Sang Yong Choi

Management of umbilical hernia complicated with liver cirrhosis: An advocate of early and elective herniorrhaphy

BACKGROUND Patients with umbilical hernias complicated by liver cirrhosis have an increased likelihood of complications following herniorrhaphy. The aim of this study was to investigate the clinical outcomes in patients with umbilical hernias complicated by liver cirrhosis. METHODS Between 2001 and 2010, 44 patients were enrolled in this study. The comparison between non-operative and operative group was performed. Patients who underwent emergency versus elective surgery were also compared. RESULTS Of the 44 patients, there were 33 men and 11 women. Thirty-one patients (70.5%) underwent surgery and 13 patients (29.5%) were treated conservatively. Overall morbidity and mortality rates following herniorrhaphy were 42% and 6.5%. The mean albumin level was significantly lower and total bilirubin, creatinine and mean model of end-stage liver disease score were significantly higher in non-operative group than in operative group. Combined resection was performed more frequently in the emergency group than in elective group. A significantly higher proportion of patients in emergency operation group had postoperative complications (P=0.01), especially ascites (P=0.02). The operative time and postoperative hospital stay were significantly shorter in the elective operation group than in emergency operation group. CONCLUSIONS Early, elective repair of umbilical hernias in cirrhotic patients should be advocated considering the hepatic reserve and patients condition. Ascites control is the mainstay of post-operative management.

Single-Incision Multiport Laparoscopic Cholecystectomy: Things to Overcome

OBJECTIVES To report on our initial experience with single-incision multiport laparoscopic cholecystectomy, together with its clinical outcomes. DESIGN Nonrandomized prospective study. SETTING University department of surgery. PATIENTS Sixty-four patients with gallstones and gallbladder polyps were enrolled after providing informed consent. Based on our experience, we excluded patients with acute cholecystitis, concomitant choledocholithiasis, a history of previous upper abdominal surgery, and a suspicion of gallbladder cancer. MAIN OUTCOME MEASURES We analyzed the outcomes and complications, based on our experience, according to the clinicopathologic and operative factors. We also compared patients who underwent single-incision multiport laparoscopic cholecystectomy with those who were converted to conventional laparoscopic cholecystectomy. RESULTS There were 2 bile duct injuries and 4 surgical site infections. We had difficulties in visualizing the Calot triangle in 22 patients. Higher levels of inflammatory markers, longer operation times, and more frequent bile juice spillage were significantly observed in those patients. Ten patients were converted to conventional laparoscopic cholecystectomy. The mean age of patients who underwent conversion surgery was significantly older than that of the no-conversion group. The more the body mass index increased, the more the conversion rate increased. CONCLUSIONS Experienced laparoscopic surgeons can safely perform cholecystectomy using conventional and curved laparoscopic instruments in selected patients. We recommend that you consider performing conventional laparoscopic cholecystectomy or that you use additional retraction devices for patients with a higher body mass index or acute cholecystitis.

Single-incision multiport laparoscopic cholecystectomy for a patient with situs inversus totalis: Report of a case

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis in patients with situs inversus totalis (SIT). Nowadays, singleincision multiport laparoscopic surgery is safe and feasible for treating benign gallbladder disease. We report a case of successful single-incision multiport laparoscopic cholecystectomy for a patient with SIT, and describe its technical advantages.

Hepatic Splenosis Diagnosed as Hepatocellular Carcinoma: Report of a Case

Abstract We report one case of splenosis. A 43-year-old male patient was referred to our hospital because of a hepatic mass. The hepatic lesion was incidentally found during an annual ultrasonographic follow-up since the patient was a known chronic hepatitis B carrier for the previous 10 years. Surgical records revealed a history of splenectomy in conjunction with a blunt abdominal trauma, which the patient had sustained 20 years prior to this admission. On abdominal computed tomography scanning, a 3.5-cm sized focal bulging mass was noted in segment 6 of the liver. An inferior phrenic artery angiogram showed a hepatic tumor and the patient was treated by chemoembolization for hepatocellular carcinoma. A partial resection of the liver with a portion of the diaphragm was done after the transcatheter arterial chemoembolization procedure. A pathologic examination revealed splenosis within the hepatic parenchyme.

Clinical characteristics of incidental or unsuspected gallbladder cancers diagnosed during or after cholecystectomy: A systematic review and meta-analysis

AIM To perform a systematic review of incidental or unsuspected gallbladder (GB) cancer diagnosed during or after cholecystectomy. METHODS Data in PubMed, EMBASE, and Cochrane Library were reviewed and 26 publications were included in the meta-analysis. The inclusion criterion for incidental GB cancer was GB cancer diagnosed during or after cholecystectomy that was not suspected at a preoperative stage. Pooled proportions of the incidence, distribution of T stage, and revisional surgery of incidental GB cancer were analyzed. RESULTS The final pooled population comprised 2145 patients with incidental GB cancers. Incidental GB cancers were found in 0.7% of cholecystectomies performed for benign gallbladder diseases on preoperative diagnosis (95%CI: 0.004-0.012). Nearly 50% of the incidental GB cancers were stage T2 with a pooled proportion of 47.0% (95%CI: 0.421-0.519). T1 and T3 GB cancers were found at a similar frequency, with pooled proportions of 23.0% (95%CI: 0.178-0.291) and 25.1% (95%CI: 0.195-0.317), respectively. The pooled proportion that completed revisional surgery for curative intent was 40.9% (95%CI: 0.329-0.494). The proportion of patients with unresectable disease upon revisional surgery was 23.0% (95%CI: 0.177-0.294). CONCLUSION A large proportion of incidental GB cancers were T2 and T3 lesions. Revisional surgery for radical cholecystectomy is warranted in T2 and more advanced cancers.

