Yao-Chi Liu

Midgut volvulus in an adult with congenital malrotation

Congenital midgut malrotation, a rare anatomic anomaly that can lead to duodenal or small-bowel obstruction, rarely is observed beyond the first year of life. Symptomatic patients present with either acute bowel obstruction and intestinal ischemia with a midgut or cecal volvulus or with chronic vague abdominal pain. Chronic symptoms often can make the diagnosis difficult. By using several modalities such as barium studies, computerized tomography, angiography, and emergency laparotomy, we diagnosed midgut volvulus and partial intestinal obstruction, which occur rarely in an adult with congenital midgut malrotation.

Long-term results of duodenectomy with highly selective vagotomy in the treatment of complicated duodenal ulcers.

BACKGROUND Highly selective vagotomy and complete circular or partial duodenectomy have been applied to complicated duodenal ulcer for many years. These procedures seem to provide better clinical results than truncal vagotomy and antrectomy. METHODS A retrospective analysis was conducted of 120 patients with complicated duodenal ulcer who underwent surgical treatment between 1986 and 1999. Patients with obstruction were treated with either circular complete (17) or partial duodenectomy (3) combined with highly selective vagotomy or truncal vagotomy and antrectomy (37). Those with perforation were treated primarily with highly selective vagotomy and partial duodenectomy, highly selective vagotomy alone, or truncal vagotomy and pyloroplasty. Every patient was followed up either by a clinic visit (75%) or questionnaire to determine the presence of ulcer pain, dumping, diarrhea, vomiting, weight loss, and Visick grade. RESULTS Long-term follow-up of patients treated with duodenectomy and highly selective vagotomy for obstruction showed that 94% had sustained weight gain whereas more than half of those treated with truncal vagotomy and antrectomy had weight loss. In patients with perforation, duodenectomy and highly selective vagotomy offered no advantage over highly selective vagotomy alone. CONCLUSIONS Highly selective vagotomy and complete circular or partial duodenectomy provide fewer sequelae and better weight gain long term than truncal vagotomy and antrectomy for patients with obstructing duodenal ulcers.

Primary squamous cell carcinoma of the liver arising from a complex liver cyst : Report of a case

A 65-year-old man who had received radiation therapy for nasopharyngeal cancer (NPC) 3 years earlier presented with a 3-week history of right upper quadrant abdominal pain and a feeling of fullness. There had been no evidence of metastasis on his follow-up examinations. Computed tomography scan showed a huge complex cyst with septa in the right hepatic lobe, and we performed an extended right hepatectomy to relieve his symptoms. Pathological examination revealed a large hepatic cyst with malignant cells along the cyst wall. The cytokeratin stain and CK-14 stains were positive, indicating an undifferentiated squamous cell carcinoma (SCC). The final diagnosis of primary SCC of the liver was confirmed by the clinical pathological features and negative in situ hybridization of Epstein–Barr ribonucleic acids (EBERs). We used EBERs to determine whether the cystic tumor was a primary lesion or a metastatic lesion from the previous NPC.

Prognostic significance of CD44v5 expression in human thymic epithelial neoplasms

BACKGROUND Cell surface glycoproteins of the CD44 family play roles in cell-cell and cell-matrix interactions. Their aberrant expression has been implicated in tumor invasion and metastasis of a variety of neoplasms, but not, to date, of thymic epithelial tumors. METHODS To investigate the expression of CD44 molecules, immunohistochemical staining using monoclonal antibodies against human CD44 standard form (CD44 s) and two common splicing variant (CD44v) isoforms, CD44v5 and CD44v6, was performed on 64 resected thymomas and 20 normal thymuses. These tumors were categorized histologically according to the World Health Organization (WHO) histologic classification, and the pathologic staging was classified according to the definitions of Masaoka. RESULTS The positive expression rates in these patients were as follows: CD44 s (normal thymuses, 10%; thymomas, 22%), CD44v5 (normal thymuses, 0%; thymomas, 67%), and CD44v6 (normal thymuses, 0%; thymomas, 26%). CD44 s and CD44v5 immunoreactivity showed a positive correlation with tumor stages (p = 0.034 and 0.027, respectively). The CD44v5 expression of neoplastic cells in tumor capsules has significant correlation with tumor stages (II, 5%; III, 70%; IVA, 100%; p < 0.001). On the basis of univariate survival analysis, the Masaoka staging system, WHO histologic classification, and CD44v5 expression showed a statistically significant positive relation to survival (p < 0.001, 0.002, 0.011, respectively). Using Coxs regression model, increasing CD44v5 expression, the Masaoka staging, and the WHO classification system were found to be significant independent prognostic factors. CONCLUSIONS CD44v5 expression is independently positively correlated with the aggressiveness of thymic epithelial tumors. The expression of CD44v5 may be a potential trigger of tumor invasion in thymomas.

