Pai-Ching Sheen

Pyogenic Liver Abscess: An Audit of 10 Years’ Experience and Analysis of Risk Factors / with Invited Commentary

Background/Aims: Despite continuous improvement in image modalities, availability of potent antibiotics and advancement in the knowledge and treatment of pyogenic liver abscess, mortality remains high. The high mortality rate has underlined the important role of prognostic factors and prompts a number of studies to identify the risk factors. The present study aims to audit our experience in managing patients with pyogenic hepatic abscess during the period of 1989–1999, and to document changes in etiology, bacteriology and outcome, and to identify any risk factor associated with mortality. Methods: One hundred and thirty-three patients with pyogenic hepatic abscess were studied to determine the demographic characteristics, clinical features, laboratory, bacteriological findings, methods of treatment, final outcome and risk factor analysis. All patients were treated with parenteral antibiotics. One hundred and twelve patients were subjected to ultrasound-guided percutaneous aspiration of the abscess. A percutaneous drainage catheter was inserted after aspiration in all patients. Laparotomy was done in 21 patients. Results: The overall hospital mortality rate was 6% (8/133). Biliary tract disease was the most frequently identified cause. Leukocytosis, hypoalbuminemia and hyperbilirubinemia were common laboratory findings. The most common microorganism cultured was Klebsiella pneumoniae. The most common concomitant disease was diabetes mellitus. On univariate analysis, large abscess, diabetes mellitus and sepsis were significantly associated with hospital mortality. On multivariate logistic regression analysis, the presence of sepsis (p = 0.0031) was found to be an independent risk factor. Conclusions: In addition to early diagnosis and prompt treatment, making every effort to treat patients with adverse prognostic factors and systemic complications, the hospital mortality rate will be decreased significantly.

Assessment of serum and bile levels of CA19-9 and CA125 in cholangitis and bile duct carcinoma

In this study, CA19‐9 and CA125 in serum and bile were measured to evaluate their diagnostic value in cholangitis and bile duct carcinoma. Patients were classified into three groups: group A, the control group, had cholelithiasis without infection (n= 23), group B had acute cholangitis (n= 25) and group C had bile duct carcinoma without bacterial infection (n= 18). All patients had undergone surgery, and bile and serum of the patients were measured for the two tumour markers by radio‐immunoassay. The positivity rate for serum CA19‐9 was 4.4% in the control group, 28.0% in group B and 61.1% in group C. The positivity rates for serum CA125 in groups control, B and C were 0%, 4% and 27.78% respectively. The diagnostic accuracy for bile duct carcinoma was 67.4% for both CA19‐9 or CA125. The concentration of CA19‐9 in bile was more than 1200 ng/mL in 72% of patients with acute cholangitis, in 61.1% of all patients with bile duct carcinoma and 0% in the control group. The frequency of concentrations of CA125 in bile greater than 200 ng/mL was 38.89% in bile duct carcinoma and none was observed in the control or acute cholangitis groups. In conclusion, the concentration of CA19‐9 was increased not only by the tumour itself, but also by infection. In the diagnosis of bile duct carcinomas, the sensitivity of CA125 was low but its specificity was very high.

Immunohistochemical Study of DPC4 and p53 Proteins in Gallbladder and Bile Duct Cancers

Gallbladder and bile duct carcinomas belong to the family of biliary tract tumors, but they demonstrate different clinical behavior. We evaluated a series of biliary tract carcinomas to determine whether they also had genotypic differences by analysis of the tumor suppressor genes DPC4 and p53. Twenty-one gallbladder cancers, 20 intrahepatic bile duct carcinomas, and 10 extrahepatic bile duct carcinomas were retrieved from the surgical pathology files of Kaohsiung Medical University Hospital. Sections were immunostained with monoclonal antibodies to the DPC4 and P53 proteins. Statistical differences between gallbladder cancer and bile duct carcinomas were determined using ?2 analysis or the Fisher’s exact test, when appropriate. Two of the 21 gallbladder cancers (9.5%), 7 of the 20 intrahepatic bile duct carcinomas (35%), and five of the 10 extrahepatic bile duct carcinomas (50%) were negatively labeled for DPC4. The differences were significant between gallbladder carcinoma and both intrahepatic bile duct carcinomas (p = 0.023) and extrahepatic bile duct carcinomas (p = 0.012). A higher frequency of P53 overexpression was found in gallbladder cancers (61.9%) than in intrahepatic bile duct carcinomas (26.3%) (p = 0.024). This study suggests that the DPC4 gene may play a limited role in gallbladder carcinoma; however, p53 gene mutation is more frequently found in gallbladder cancers. In contrast, DPC4 deletion may be more common in bile duct carcinomas, especially in those arising from the extrahepatic bile duct. These findings support the concept that gallbladder and bile duct carcinomas are different tumors with differing etiologies and tumorigenesis.

