Laparoscopic cholecystectomy: a report of 409 consecutive cases and its future outlook

A retrospective study was conducted on 409 patients who underwent laparoscopic cholecystectomy at Teikyo University Hospital between May, 1990 and October, 1992. The operation had to be converted to an open cholecystectomy in ten of these patients because of uncontrollable bleeding from the cystic artery in one, venous bleeding due to portal hypertension in one, extensive adhesions of the omentum and the duodenum to the gallbladder in two, extensive adhesions around the gallbladder in four, and extensive adhesions between the gallbladder and the common bile duct (CBD) in two. The time taken to complete the procedure ranged from 30 to 235 min, the average time being 81 min, and the postoperative hospital stay ranged from 3 to 56 days, the average stay being 6.5 days. Eleven patients developed complications intra- or postoperatively: bile duct injury which became manifest after the operation and required laparotomy in three patients; injury to the right hemidiaphragm resulting in a right pneumothorax in one; periumbilical subcutaneous emphysema in one; mild bile leaks which resolved in a few days in two; and a severe bile leak which resolved after 6 days in one. The indications for laparoscopic cholecystectomy have widened with experience and now, CBD stones and a history of previous gastrectomy are no longer contraindications for laparoscopic cholecystectomy. Thus, it seems that laparoscopic cholecystectomy can be performed as safely as a standard cholecystectomy, provided the patients are selected properly and appropriate caution is exercised.

Novel factor Xa and plasma kallikrein inhibitory-activities of the second Kunitz-type inhibitory domain of urinary trypsin inhibitor

Urinary trypsin inhibitor is a glycoprotein with a structure in which two Kunitz-type inhibitory domains are linked in a row. We isolated two genes encoding the 70 amino acid sequence from the 78th amino acid (Thr) to the C-terminal and the 68 amino acid sequence from the 80th (Ala) to the C-terminal of human urinary trypsin inhibitor, both which correspond to the second Kunitz-type inhibitory domain, and then constructed expression plasmids by ligating it to the E. coli alkaline phosphatase signal peptide gene. These plasmids under the control of the tryptophan promoter expressed the second domain in E. coli strain JE5505 which lacks the membrane lipoprotein. The recombinant second domain purified from the culture supernatant of the transformant inhibited trypsin, plasmin, leukocyte elastase and chymotrypsin which are known to be inhibited by urinary trypsin inhibitor. In addition it inhibited blood coagulation factor Xa and plasma kallikrein in a concentration dependent and competitive manner, and significantly prolonged the plasma-based activated partial thromboplastin time (APTT). The truncated natural counterpart obtained by a limited degradation of human urinary trypsin inhibitor also revealed the identical inhibitory activities.

Impaired immunity in obesity: suppressed but reversible lymphocyte responsiveness

Although obese people have been reported to have a higher incidence of infections and some types of cancer, the immunocompetence of obese subjects remains poorly understood. To investigate whether obesity affects immunity, we studied obese subjects (BMI > 30 kg/m2) whose health was uncomplicated by any other disorder, including hyperglycemia. We compared mitogen-induced blastogenic response of peripheral blood lymphocytes in 34 obese subjects (mean +/- s.e. BMI: 38.4 +/- 2.0 kg/m2) and 35 non-obese controls (BMI: 21.3 +/- 0.4 kg/m2) who were matched for age and sex. The effects of weight reduction were also evaluated in 19 obese persons (BMI: 36.4 +/- 1.8 kg/m2) on a very low calorie diet. Mean (+/- s.e.) intracellular incorporation of [3H]-thymidine, on stimulation of T lymphocytes with either phytohaemagglutinin (PHA) or concanavalin A (Con A), and B lymphocytes with pokeweed mitogen, was significantly diminished in obese subjects compared to non-obese controls (47552 +/- 6917 vs. 83720 +/- 6252 cpm, P < 0.001; 30301 +/- 6018 vs. 45942 +/- 3723 cpm, P < 0.05; 13669 +/- 2971 vs. 23735 +/- 2048 cpm, P < 0.01, respectively). After weight reduction (BMI: 27.8 +/- 1.2 kg/m2), the mean T lymphocyte responses to PHA and Con A were increased significantly vs. baseline (98404 +/- 2444 vs. 50337 +/- 9516 cpm, P < 0.05 and 69523 +/- 15480 vs. 36695 +/- 8006 cpm, P < 0.05, respectively). Depressed blastogenesis of B lymphocytes was also augmented but was not statistically significant. The results suggest that obese subjects have underlying immune impairment in responsiveness of lymphocytes and that these impairments are reversible with adequate weight reduction.