Primary Malignant Mesothelioma of the Greater Omentum: Report of a Case

We report a rare case of primary malignant mesothelioma of the greater omentum. To our knowledge, only one other such case has been described in the English literature. The patient was a 61-year-old Taiwanese woman without any history of exposure to asbestos, who presented with lower back pain. Abdominal sonography and computed tomography showed a 12 × 9 × 9-cm3 mass occupying the lower abdomen. Laparotomy revealed a tumor in the greater omentum, invading the posterior wall of the uterus, without diffuse mesenteric thickening or multiple small nodules in the peritoneum. We performed en bloc resection of the mass, which involved omentectomy, hysterectomy, and bilateral salpingo-oophorectomy. Microscopically, the tumor cells were arranged in a tubulopapillary pattern lined by a single layer of uniform, cuboidal cells. A pattern of sclerotic stroma with irregular glandular elements was also recognized. Immunohistochemically, the tumor cells showed strong positivity for calretinin. The final pathologic diagnosis was malignant mesothelioma. The patient did not receive chemotherapy or radiotherapy, and has remained in good health without any evidence of recurrence for almost 3 years since her operation.

Spontaneous splenic rupture associated with hepatosplenic gammadelta t-cell lymphoma

Spontaneous splenic rupture is an uncommon but life-threatening complication of hematologic malignancies, despite the frequent involvement of the spleen in these diseases. It has been reported in patients with acute and chronic leukemia, Hodgkins disease, non-Hodgkins lymphoma, and histiocytic lymphoma. A 50-year-old previously healthy man presented with acute symptoms of spontaneous splenic rupture. Emergency splenectomy with liver biopsy was performed. The clinicopathologic features suggested a hepatosplenic gammadelta T-cell lymphoma (HSgammadeltaTL). Here, we report a rare case of spontaneous splenic rupture associated with HSgammadeltaTL, unspecified in the World Health Organization classification.

Anterior approach for a symptomatic giant hepatic haemangioma (>30 centimetre).

Haemangiomas are the most common benign liver tumour. They occur in all age groups but predominantly in women. Most haemangiomas are small and do not cause symptoms. They often do not need to be removed or treated. However, they may be large and produce a mass effect. Those with a diameter of more than 4 cm are called giant haemangiomas.1 Some of these patients with giant haemangiomas present with hepatomegaly, cardiac failure from arteriovenous shunting within the liver and coagulopathy. Secondary portal hypertension, spontaneous rupture and traumatic rupture were unusual. Although, they had been reported before.2–4Therapeutic options include steroids, hepatic artery ligation, hepatic artery embolization, radiation therapy, a-interferon, surgical resection and liver transplantation. Indications for surgical resection are usually determined by the presence of symptoms, a high risk of rupture and possible malignancy. Herein, we described a middle-age woman with a giant haemangioma (>30 cm) of the right hepatic lobe. It nearly occupied the whole right liver and increased the incidence of rupture. It is very difficult to resect the whole tumour using the conventional approach. Alternatively, the anterior approach could be adopted for this patient. We had also successfully carried out the surgery of the extended right lobectomy for the symptomatic giant haemangioma using the anterior approach. The procedure and advantage of this technique are discussed.

