Biliary Cast Successfully Removed by Percutaneous Transhepatic Cholangioscopy, and This Developed in a Patient Who Received Orthotopic Liver Transplantation

"Biliary cast syndrome" describes a cast formed from retained lithogenic material, and this cast is morphologically confined to the bile duct; this develops in 4∼18% of liver transplant recipients. The pathogenesis of cast formation is not clearly understood. The proposing etiological factors for biliary cast syndrome include acute cellular rejection, a prolonged cold ischemic time, use of postoperative biliary drainage tubes and biliary infection. These casts are more likely to develop in the setting of hepatic ischemia and biliary stricture. Endoscopic and percutaneous cast extraction might achieve favorable results and this should be attempted before surgical therapy. We report here on a case of biliary cast syndrome that was secondary to orthotopic liver transplantation; this was successfully treated via percutaneous choledochoscopic removal. We also include a review of the literature.ope

Hepatoid carcinoma of the pancreas combined with neuroendocrine carcinoma.

Hepatoid carcinoma is a primary extrahepatic carcinoma whose morphology, immunohistochemistry, and behavior are similar to those of hepatocellular carcinoma. The most common sites of extrahepatic carcinoma are the stomach and ovary, but nine cases of hepatocellular differentiation of the pancreas have been reported in the literature. We report another case of hepatoid carcinoma of the pancreas that was associated with the development of a pancreatic endocrine carcinoma in a 46-year-old man. Serum alpha-fetoprotein (AFP) was elevated to 262.49 IU/mL and radiological examinations revealed a mass measuring 7.5 cm in diameter in the head of the pancreas. He underwent a conventional Whipple operation, and light microscopy showed adenocarcinoma that was immunopositive for AFP, hepatocyte antigen, cytokeratin, chromogranin, synaptophysin, and alpha-1 antichymotrypsin. Although hepatoid differentiation was not shown unequivocally histologically, other immunohistochemistry findings supported the diagnosis of hepatoid carcinoma combined with neuroendocrine carcinoma. The patient was healthy and had no evidence of recurrence at 4 months after the surgery. This report describes why hepatoid carcinoma should be considered as a differential diagnosis of a pancreatic mass, especially when serum AFP is elevated.ope

A Case of Aortobronchial Fistula with Massive Hemoptysis after Aortic Stent Graft

Aortobronchial fistula may cause a massive fatal hemoptysis. Recently prosthetic aortic graft insertion or endovascular stent graft is a cause of aortobronchial fistula. We report a rare case of hemoptysis from a fistula between an aortic arch aneurysm and the left main bronchus in a patient who had undergone an endovascular stent graft in pseudoaneurysm of descending thoracic aorta one year before.ope