Ultrasound-Guided Percutaneous Cholecystostomy as an Initial Treatment for Acute Cholecystitis in Elderly Patients

Background/Aims: Acute cholecystitis may atypically present itself in the elderly, thus causing diagnostic and therapeutic problems, and it is well recognized as a high-risk condition for morbidity. The outcome has been attributed to the presence of servere co-morbid disease. In an attempt to minimize the postoperative morbidity and mortality, we performed ultrasound-guided percutaneous transhepatic cholecystostomy (PC) on elderly patients with acute cholecystitis for both initial treatment and subsequent diagnosis of their biliary tract disorders. Methods: Those being more than 70 years old, had acute episode of cholecystitis for more than 48 h and still had positive Murphy’s signs and distended gallbladders were candidates for ultrasound-guided PC. Results: Forty-two elderly patients underwent ultrasound-guided PC. Once the condition of each patient showed signs of improvement and stability, cholangiography was performed via PC tube. The results of the cholangiography showed 20 patients with gallbladder stones, 16 with common bile duct stones and 6 with acalculous cholecystitis. Once stable enough, 32 patients underwent definite surgery, 18 having cholecystectomies, 14 having cholecystectomies and choledocholithotomies. The 6 patients with acalculous cholecystitis had the PC tube removed 3 weeks later, without further surgery. Two patients had gallbladder stones removed by choledochofiberscope. Two patients had common bile duct stone removed by endoscopic sphincteroplasty. Although postoperative complications occurred in 5 patients (11.9%), no instance of operative mortality was found. Conclusion: Our findings lead us to conclude that the use of PC in the early treatment of acute cholecystitis in elderly patients can decrease postoperative morbidity and mortality.

Long-Term Results of One Hundred and Seven Hepatic Resections for Intrahepatic Stones

During 11 years, 107 of 586 patients (18.3%) with intrahepatic stones underwent hepatic resection to remove intrahepatic stones at Kaohsiung Medical College Hospital. Guided by the location of the int

Mucin Content in Gallbladderswith Brown Pigment Stones orCombination Stones with a Brown Periphery

Background/Aims: Gallbladder mucus itself has been recognized to play an important role in gallstone development. Despite the diverse mechanisms of stone induction and the differences in stone composition, there is a quantitative increase in the epithelial mucus production period before stone formation. As brown pigment stones are found frequently in gallstone disease, we conducted a study on gallbladders with brown pigment stones or combination stones with a brown periphery to evaluate the mucin content in the gallbladder epithelium in comparison to gallbladders with cholesterol stones and those without stones. Methods: Gallbladder specimens were fixed in 10% formalin immediately after cholecystectomy and then embedded in paraffin. The specimens were sectioned for periodic acid-Schiff-alcian blue (PAS-AB, pH 2.5) double stain to evaluate the intra-epithelial mucin content. The PAS-AB index was calculated as a proportion of the PAS-AB-positive mucin area to the total epithelial area, using a computerized image analyzer. Results: Evaluation of the PAS-AB index on the lining epithelia of gallbladders showed that it was 32.43 ± 9.96% in gallbladders with brown stones, which is significantly (p < 0.001) higher than in gallbladders with cholesterol stones (15.63 ± 6.75%) and gallbladders without stones (9.55 ± 4.77%). Conclusion: The results show that gallbladders with brown stones contain more abundant mucin than gallbladders with cholesterol stones or those without stones. They also suggest that the gallbladder epithelium per se might play a more important role in stone formation in those with brown stones than in those with cholesterol stones.

Proliferating Cell Nuclear Antigen Expression in Peribiliary Glands of Stone-Containing Intrahepatic Bile Ducts