Unusual Presentation of Cystic Liver Metastases from Nasopharyngeal Carcinoma

Accessible online at: www.karger.com/onk Fax +49 761 4 52 07 14 Information@Karger.de www.karger.com sheet-like pattern with pleomorphism, a high nucleus/ cytoplasm (N/C) ratio, and a single distinct nucleolus. Asso ciated infiltration of lymphoplasma cells was also seen. The evidence of undifferentiated NPC was supported by positive cytokeratin-18 and latent membrane protein-1 (LMP1) histochemical stains (fig. 2). Intermittent drainage of the hepatic cystic lesions for abdominal decompression was done, and adequate analgesia with psychological treatment was performed continuously. The patient eventually died from hepatic failure (total bilirubin, 24.7 mg/dl; GOT, 295 U/l; GPT, 92 U/l; alkaline phosphatase, 612 U/l). In various reports, the incidence of distant metastases from NPC ranges from 17 to 54% [1]. Bone, lung, liver, and distant lymph nodes are the most common sites of distant metastases [2]. Liver is the third most frequent site of metastases with an incidence of 29.3–38% [1, 2]. Cystic liver metastases are rare; they usually derive from colorectal cancer [3] and rarely from pancreatic, gastric, or lung cancer [4]. The cause of the cystic change in these secondary liver tumors is not well understood. It is believed that the hemorrhage and necrosis usually present in these lesions indicate that the tumor has grown rapidly, outstripping/depleting its blood supply [5]. NPC with liver invasion usually presents solitary or multiple solid tumor metastases. Metastatic cystic hepatic lesions deriving from NPC have not been reported before, as it is difficult to distinguish these from other cystic hepatic lesions. An accurately defined diagnosis by a computed tomogram or ultrasound is not easy, and histological confirmation is necessary. Therefore, fluid cytology plus cell block by liver cyst aspiration is recommended to be performed obligatorily. Concurrent chemoradiotherapy is the standard treatment for the primary tumor site and the metastatic NPC [6]. The distant metastasis in NPC has remained the major cause of mortality and treatment failure despite better locoregional control of the disease [2]. In the case reported here, chemotherapy had a poor response in the paDear editors, In January 2005, a 35-year-old woman presented with a 2month history of enlarged nodules located on the right side of the neck and numbness of the right face. Nasopharyngeal endoscopy showed a bulging mass over the right Rosenmuller’s fossa, and a biopsy was performed. The histological diagnosis revealed nasopharyngeal carcinoma (NPC) of an undifferentiated type. Magnetic resonance imaging of the nasopharynx and neck showed an infiltrating tumor invading into the bilateral locoregional lymph nodes, skull base, and C-spines. A whole-body bone scan confirmed the NPC with bone metastases. There were no pathological findings on abdominal ultrasound. The stage of NPC was determined to be pT4N2M1, stage IVc, Eastern Cooperative Oncology Group (ECOG): 0, VAS: 1. The patient was treated by local radiation therapy combined with chemotherapy with cisplatin, 5-fluorouracil. 18 courses of these chemotherapeutic agents were administered. 1 year later, an abdominal sonogram showed multiple cystic lesions on the right liver lobe, and liver metastases were suspected. The chemotherapeutic agents were changed to cisplatin and docetaxel due to prior poor response. Over the next 6 months, the patient complained of abdominal fullness, poor appetite, and general weakness. She was then admitted to the hospital for further treatment. During hospitalization, physical examinations showed an ovoid shape of the abdomen with tenderness. Laboratory data showed: hemoglobin, 9.2 g/dl; platelets, 177,000/μl; glutamate-oxalacetate transaminase (GOT), 128 U/l; glutamate-pyruvate transaminase (GPT), 63 U/l; total bilirubin, 1.9 mg/dl; alkaline phosphatase, 442 U/l; albumin, 2.8 g/dl. A computed tomography scan of the abdomen revealed hepatomegaly with multiple huge cystic lesions over both lobes of the liver (maximal one: 16 × 17 × 19 cm) and one cystic lesion on the spleen (fig. 1). Liver aspiration with fluid cytology was performed. Histological examination showed hyperchromatic cells with oval to spindle shapes arranged in a Unusual Presentation of Cystic Liver Metastases from Nasopharyngeal Carcinoma

Carcinoid Tumor of the Spleen: Report of a Case

Abstract Carcinoid tumors are uncommon tumors of the neuroendocrine system. They grow slowly and may remain silent for years before presenting with carcinoid syndrome. A diagnosis of asymptomatic carcinoid tumor is difficult. Wide resection of the primary tumor and metastatic lesions is the first choice of treatment. Primary carcinoid is sometimes distributed through-out the entire body, but it is rare in the spleen. We herein present a rare case of a symptomless carcinoid tumor that predominantly invaded the spleen with liver metastasis.

Experience with Reversed L-Shaped Incision for Right Hemicolectomy Combined with Liver Resection

BackgroundVarious types of incisions have been applied in simultaneous resections of colorectal cancer and synchronous liver metastases. We describe our experience with the reversed L-shaped incision for simultaneous right hemicolectomy and liver resection.MethodsWe applied the reversed L-shaped incision in nine patients who underwent simultaneous right hemicolectomy and right liver resection or left hepatectomy. A reversed L-shaped incision of the abdomen was consisted of midline and transverse incisions with the junction of the umbilicus. The operative field was kept open using Kent retractors. First, right colon mobilization was performed easily and right hemicolectomy was performed. Subsequently, liver mobilization with identification of hepatic vessels was achieved and right liver resection or left hepatectomy was performed.ResultsThe reversed L-shaped incision successfully provided a good and rapid exposure in nine patients. There were no complications, such as wound infection, lung atelectasis/pneumonia, or incisional hernia, in patients with the reversed L-shaped incision.ConclusionsOur preliminary experience demonstrated that the reversed L-shaped incision might be a good choice in a subset of patients with simultaneous right hemicolectomy and right liver resection or left hepatectomy. However, a large, prospective, controlled study comparing different incision types in the same procedure with variables, such as operating time, postoperative pain scores, patient’s satisfaction, and postoperative complication, is needed to support the benefit of the reversed L-shaped incision.