인체 담낭암에서의 Hedgehog 신호전달체계 물질의 발현에 관한 분석

Dept. of Medicine/석사[한글] 배경: Hedgehog (Hh) 단백은 소화기암 발생에 필수적인 물질로, Hedgehog 신호 전달 체계의 혼란은 소화기암의 발생과 연관되며, 또한 최근 조혈 및 신경 줄기세포의 자가재생 능력의 조절과 연관되는 것으로 알려져 있는 Bmi-1은 Hedgehog 신호전달체계의 하류 전사 인자로써 작용한다. 이러한 과정들이 적절히 조절되지 못할 경우 암 발생의 중요한 원인이 되며, 이러한 사실들은 종양줄기세포를 표적으로 하는 치료적 접근의 합리적 가능성을 제시한다. 한편, 담낭암은 전세계적으로 드문 암이지만 그 발생률에 있어서 상당한 지역적 편차를 보이며 늦은 진단과 불만족스러운 치료성적으로 인해 예후가 좋지 않은 암으로 알려져 있어 새로운 치료방법의 개발이 절실히 요구되고 있다.목적 및 방법: Shh, Patched-2, Gli-1 및 Bmi-1을 포함하는 Hedgehog 신호전달체계가 인체 담낭암에서 어떤 역할을 하는지 알아보기 위하여, 2000년 1월부터 2006년 6월까지 신촌 세브란스 병원에서 담낭암으로 수술적 절제를 받은 환자로부터 얻은 담낭암 조직을 사용하여 면역화학염색 및 역전사효소 중합 연쇄반응을 시행하여 암의 분화도와 병기 등에 따른 차이를 평가하였다.결과: 총 59명의 환자 중에서 19명(32.2%)은 남성이었고 40명(67.8%)은 여성이었으며, 환자의 평균나이는 61(범위: 28-80)세였다. 각각 4쌍의 정상과 암 조직의 역전사효소 중합 연쇄반응 비교에서, 정상조직에 비해 담낭암 조직에서 Shh, Ptc-2, Gli-1 및 Bmi-1의 발현이 상대적으로 증가되어 있었으며 (Shh, 100%(4/4)., Ptc-2, Gli-1, Bmi-1, 75%(3/4)), 면역화학 염색에서는 Shh, Ptc-2, Gli-1과 Bmi-1에 대하여 각각 77.0 % (47/59), 80.4% (49/59), 77.0% (47/59) ,71.2% (42/59)의 환자에서 양성반응을 보였다. 낮은 병기일수록 강하게 염색되는 경향을 보였지만 (Shh p = 0.002., Bmi-1 and Ptc-2 p < 0.001., Gli-1 p = 0.001)., 담낭암의 분화도와 면역염색 정도간에 통계적 유의성은 없었다 (shh p = 0.108., Bmi-1 p=0.689., Ptc-2 p= 0.804., Gli-1 p = 0.613). 또한, Shh, Ptc-2, Gli-1 및 Bmi-1 모두 염색강도가 높을수록 더 긴 생존기간을 갖는 경향을 보였지만 Bmi-1만이 통계적으로 의미 있는 연관성을 보였다 (Shh p = 0.276., Bmi-1 p = 0.025., Ptc-2 p = 0.626., Gli-1 p = 0.574).결론: Hedgehog 신호전달체계와 Bmi-1은 인체 담낭암의 발현에 관여하고, 특히 Bmi-1은 예후와 강한 연관성을 보이지만, 암이 진행됨에 따라 인체 담낭암에서 이들의 역할은 점차 감소한다. [영문] Background: Although gall bladder (GB) cancer is not a common neoplasm, it shows significant geographic variation in incidence. GB cancer is often diagnosed in advanced stage, obviating curative resection. In advanced stage GB cancers are not amenable to radiotherapy or chemotherapy. It is necessary, therefore, to elucidate molecular mechanism leading to cancer in order to develop effective treatment methods.Hedgehog (Hh) protein is an essential molecule for normal development of the gastrointestinal tract and the maintenance of the stem cell population, and disruption of Hh signaling is linked to various gastrointestinal tumors. Bmi-1, which is a member of polycomb gene, has recently been identified to play a role in the regulation of stem cell self-renewal and function as a downstream target of the Hh pathway. Deregulation of these processes during carcinogenesis may result in derangement in a stem cell compartment, a key event in carcinogenesis. Strategies aimed at inhibiting these pathways represent a rational therapeutic approach to target cancer stem cells.AIMS & METHODS: We performed Hh immunohistochemical staining (IHC) and reverse transcription-polymerase chain reaction (RT-PCR) to investigate the role of Hh signaling and Bmi-1 in human GB cancers. We also analyzed the change of expressions according to tumor stage and degree of differentiation. The GB cancer samples were obtained from patients who underwent radical surgery for GB cancer at the Severance hospital from January 2000 through June 2006. Immunohistochemical staining was carried out using formalin-fixed paraffin section and RT-PCR using fresh frozen tissue for the Hh signaling components (Shh, Ptc-2, Gli-1) and Bmi-1.RESULTS: Among the total of 59 patients, 19(32.2%) were male and 40(67.8%) were female. Mean age was 61(range: 28-80) years. On RT-PCR, the Ptc-2, Gli-1, and Bmi-1 mRNA levels were increased in human gallbladder cancers compared to non-tumorous tissue. On immunohistochemical staining, 77.0 % (47 of 59), 80.4% (49 of 59), 77.0% (47 of 59), and 71.2% (42 of 59) of the GB cancers were positive for Shh, Ptc-2, Gli-1, and Bmi-1, respectively. The expressions of Shh, Bmi-1, Ptc-2, and Gli-1 (Shh p = 0.002; Bmi-1 and Ptc-2 p<0.001; Gli-1 p = 0.001) was, however, inversely correlated with tumor stage, showing more robust expression in tumors with earlier stage.There was no difference in the levels of expression and the degrees of histologic differentiation of tumors. (Shh p = 0.108; Bmi-1 p = 0.689; Ptc-2 p = 0.804; Gli-1 p = 0.613). Strong expression of Bmi-1 gene was associated with longer survival (shh p = 0.276; Bmi-1 p = 0.025; Ptc-2 p = 0.626; Gli-1 p = 0.574).CONCLUSION: The results suggest that the Hh signaling pathway and Bmi-1 may play a role in the initiation of GB carcinogenesis. As cancers progress, they become less dependent on the Hh signaling and Bmi-1.ope