All cases of hepatolithiasis showed features ofchronic proliferative cholangitis, and it has beenspeculated that the atypical glandular proliferationmight be a precursor to overt cholangiocarcinoma. Proliferative cell nuclear antigen (PCNA) is anuclear protein synthesized in the G1/S phaseof the cell cycle and therefore is related to cellproliferative activity. In an attempt to assess the activity of cell proliferation ofstone-containing intrahepatic bile ducts, we conducteda study using immunohistochemical staining withmonoclonal antibody to score PCNA in intrahepatic bileducts. Thirty patients (10 men, 20 women; mean age52.4 years) having hepatolithiasis surgically resectedwere studied. Ten stone-free patients served ascontrols. All 40 specimens were immunostained for PCNA using PC 10 monoclonal antibody. PCNA of bothstone-containing and stone-free intrahepatic bile ductswere assessed by counting positive staining nuclei per500 cells and expressed as labeling index (LI), ie, percentage of positive nuclei to the totalnumber of nuclei. The PCNA LI in stone-free intrahepaticbile ducts was generally low: 10.0 ± 13.2%, 10.4± 10.7% and 7.9 ± 9.6% for extramuralglands, intramural glands, and epithelial lining,respectively. In contrast, the PCNA LI forstone-containing intrahepatic bile ducts weresignificantly higher than those of controls (P <0.001): 49.4 ± 8.3%, 40.6 ± 7.0% and 34.1± 6.8% for extramural glands, intramural glands,and epithelial lining, respectively. The extramuralglands had a significantly higher PCNA LI (P < 0.001)than the intramural glands and controls. Hyperplasia was found inall specimens, while dysplasia was found in six of 30cases with hepatolithiasis. The dysplastic cells alsohad a higher PCNA LI (P < 0.001) than thehyperplastic cells and normal epithelium. Our findingsshowed that there is marked increase of activity of cellproliferation in stone-containing intrahepatic bileducts. It is well known that genetic mutations are facilitated in proliferating cells. Therefore,our results suggest that the high epithelial turnover indysplastic cells and extramural glands had higherpotential for proliferation and neoplastictransformation in long-standing untreatedhepatolithiasis.

Percutaneous post-operative choledochofiberscopic lithotripsy for residual biliary stones

SummaryA total of 5,116 post-operative percutaneous choledochofiberscopy (POC) sessions were performed on 739 patients with residual bile duct stones between 1980 and 1988. These residual stones were detected and removed by choledochoscopy. The success rate of non-surgical stone removal using POC was 100% for residual common duct stones and required 414 treatment sessions in this group of 168 patients. The success rate was 92.2% (525/569) for patients with residual intrahepatic stones; in this group a total of 4,694 treatment sessions were needed. Two patients with residual cystic duct stones were also successfully treated with POC. The distribution of residual intrahepatic stones was as follows: 166 (29.2%) in the right hepatic duct, 255 (44.8%) in the left hepatic duct and 148 (26.0%) in both hepatic ducts. Complications after POC were minimal and subsided after conservative treatment except in 2 patients. One patient had hemobilia and another a large subphrenic abscess, which required surgical drainage. Choledochofiberscopic electrohydraulic shockwave lithotripsy was effective treatment for large stones and was well tolerated. Residual stones in Oriental gall-stone disease are not preventable, and we believe that POC should be the first choice for these patients. Many of the problems associated with residual stones can be overcome by this method and good results achieved.

Spontaneous multiple cholecystoenteric fistulas--a case report.

Spontaneous multiple cholecystoenteric fistulas are relatively rare complications of chronic cholecystitis. One cholecystoduodenal and two cholecystocolonic fistulas were observed in a 65-year-old woman whose symptoms included fever, chills, jaundice, diarrhea, and prolonged right upper quadrant pain. Pneumobilia, which is a pathognomonic sign of bilioenteric fistula, was also detected by her plain abdomen X-ray on admission. Both types of fistulas were correctly diagnosed preoperatively by barium enema, upper GI series and endoscopic retrograde cholangiopancreaticography. The patient was referred for surgery and fistulas were identified during laparotomy. Cholecystectomy, division of these fistulas, and primary repair of these bowel defects were successfully performed. The postoperative course was unremarkable. We report this unusual case and briefly review the hypothesized pathogenesis, typical symptomatology, radiographic diagnosis, complications and therapeutic modalities of this condition.

Solid and Cystic Tumor of the Pancreas - Three Cases Report

Solid and cystic tumor of the pancreas is a rare, low-grade malignant tumor that predominantly occurs in young women. Clinically, the patients are often asymptomatic and are usually found incidentally due to other diseases. The pre-operative diagnosis is difficult due to the similarity to other cystic pancreatic lesions (such as serous adenoma, mucinous cystadenoma and endocrinologically inactive islet cell tumor), or inflammatory changes (such as pancreatic pseudocyst). This tumor has a slow growth, usually does not have metastases and has a favorable prognosis. Complete removal is the treatment of choice for the tumors arising anywhere in the pancreas. We collected specimens of pancreatic tumors that were kept at Kaohsiung Medical University Hospital (KMUH) in the past 11 years. Three cases varying in clinical course were found. The first is a case of a middle aged woman with a slow growing tumor who had a misdiagnosis of pseudocyst eight years ago. The second is a case of a young woman that showed no symptoms, while the third case was also a young woman diagnosed with a huge tumor with portal vein and inferior vessel encasement. We review some articles to revise the study of this disease in order to make the correct diagnosis before proceeding with the operation, and to provide proper treatment.