Peutz-Jeghers syndrome with multiple genital tract tumors and breast cancer: A case report with a review of literatures

We report here on the multiple genital tract neoplasms in a 41-yr-old Korean woman with Peutz-Jeghers Syndrome (PJS). The patient presented with lower abdominal pain. Her previous medical history was PJS and breast cancer. Pelvic ultrasound showed a multilocular cyst at the right adnexal region, diagnosed as bilateral ovarian mucinous borderline tumors. An ovarian sex cord tumor with annular tubules was incidentally diagnosed together with a minimal deviation adenocarcinoma of the uterine cervix and mucinous metaplasia of both the Fallopian tubal mucosa and the endometrium. Although the cases of multiple genital tract tumors with PJS has rarely been reported, the present case appears to be the first in Korea in which the PJS syndrome was complicated by multiple genital tract tumors and infiltrating carcinoma of the breast. The clinical significance of the multiple genital tract tumors and breast cancer associated with PJS is reviewed.

Expression and Clinical Significance of Cell Cycle Regulatory Proteins in Gallbladder and Extrahepatic Bile Duct Cancer

Disruption of cell cycle controls is a pathognomonic feature of all malignant cells. Therefore, we immunohistochemically investigated the relationship between cell cycle regulatory proteins and clinicopathologic features in order to identify the biomarkers related to the outcome of patients with biliary tract cancer (BTC). A cohort of paraffin-embedded specimens were selected from 36 patients, including 18 gallbladder and 18 extrahepatic bile duct cancers, who underwent curative or palliative surgical resection at Korea University Medical Center from June 1998 to December 2004. Tissue microarrays were used to investigate the immunohistochemical staining for p21, p27, p53, cyclin D1, bcl2, and Ki-67. Univariate and multivariate survival analyses were performed to determine the prognostic significance of each protein expression. Absence of p21 expression independently predicted poor outcome in all cases. Well-differentiated tumor was found to be an independent good prognostic factor in gallbladder cancer. Absence of p21 expression and moderately to poorly differentiated tumor were found to be an independent poor prognostic factor in patients with negative for neural invasion. Absence of p21 and bcl2 were found to be an independent poor prognostic factor in patients with no lymph node metastasis. Absence of p21 expression was a significant independent poor prognostic factor in BTC, partly in patients with biologically less aggressive phenotypes. This finding suggests that determination of p21 expression in surgically resected specimens may provide prognostic information in addition to conventional pathologic findings for patients with BTC, especially those who have biologically less aggressive phenotypes.

An interesting hepatic mass: Splenosis mimicking a hepatocellular carcinoma (2003:9b)

We report a splenosis mimicking hepatocellular carcinoma in a patient with chronic liver disease. Knowledge of these imaging findings, including helical CT, angiography, CT hepatic arteriogram, CT arterioportogram, and iodized-oil CT, may obviate unnecessary surgery.

Hepatocellular carcinoma in extrahepatic bile ducts

An elongated solid lesion observed on ultrasonography and CT in the biliary tree causing a smooth filling defect on cholangiography was observed in 2 patients. No tumor was observed in the liver parenchyma either on radiography or at operation. Histopathology showed hepatocellular carcinoma. After removal of the intraductal tumors, recurrence was observed in 2 and 6 months, respectively.

Molecular mechanism of HIF-1-independent VEGF expression in a hepatocellular carcinoma cell line

Hypoxia-inducible factor-1 (HIF-1) is a master transcription factor that plays a central role in the hypoxic expression of various genes. Vascular endothelial growth factor (VEGF), a known target gene of HIF-1α, has been shown to be induced by hypoxia through a HIF-1α-independent pathway. HIF-1α dominant-negative lentiviral vectors were introduced to decrease the expression of HIF in Hep3B cells. Cells were incubated under normoxic or hypoxic conditions. We performed a VEGF enzyme-linked immunosorbent assay (ELISA) using cell culture supernatants, and Western blotting using cell lysates. To validate signaling via HIF-1-dependent or HIF-1-independent pathways, we treated cells with an extracellular signal-regulated kinase (ERK) kinase inhibitor, a phosphoinositide 3-kinase (PI3K) inhibitor, and transfected cells with siSP1. HIF-1α protein expression was induced and the levels of VEGF increased under hypoxic conditions. Cells were transfected with siHIF-1α and incubated under normoxic or hypoxic conditions. We found that a significant amount of VEGF was produced by a HIF-1-independent pathway. PI3K inhibitor treatment and siSP1 transient transfection decreased VEGF expression in siHIF-1α-transfected cells. Therefore, VEGF regulation in Hep3B cells is primarily controlled by the Akt/PI3K and SP1 pathways and is independent of HIF-1 under hypoxic conditions.