Weak N activity of En(a-) human erythrocyte membranes

The propositus's erythrocytes with phenotype En(a-), which was found for the first time in a Japanese family, reacted more weakly with anti-N serum than the ordinary phenotype N erythrocytes. The En(a-) erythrocytes lack the major membrane sialoglycoprotein (glycophorin A) as demonstrated by Bio-Gel 1.5m gel filtration from active sialoglycoproteins, which were isolated from En(a-) erythrocyte membranes by the method of lithium diiodosalicylate (LIS)-phenol extraction. It is suggested from observation via enzyme-linked immunosorbent assay (ELISA) that N activity is derived from the glycophorin B molecule on En(a-) erythrocyte membranes.

[Separation of glycoproteins from cyst fluids of human ovarian cystomas in benign and their some chemical and serological properties]

Perchloric acid-soluble fractions (PASFs 1-3) which were obtained from cyst fluids of two patients [(Nos. 1 (blood group B) and 2 (blood group A))] with ovarian mucinous cystadenoma and one patient (No. 3 (blood group A)) with ovarian dermoid cyst in benign, were identified as glycoproteins by their chemical composition analyses, respectively. Reactivities of PASFs 1-3 against blood group anti-sera and lectins suggest that these PASFs did not contain MN blood group substances, Vgu glycoproteins and T-active glycoproteins. PASF 1 was separated into 11 fractions by Sephacryl S-500 gel filtration. From chemical composition, SDS-PAGE and serological property of the main fraction (Fr. 5), other one fraction (Fr. 7) and mild acid hydrolysates of these two fractions, it is possible to presume that PASF 1 consisted of a large number of AB-active and fucose-rich glycoproteins with high molecular weights and some of these glycoproteins bear either NeuNAc alpha 2-->6GalNAc (sialyl Tn) group or both sialyl Tn and sialylated T groups.

[Magnetic stimulation of the facial nerve]

Intracranial activation of the facial nerve and the face-associated motor cortex are now possible with noninvasive magnetic stimulation techniques. Compound muscle action potentials (CMAPs) and the Blink reflex, in response to magnetic stimulation, were investigated. Subjects were 10 normal controls and 2 Bell's palsy patients. CMAPs were elicited in the orbicularis oris muscle by magnetic stimulation at the parieto-occipital skull and stylomastoid foramen. Furthermore, CMAPs were evoked by a magnetic coil oriented over the cortex. CMAP recording was possible with magnetic stimulation and the latencies of CMAPs at the parieto-occipital skull were slightly greater than those at the stylomastoid foramen. In 10 normal subjects, the mean onset latency following transcranial magnetic stimulation of the facial nerve at the parieto-occipital skull was 5.07 msec (SD = 0.40), while transcutaneous latency at the stylomastoid foramen was 2.77msec (SD = 0.539). In the blink reflex, R1 latency was 10.99 msec (SD = 1.27), ipsilateral-R2 latency was 37.46 msec (SD = 2.57), and contralateral-R2 latency was 38.925 msec (SD = 3.20). The blink reflex thus had a configuration similar to that evoked by conventional electrical stimulation. In the patients with Bell's palsy, CMAPs elicited by magnetic stimulation were of low amplitude with normal latency. However, in the blink reflex, only a contralateral R2 response could be recorded, and R1 and ipsilateral-R2 showed no response to stimulation at the affected side. Investigation of patients with Bell's palsy using this technique may therefore prove useful in the evaluation of peripheral facial nerve disorders.

Strong immunogenicity of a multicomponent peptide vaccine developed with the branched lysine oligopeptide method for human immunodeficiency virus infection

We synthesized one V3 peptide each from HTLV-IIIB, Thai A and Thai B, conjugating them to the T cell epitope of the env region, and we also synthesized a p17 protein peptide of the gag region (HGP-30). These peptides were then coupled to 8-lysine copolymers using N-succinimidyl maleimido carboxylate (M(r) = ca 60,000). We designated this the branched lysine oligopeptide method. The large peptide complexes constructed from these four macromolecular peptides were used with aluminium hydroxide or complete Freund's adjuvant to immunize mice and rabbits four times. ELISA assay showed high titres of anti-peptide antibodies to each V3 loop peptide and the HGP-30 peptide. Strong inhibition of CD4+ dependent cell fusion was obtained with these antisera when IIIB, Thai A and Thai B strains of the human immunodeficiency virus (HIV) were used. Strong anti-fusion inhibition was also observed with two other HIV strains. In addition, an increase of the anti-HIV effect was observed when we used sera obtained by multicomponent vaccine immunization. The same kind of inhibition was also observed in p24 assay systems using these immunized antisera. Activation of IL-2 production in lymphocytes was observed in mice immunized with this vaccine. These results suggest that immunization with macromolecular peptide complexes can result in strong immunogenicity towards HIV-1.

