68%) episodes from 99 patients had microbiologically-documented infection. Initial peak PCT and CRP levels were not associated with treatment failure and 28-day mortality. However, PCT clearance (PCTc) and CRP (CRPc) clearance were significantly associated with treatment failure (p = 0.027 and p = 0.030, respectively) and marginally significant with 28-day mortality (p = 0.064 and p = 0.062, respectively). The AUC for prediction of treatment success was 0.71 (95% CI, 0.61–0.82) for PCTc and 0.71 (95% CI, 0.61–0.81) for CRPc. The AUC for survival prediction was 0.77 (95% CI, 0.66–0.88) for PCTc and 0.77 (95% CI, 0.67–0.88) for CRPc. Changes in PCT and CRP concentrations were associated with outcomes of critically ill septic patients. CRP may not be inferior to PCT in predicting outcome in these patients.

Decreased Expression of p12DOC-1 Is Associated with More Advanced Tumor Invasion in Human Gastric Cancer Tissues

Background/Aims: p12DOC-1 is a well-known growth suppressor; however, its role in gastric carcinogenesis is still unclear. We investigated the expression of p12DOC-1 in gastric cancer tissues and its possible correlation with p53 expression, and determined its clinical significance. Methods: Immunohistochemical staining using the tissue array method was performed on 180 human gastric carcinomas. The clinicopathological features and prognostic significance were analyzed. Results: Of the 180 tissue samples, p53 expression was positive in 85 (47.2%) and p12DOC-1 expression was negative in 140 (77.8%). The negative expression of p12DOC-1 was significantly associated with a more advanced depth of tumor invasion and stage (p < 0.05). No apparent correlation was found between p12DOC-1 and p53 expressions. The 5-year survival rate of the p12DOC-1-positive cases (53.7%) was higher than that of the p12DOC-1-negative cases (39.3%); however, neither p12DOC-1 nor p53 expression status had any statistically significant prognostic value. Multivariate analysis revealed that lymph node metastasis, distant metastasis, lymphatic invasion and perineural invasion were independent prognostic factors. Conclusions: This is the first report that suggests that p12DOC-1 may be involved in the development and progression of gastric cancer. Further studies are required to clarify its exact role in the mechanism of gastric carcinogenesis.

Clinical outcomes after rescue extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest.

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to have survival benefit in patients who had in-hospital cardiac arrest (IHCA). However, limited data are available on the role of extracorporeal membrane oxygenation (ECMO) for out-of-hospital cardiac arrest (OHCA). Therefore, we aimed to investigate clinical outcomes and predictors of in-hospital mortality in patients who had OHCA and who underwent ECPR. Methods From January 2004 to December 2013, 235 patients who received ECPR were enrolled in a retrospective, single-centre, observational registry. Among those, we studied 35 adult patients who had OHCA. The primary outcome was in-hospital mortality. Results Among 35 patients with a median age of 55 years (IQR 45–64), 29 (82.9%) of whom were male, ECMO implantation was successful in all and 10 patients (28.6%) lived to be discharged from the hospital. In 18 cases (51.4%), first monitored rhythms were identified as ventricular tachycardia/ventricular fibrillation, that is, shockable rhythm. There were no differences between in-hospital survivors and non-survivors regarding median time of arrest to cardiopulmonary resuscitation (CPR) (survivors: 23.5 min (IQR 18.8–27.3) vs non-survivors: 20.0 min (IQR 15.0–24.5); p=0.41) and median time of CPR to ECMO pump-on (survivors: 61.0 min (IQR 39.8–77.8) vs non-survivors 50.0 min (IQR 44.0–72.5); p=0.50). In 23 cases (65.7%), ischaemic heart disease was diagnosed and successful revascularisation was achieved in a significantly higher proportion of the survivor group (8/10 (80.0%)) than the non-survivor group (8/25 (32.0%)) (p=0.02). Witnessed arrest (HR=3.96; 95% CI 1.38 to 11.41; p=0.01), bystander CPR (HR=4.05; 95% CI 1.56 to 10.42; p=0.004) and successful revascularisation (HR=2.90; 95% CI 1.23 to 6.86; p=0.02) were independent predictors of survival-to-discharge in patients who had OHCA in univariate Cox regression analysis. Conclusion Survival rate for ECPR in the setting of OHCA remains poor. Our findings suggest that ECMO implantation should be very carefully considered in highly selected patients who had OHCA with little no-flow time and a reversible cause.

Feasibility and Safety of Early Physical Therapy and Active Mobilization for Patients on Extracorporeal Membrane Oxygenation.