미소전극을 이용한 수중 중금속의 동시 분석

학위논문(석사) - 한국과학기술원 : 화학과, 2000.2, [ v, 44 p. ]Heavy metal ions such as zinc, cadmium, lead and copper in water were analyzed with microelectrode. Platinum microelectrodes were made by the chemical vapor deposition (CVD) process, and mercury was electroplated on platinum to yield a mercury microelectrode. Metal ion analysis was performed with these mercury coated microelectrodes. Employing the square wave anodic stripping voltammetry (SWASV) technique with the microelectrode, Cu, Zn, Cd, and Pb could be detected simultaneously. Their peak currents were directly proportional to ion concentration and detection limit was several ppb. The same experiment was carried out in the condition without supporting electrolyte. Cd and Pb were still analyzable and there was no loss in sensitivity. In all experiments, there was no need to stir sample solutions. The analytic performance enhanced by reducing the size of working electrode. The sensitivity increased to the detection limit of 1 ppb and fast response was achieved to shorten the analysis time.한국과학기술원 : 화학과

미소 전기화학센서의 제작 및 활용

학위논문(박사) - 한국과학기술원 : 화학과, 2005.2, [ iv, 98 p. ]Increasing concerns for environmental control, health care and effective process monitoring have created considerable demands for innovative analytical methodologies. New devices and protocols with in situ real-time monitoring capability are particularly needed for addressing the challenges. The coupling of modem electrochemical detection principles with recent advances in molecular recognition, microelectronics, and microfabrication has led to powerful, compact, and ``user-friendly`` analytical devices. The unique features of such electrochemical monitoring systems make them particularly attractive for addressing environmental and industrial problems. These developments allow the instrument to be taken to the sample (rather than the traditional way of bringing the sample to the laboratory) and hence to ensure effective process or pollution control. Such devices can perform automated chemical analyses in complex matrices and provide rapid, reliable and inexpensive measurements of a variety of inorganic and organic pollutants. To match the increasing demand to chemical sensor systems, electrochemical sensors were made in our laboratory. The electrochemical sensors including solid state reference electrode, silicon based in situ FT-IR cells, micro environmental sensors, and indium-tin oxide based enzyme sensors are introduced in this article These sensors were examined by various electrochemical techniques such as cyclic voltammetry, bulk electrolysis and square wave anodic stripping voltammetry as well as other traditional analytical methods like spectrometry and ICP/MS. They were proven to be powerful sensors, and these sensors can be applied in many practical situations. The detailed explanation to individual sensor is given in each chapter.한국과학기술원 : 화학과

A pilot study of capsule endoscopy for the diagnosis of radiation enteritis

BACKGROUND/AIMS: Capsule endoscopy may be a useful diagnostic tool for radiation enteritis in select situations. We conducted this pilot study to test feasibility of capsule endoscopy in the diagnosis of radiation enteritis. METHODOLOGY: Patients who received chemoradiotherapy to treat pancreatic cancer were enrolled. To increase the diagnostic yield of radiation enteritis, capsule endoscopy was performed in patients having anemia or chronic abdominal pain after chemoradiotherapy. RESULTS: Fifteen patients were enrolled between June 2007 and December 2008. The mean age was 63.4 +/- 8.0 years. The median radiation dose was 5040cGy with range of 4500-5994cGy. The mean total operating time of capsule was 10h 12 min +/- 2h 37 min, and the complete examination rate to the cecum was 93.3%. Nine patients (60%) were suspected to have radiation enteritis, and of these, five (33.3%) had abnormal findings that strongly suggested radiation enteritis. Congested mucosa and erythematous mucosa were the most frequent abnormal lesions. No capsule retention or other complications occurred. CONCLUSIONS: Capsule endoscopy may safely and effectively diagnose radiation enteritis in patients previously treated with chemoradiotherapy on the upper abdomen, although a larger trial is needed to confirm this.ope

Effectiveness of self-expanding metal stents for malignant antropyloric and duodenal obstruction with a comparison between covered and uncovered stents