[Serological property of perchloric acid-soluble glycoprotein fractions of human meconium]

Perchloric acid-soluble fractions (PASFs) were separated, in yields of 87.0-151.9 mg per 1.0 g of wet meconium sample, from six samples of human meconium, and identified as glycoproteins having 41.2-74.1% carbohydrate by chemical composition analysis. Six PASFs reacted with anti-A, -B, -Lea and -Leb sera, but did not react with anti-M and -N sera. These PASFs alos reacted with many lectins such as DBA, UEA-I, Vicia graminea lectin (VGA), Vicia unijuga lectin (VUA), Con A, WGA, RCA-I, PHA-E, SBA, SJA, and influenza A and B viruses. The serological results show that six PASFs contained VGA or VUA-binding (Vgu) glycoproteins as new oncofetal substances, but did not contain M and N blood group substances.

[Percutaneous transhepatic cholangioscopic lithotripsy]

With an advent of cholangiofiberscope in 1975, tremendous changes have been made in thinking way on the treatment of biliary tract stones. The technique of percutaneous transhepatic cholangioscopy (PTCS) was detailed and its clinical significance was discussed in this paper. PTCS is the technique which is conducted by insertion of cholangiofiberscope into the biliary tract through the dilated fistula produced by percutaneous transhepatic biliary drainage (PTBD). Advantages of this techniques are; (1) it is applicable to the cases who had had bilio-enteric anastomosis or gastro-jejunostomy before, (2) it can be repeatedly carried out if the fistula is maintained open, (3) stones visible are readily removable with the instruments guided by cholangiofiberscope and finally, (4) the informations necessary to select an adequate surgical procedure can be obtained by PTCS, because biliary architecture is clearly delineated. For the period of 18 years started from 1975, 126 cases with intrahepatic stones have been encountered in our Hospital, endoscopic stones extraction technique was successful in 106 out of 121 cases excluding 5 cases converted for hepatic lobectomy. And the prognosis of the cases in which stones were successfully extracted were, in general, good. Therefore, the authors believe that the therapeutic results would be significantly improved with the routine use of PTCS.

Dephosphorylation of microtubule-binding sites at the neurofilament-H tail domain by alkaline, acid, and protein phosphatases

The dephosphorylation-induced interaction of neurofilaments (NFs) with microtubules (MTs) was investigated by using several phosphatases. Escherichia coli alkaline and wheat germ acid phosphatases increased the electrophoretic mobility of NF-H and NF-M by dephosphorylation, and induced the binding of NF-H to MTs. The binding of NFs to MTs was observed only after the electrophoretic mobility of NF-H approached the exhaustively dephosphorylated level when alkaline phosphatase was used. The number of phosphate remaining when NF-H began to bind to MTs was estimated by measuring phosphate bound to NF-H. NF-H did not bind to MTs even when about 40 phosphates from the total of 51 had been removed by alkaline phosphatase. The removal of 6 further phosphates finally resulted in the association of NF-H with MTs. A similar finding, that the restricted phosphorylation sites in the NF-H tail domain, but not the total amount of phosphates, were important for binding to MTs, was also obtained with acid phosphatases. In contrast to alkaline and acid phosphatases, four classes of protein phosphatases (protein phosphatases 1, 2A, 2B, and 2C) were ineffective for shifting the electrophoretic mobility of NF proteins and for inducing the association of NFs to MTs.

Isolation and influenza virus receptor activity of glycophorins B, C and D from human erythrocyte membranes

(1) Glycophorins (GPs) AM, AN, B, C and D were each isolated into a high state of purity from human erythrocyte membranes by a combination of lithium diiodosalicylate (LIS)-phenol extraction, gel-filtration with Bio-Gel A1.5m and HPLC with LiChrospher 1000 TMAE. (2) GPs-B, -C and -D reacted with influenza A and B viruses as well as GPs-AM and -AN and the order of reactivities against two viruses of the glycophorins was as follows: GP-B > GP-C > GP-AM = GP-AN >> GP-D for the former virus and GP-C > GP-B > GP-AM = GP-AN >> GP-D for the latter virus.