Physical therapy (PT) and early mobilization for critically ill patients have been popularized to decrease the length of hospital stay and to improve the quality of life after discharge. We reviewed our experience of PT and active mobilization for patients on extracorporeal membrane oxygenation (ECMO) in terms of its technical feasibility and safety. Study endpoints were safety events during PT and PT interruptions due to unstable vital signs. Of the eight patients, one patient (12.5%) had venoarterial ECMO, seven patients (87.5%) had venovenous ECMO. Among total of 62 sessions including 31 sessions (50%) of passive range of motion and electrical muscle stimulation, 17 sessions (27.4%) were performed for patients who were sitting in bed or on the edge of bed, two sessions (3.2%) were for strengthening in sitting, 11 sessions (18%) were for standing or marching in place, one session (2%) was for walking. Eight sessions (13%) of sitting were supported with invasive mechanical ventilation. Three sessions (5%) were stopped due to tachycardia (n = 1) and tachypnea (n = 2). There was no clinically significant adverse event in patients. Thus, early PT and mobilization for patients on ECMO might be feasible and safe at an experienced ECMO center.

Hepatocellular carcinoma in advanced liver cirrhosis: CT detection in transplant patients

Computed tomography (CT) is being used as the standard pretransplantation imaging for recipients and donors in the evaluation of liver volume, liver reserve function, vascular anatomy, diagnosis of hepatocellular carcinoma and metastasis, and global information of the abdominal cavity. Whereas CT detection of hepatocellular carcinoma in noncirrhotic patients is satisfactory, detection sensitivity in severely cirrhotic patients is limited, with a reported sensitivity of 53% to 68%. Tumors smaller than 2 cm are more difficult to detect. Innumerable regenerative nodules, localized or diffuse fibrosis, arterioportal shunts, nodular surface, and distorted anatomy in end-stage liver cirrhosis make it difficult to detect small hepatocellular carcinoma. Because of the shortage of cadavers and living donors, judicious use of CT is necessary in the selection of candidates and the decision of priority for liver transplantation in patients with advanced liver cirrhosis.

Effect of Early Intervention on Long-Term Outcomes of Critically Ill Cancer Patients Admitted to ICUs.

Objectives:The objective of this observational study was to evaluate whether early intervention was associated with improved long-term outcomes in critically ill patients with cancer. Design:Retrospective analysis with prospectively collected data. Setting:A university-affiliated, tertiary referral hospital. Patients:Consecutive critically ill cancer patients who were managed by a medical emergency team before ICU admission between January 2010 and December 2012. Interventions:None. Measurements and Main Results:During the study period, 525 critically ill cancer patients were admitted to the ICU with respiratory failure (41.7%) and severe sepsis or septic shock (40.6%) following medical intervention by a medical emergency team. Of 356 ICU survivors, 161 (45.2%) received additional treatment for cancer after ICU discharge. Mortality was 66.1% at 6 months and 72.8% at 1 year. Median time from physiological derangement to intervention before ICU admission was significantly shorter in 1-year survivors (1.3 hr; interquartile range, 0.5–4.8 hr) than it was in nonsurvivors (2.9 hr; interquartile range, 0.8–9.6 hr) (p< 0.001). Additionally, the early intervention (⩽ 1.5 hr) group had a lower 30-day mortality rate than the late intervention (> 1.5 hr) group (29.0% vs 55.3%; p < 0.001) and a similar difference in mortality rate was observed up to 1 year. Other factors associated with 1-year mortality were illness severity, performance status, malignancy status, presence of more than three abnormal physiological variables, time from derangement to ICU admission, and the need for mechanical ventilation. Even after adjusting for potential confounding factors, early intervention was significantly associated with 1-year mortality (adjusted hazard ratio, 0.456; 95% CI, 0.348–0.597; p < 0.001). Conclusion:Early intervention for clinical derangement on general wards was significantly associated with long-term outcomes in critically ill cancer patients.

Impact of Eastern Cooperative Oncology Group Performance Status on hospital mortality in critically ill patients

INTRODUCTION This study evaluates the association between the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) and hospital mortality in general critically ill patients. MATERIALS AND METHODS This is a retrospective cohort study that analyzes prospective collected data from the Validation of Simplified acute physiology score 3 in Korean Intensive care unit study. The study population comprised patients who were consecutively admitted to participating intensive care units from July 1, 2010, to January 31, 2011. Univariate and multivariate logistic regression models were used to evaluate the effect of ECOG-PS on hospital mortality. RESULTS A total of 3868 patients were included in the analysis. There was a significant trend for increasing hospital mortality as the ECOG-PS grade became higher (P<.001). There was a trend of increasing adjusted odds ratio for hospital mortality, with grade 1 of PS 1.4 (95% confidence intervals [CIs], 1.0-1.8), grade 2 of PS 2.0 (95% CIs, 1.5-2.7), grade 3 of PS 2.9 (95% CIs, 2.1-4.1), and grade 4 of PS 2.5 (95% CIs, 1.6-3.9). Also, there was a significant difference in all grades. Subgroup analysis showed a trend of increasing hospital mortality regardless of the presence of cancer. CONCLUSION Preadmission PS, assessed with ECOG-PS in critically ill patients, has prognostic value in general critically ill patients.

Factors related to post-operative metabolic acidosis following major abdominal surgery

Metabolic acidosis is frequently observed in perioperative patients, especially those who undergo major surgery. The aim of this study was to evaluate the factors related to post‐operative metabolic acidosis and to attempt to identify the clinical effect of metabolic acidosis following major abdominal surgery.