BACKGROUND/AIMS: We evaluated overall clinical outcomes when self-expanding metal stents were used to treat malignant gastroduodenal obstruction; we also evaluated the differences in technical feasibility, effectiveness, and outcomes between covered and uncovered stents. METHODOLOGY: We reviewed 134 patients who underwent endoscopic treatment for malignant antropyloric and duodenal obstructions with self-expanding metal stents. RESULTS: In all but two cases, the procedures were successful in restoring passage through the obstruction. Forty-two patients (31.8%) experienced stent failure during the follow-up period (23/79 (29.1%) with uncovered stents, 19/53 (35.8%) with covered stents). Stent migration was the most common cause for failure in covered stents (73.7%), while tumor ingrowth was the most common cause in uncovered stents (52.2%). The median technical survival in the uncovered stent group was similar to covered stent group (253 days vs. 247 days, p>0.05). Improvement of oral intake was associated with improvement in performance score, which was significantly improved following stent insertion (p<0.05). In addition, patients whose performance score was improved by stenting had better survival than those who did not (median survival 173 days vs. 74 days, p<0.05). CONCLUSIONS: Endoscopic stenting for malignant gastroduodenal obstruction appears to be an effective therapeutic modality in terminally ill patients, irrespective of the type of stent. Improvement in stent technology will improve patients' oral intake, which in turn will improve patients' quality of life and survival rate.ope

Assessment of the Definition of Early Extrahepatic Bile Duct Cancer through the Prognosis Analysis of Patients Who Had Received Curative Resection

Background/Aims: The definition of early extrahepatic bile duct cancer might be different from that of other gastrointestinal cancer because of the differences of histologic features including the lack of muscularis mucosa and submucosal layer in bile duct. The purpose of this study was to evaluate the concept of early extrahepatic bile duct cancer in Korea. Methods: We evaluated seventynine cases of extrahepatic bile duct cancer who had received curative resection in Severence Hospital, Yonsei University from March 1986 to October 2005. We retrosptectively reviewed the medical records and analyzed variable prognostic factors to define early extrahepatic bile duct cancer. Results: Invasion limited to the mucosa was noted in 5 cases (6.3%), fibromuscular layer in 12 cases (15.2%), adventitia of fibromuscular layer and serosa in 26 cases (32.9%), and invasion of adjacent organs in 36 cases (45.6%). Disease free 5-year survival according to the depth of invasion were 80.7% in tumor confined within mucosa, 80.0% within fibromuscular layer, 57.2% within adventitia of fibromuscular layer and serosa, and 51.5% in tumor with invasion of adjacent organ. There was no significant difference in the survival rate between patients with tumor confined to mucosa and patients with tumor invasion limited to the fibromuscular layer. However, the survival rate of patients with tumor limited to the mucosa or fibromuscular layer was significantly higher than that of patients with tumor invaded beyond fibromusular layer. In early cancer, there were more papillary polypoid type in gross finding and papillary adenocarcinoma in pathologic finding when compared to advanced cancer. Conclusions: Early extrahepatic bile duct cancer can be defined as the tumor invasion limited to the mucosa and fibromuscular layer.ope

Self-expandable metal stents for recurrent malignant obstruction after gastric surgery

BACKGROUND/AIMS: It is well known that endoscopic insertion of self-expandable metallic stents (SEMS) is safe and effective for the palliative treatment of malignant strictures involving the upper gastrointestinal tract. But, most previous studies focused on stent insertion for esophageal or gastroduodenal obstructions. Only a few cases of stent insertion for recurrent malignant obstruction after gastric cancer surgery have been reported in studies in fewer than 40 patients. The aim of this study was to evaluate the clinical effectiveness of the placement of SEMS in patients with anastomotic recurrence after gastric cancer surgery and compare the clinical outcome according to stent and operation type. METHODOLOGY: The data were collected from 47 patients in whom SEMS were placed by endoscopic approach for recurrent malignant obstruction after gastric cancer surgery. Technical and clinical success and complications according to operation and stent type were evaluated. Also, Overall survival and stent patency rates were calculated. RESULTS: Stent placement was technically successful in 45 of the 47 patients (95.7%). After stent placement, 91.5% of the patients showed improvement in their dietary intake level. A statistically significant improvement in overall Gastric Outlet Obstruction Scoring System between pre- and postprocedure was noted (p<0.001). Stent failure occurred in 13 patients (stent migration: 4; tumor overgrowth: 1; tumor ingrowth: 8). The median survival and stent patency period were 101 days and 63 days, respectively. CONCLUSIONS: SEMS insertion in patients with anastomotic recurrence of gastric cancer after gastric cancer surgery is technically feasible and clinically effective.ope