Strong synergistic effects of multicomponent vaccine for human immunodeficiency virus infection

Several peptides were synthesized, based on sequences of the HTLV-IIIB, HTLV-IIRF, and HTLV-IIIMN strains. These corresponded to the V3 region, the killer T cell activating site, the constant region of env, gag region protein and the helper T cell activating site. Some of these peptides were coupled to keyhole limpet hemocyanin (KLH), and some of them were polymerized with m-maleimido benzoyl-N hydroxysuccinimide ester (MBS). These peptides were used to immunize rabbits and mice. Antisera from immunized animals showed good levels of inhibition of CD4-dependent cell fusion by in vitro HIV infection. The antisera also inhibited the production of p24 protein in the HIV-infected culture system. Interestingly, a strong synergistic HIV growth inhibition by antiserum was observed when we immunized animals with multicomponent vaccine. In addition, substantial levels of HIV antigen-specific IL-2 producing and interferon-gamma (IFN-gamma) producing cells were also observed in lymph node cells from vaccinated mice. These results suggest that immunization with multicomponent vaccine can induce high levels of humoral antibodies as well as activate HIV-specific cellular immunity.

Activation of Ca2+/calmodulin-dependent protein kinase II by stimulation with bradykinin in neuroblastoma x glioma hybrid NG108-15 cells

To elucidate the mechanisms of the intracellular signal transduction elicited with bradykinin in NG108-15 neuroblastoma x glioma hybrid cells, we examined the activation of Ca2+/calmodulin-dependent protein kinase II (CaM kinase II) by bradykinin stimulation. When the extract of NG108-15 cells was immunoprecipitated with the affinity-purified antibody to brain CaM kinase II, a 50-kDa protein in the immunoprecipitate mainly became autophosphorylated in a Ca2+/calmodulin-dependent manner. The results suggest that the 50-kDa protein is the subunit of CaM kinase II in NG108-15 cells. The Ca2+/calmodulin-independent activity (autonomous activity) of the enzyme increased twice within 10 s by stimulation with 1 microM bradykinin in the cells. The increase in the autonomous activity of the enzyme had two phases: the transient early-peak phase and the long late-plateau phase. The former was abolished by the pretreatment of the cells with 10 mM caffeine or 20 microM BAPTA-AM, and the latter was abolished by the removal of the extracellular Ca2+ with 1 mM EGTA or by the pretreatment with 1 microM nifedipine. Stimulation of 32P-labeled NG108-15 cells with 1 microM bradykinin increased the autophosphorylation of CaM kinase II and this increase was abolished by pretreatment with caffeine or BAPTA-AM. These results suggest that CaM kinase II is activated via the inositol phospholipid signaling pathway induced with bradykinin in NG108-15 cells.

Red cell velocity and microvessel diameter measurement by a two fluorescent tracer method under epifluorescence microscopy: application to cerebral microvessels of cats

Fluorescein isothiocyanate (FITC)-labeled red blood cells (RBCs) and rhodamine-B isothiocyanate (RITC)-labeled dextran were used as two fluorescent tracers under intravital fluorescence microscopy. RBC velocity in cerebral microvessels of cats was measured with a dual window technique using FITC-labeled RBCs as a flow tracer. Measurement of the vessel diameter was performed using a digital image processor system by staining plasma with RITC-labeled dextran. The RBC velocity, obtained directly with digital cross-correlation of videodensitometric signals derived from the two windows, coincided with those obtained with the frame-by-frame analysis. The obtained RBC velocity ranged between 12.9 and 0.45 mm/sec in arterioles (< 60 microns) in diameter, 4.2 and 0.18 mm/sec in venules (< 60 microns in diameter), and 1.1 and 0.26 mm/sec in capillaries. The use of the labeled RBCs as the flow tracer enabled us to measure a wide range of RBC velocity (up to about 7 mm/sec) by setting the distance between the two windows beyond about 200 microns.

Preliminary experience using an ultrasonic aspirator for laparoscopic cholecystectomy

An ultrasonic aspirator (Olympus) specially designed for laparoscopic surgery, which also includes cautery and suction-irrigation systems, was evaluated in 40 patients undergoing laparoscopic cholecystectomy. The generating power of each system is controlled by hand or foot switches, and most operating procedures could easily be performed through a 10 mm trocar inserted through the abdominal wall. The ultrasonic aspirator successfully fragmented and aspirated soft tissue, allowing a precise differentiation between the cystic duct and artery, small vessels, lymphatics and fibrous tissue. Removal of the gallbladder could be performed successfully using the cautery and ultrasonic aspirator, whereby parts of cauterization or division could easily be identified. Identification of the cystic duct and artery, course of the cystic duct and Hartmann's pouch in the same field of vision was possible which is important for avoiding major complications such as injury of the common bile duct. No complications were seen during or after surgery in any of the patients.

[Experimental study on the effect of injection with anticancer agent-oil suspension]

Local injection of an anticancer agent guided by endoscopy is thought to be effective for cancerous lesion associated with lymph node metastasis, if the anticancer drugs are drained into the lymph nodes. In the experimental study, anticancer drug-oil (nimustine-Lipiodol) (N-L) suspension (5 mg/ml) was injected into the tumor (Lewis lung cancer) that had been implanted sub dorsally in mice (57 black/6 mice) for the purpose of finding out the antitumor effect on the primary lesion. Then it was injected into sarcoma-180 that had been implanted into hind feet of mice (ICR mice) for the purpose of finding out the antitumor effect on metastatic lymph nodes. The results showed that the N-L suspension was effective for the primary cancerous lesion and metastatic lesions.

A fuzzy logic controller

This paper describes a fuzzy sets method which is very useful for handling uncertainties and essential for knowledge acquisition of a human expert. Kinetics of a reactor is often complex and not trivial to describe by mathematical equations. Reactor control by traditional control technology is therefore difficult. A novel technology is presented. In the following a fuzzy inference (approximate reasoning) is used for decision making in analogy to human thinking, facilitating a more sophisticated control. Readers of this paper do not need any advanced mathematics beyond the four basic operations in arithmetic (+, -, x, divided by) and using the maximum and minimum values. This fuzzy inference is introduced to construct a fuzzy logic controller which is suitable for a nonlinear, multivariable and time variant system applied to a bioreactor.

Fistuloscopy for the management of postoperative intra-abdominal abscesses

A new technique of fistuloscopy for evaluation and treatment of postoperative intra-abdominal abscesses is described which was used in 8 patients in whom drainage of abscesses following surgery was insufficient. A cholangiofiberscope was introduced into the fistula canal produced by the postoperative drainage. Fistuloscopy was combined with fistulography in all cases to delineate the extent of the inflammatory process. The guidewire was then placed under visual control through the endoscope followed by re-introduction of the drainage tube until a position most effective for pus drainage was achieved. Following this procedure, fever resolved in all 8 patients. Fistuloscopy is recommended to achieve sufficient drainage of intra-abdominal abscesses in those cases where percutaneous ultrasound- or CT-guided drainage fails to lead to significant clinical improvement.

Synthesis and structure-activity relationships of substituted 2-[(2-imidazolylsulfinyl)methyl]anilines as a new class of gastric H+/K(+)-ATPase inhibitors. II

A series of 2-[(2-imidazolylsulfinyl)methyl]anilines (2) having various substituents on their imidazole and aniline rings was synthesized and examined for their H+/K(+)-ATPase (adenosine triphosphatase) inhibitory effects and antisecretory activity against histamine-stimulated gastric acid secretions in Heidenhain pouch dogs. Although substitutions on the imidazole ring did not enhance biological activity, substitutions on the aniline ring by electron-donating substituents potently enhanced the enzyme inhibitory activity and also showed an inhibitory effect on histamine-stimulated gastric acid secretion after oral administration. In particular, the in vitro activity of the dimethyl (2u--w) and trimethyl (2ac) derivatives was about 10 times that of omeprazole. Also, 4-methyl (2k), 4-methoxy-5-methyl (2y) and 3,5-dimethyl-4-methoxy (2ab) derivatives showed a potent antisecretory effect of more than 80% after oral administration at 6 mg/kg. Although these aniline derivatives have relatively low stabilities in aqueous solution, replacement of the isobutyl group at the aniline nitrogen atom with N-(2-methoxyethyl) group enhanced the stability.

Cell-free plasma layer in cerebral microvessels

Two diameters of vessel and red cell column in cerebral microvessels (> 29.8 microns in diameter) of cat were measured together with red cell velocity, using a two fluorescent tracer method. A fluorescein isothiocyanate (FITC)-labeled red cell was adopted as a flow tracer to measure the cell velocity with a dual window technique. Based on the fluorescence image, the red cell column diameter was measured. Plasma was stained with rhodamine-B isothiocyanate (RITC)-labeled dextran to measure the vessel diameter. The thickness of the cell-free plasma layer could be determined from the difference of the two diameters. The obtained thickness of the cell-free layer was not described by a simple function of vessel diameter or red cell velocity; it was dependent on the pseudo shear rate defined by the ratio of cell velocity to vessel radius. The layer thickness increased with a decrease in the pseudo shear rate.