Blunt pancreatic trauma with main pancreatic duct disruption managed successfully with total parenteral nutrition: report of a case

Although surgery is the usual treatment of choice for pancreatic trauma with disruption of the main pancreatic duct, we report herein the case of a patient in whom blunt pancreatic trauma with disruption of the proximal main pancreatic duct was successfully managed by conservative treatment. An 18-year-old women presented with abdominal pain 22 days after being involved in a car accident in which her upper abdomen was thrust against the steering wheel. Computed tomography revealed a pancreatic pseudocyst and a prevertebral pancreatic fracture, and endoscopic retrograde pancreatography showed complete disruption of the main pancreatic duct at the neck. Considering that the patient had been clinically stable since the accident, we elected to continue with conservative management and placed her on total parenteral nutrition. Rapid recovery followed and 6 years later, the patient remains well without any exocrine or endocrine insufficiency despite atrophy of the distal pancreas. This experience indicates that selected cases of main pancreatic duct disruption following blunt trauma may be amenable to conservative management.

Carcinoma of the ampulla of Vater: histopathologic analysis of tumor spread in Whipple pancreatoduodenectomy specimens

Controversies exist regarding the application of the pylorus-preserving pancreatoduodenectomy (PPPD) to malignancies. This study was intended to disclose the pattern of spread of ampullary cancer and to substantiate that tumor spread at resectable stages does not involve the tissues preserved by PPPD. We examined 40 consecutive Whipple pancreatoduodenectomy specimens: mucosal cancer, 4 cases; cancer invading (but not penetrating) the sphincter of Oddi, 1; cancer invading the submucosa of the duodenum, 12; cancer invading the proper muscle of the duodenum, 5; cancer invading the subserosal layer of the duodenum, 7; and cancer invading pancreatic parenchyma, 11. Five cases of mucosal cancer or cancer invading (but not penetrating) the sphincter spread locally without nodal involvement and showed a 5-year survival of 80% without recurrence, being better (p < 0.05) than the 40% survival for patients with more advanced cancers. Sixty-three percent of the remaining 35 cases had metastasis to regional lymph nodes. The 5-year survival of 28% among those with cancer penetrating the proper muscle was worse (p < 0.05) than the 59% survival for those with less advanced cancers. No cases had involved the anatomic structures that would have been preserved by a PPPD. In three cases (7.5%), gastric cancer coexisted. In conclusion, ampullary cancer not penetrating the sphincter spreads locally. Once penetrating the sphincter, it often spreads regionally and causes recurrence. Cancer penetrating the proper muscle of the duodenum bears a worse prognosis. PPPD is an attractive alternative to the Whipple operation for ampullary cancer because no involvement was found in the tissue preserved by the PPPD. However, surgeons should be aware of a concomitant gastric cancer when doing a PPPD.

Long-term results after nonshunt operations for esophageal varices in children

The clinical results of nonshunt operations for esophageal varices in 15 children were evaluated. The varices were caused by congenital extrahepatic portal obstruction (EHPO) in 10, liver cirrhosis or fibrosis (C/F) in 3, and idiopathic portal hypertension (IPH) in 2. The operative procedures were transthoracic esophageal transection with paraesophageal devascularization (TR) for 2 EHPO patients under 5 years of age, TR combined with splenectomy and paragastric devascularization (Sugiura procedure) for 11 (8 EHPO, 3 C/F), and splenectomy with devascularization (SP) or splenectomy for the 2 IPH patients. In the EHPO patient under 5 years of age, TR is associated with a likelihood of gastric or esophageal hemorrhage resulting from hypersplenism, gastric congestion, or persistent distal esophageal varices, which can be treated with partial splenic arterial embolization (PSE), endosclerotherapy, or an additional abdominal procedure. The Sugiura procedure has provided satisfactory long-term results, without rebleeding from esophageal varices, in patients with EHPO and C/F for 1 to 20 years. But EHPO patients who undergo the Sugiura procedure before age 6 can have gastric hemorrhage, because of mucosal congestion, for more than 10 years after the procedure, and selective gastric arterial embolization (GAE) might be necessary. In some EHPO patients, especially young ones who have variceal bleeding, a significant increase in hepatopetal portal flow may not develop, but hepatofugal natural shunts may progress. Therefore we recommend direct operative procedures, ie, TR for patients < or = 6 years of age and a one- or two-stage Sugiura procedure for those over 7 years old.(ABSTRACT TRUNCATED AT 250 WORDS)

Cranberry juice and its impact on peri-stomal skin conditions for urostomy patients

In urostomy patients, peristomal skin problems are common and may stem from alkaline urine. Cranberry juice appears to acidify urine and has bacteriostatic properties, and is widely recommended for the reduction of urinary tract infections. Therefore, it is hypothesized that drinking cranberry juice might also prevent and/or improve skin complications for urostomy patients. To test this hypothesis, pH measurements of the skin around the stoma and of the urine of 13 urostomy patients were taken before and after instituting a regimen of drinking 160 to 320 g of cranberry juice each day for an average period of six months. Results showed an improvement in skin condition from 6 patients with erythema, maceration or pseudoepithelial hyperplasia at the beginning of the study to 2 patients with maceration or PEH. The average pH of the urine taken from the patients' pouches decreased a statistically significant amount from 8.0 to 7.3 (p = 0.0277), yet unexpectantly, the average pH of the fresh urine increased a statistically significant amount from 5.8 to 6.2 (p = 0.0178). Other results were not statistically significant. The authors conclude that while drinking cranberry juice did not appear to acidify the urine as expected, improvements were still seen in the skin conditions of the study participants, suggesting that drinking cranberry juice does positively impact the incidence of skin complications for these patients.

Peritoneal interleukin-6, interleukin-8 and granulocyte elastase activity after elective abdominal surgery

In this study we investigated the interleukin-8 concentration (IL-8) and granulocyte elastase activity (GE) after elective abdominal surgery. Postoperative interleukin-6 (IL-6), IL-8 concentrations and GE in the peritoneal fluid were examined in 27 patients who underwent various types of elective abdominal surgery. We compared these results with clinical parameters of surgical stress, operating time (OT) and blood loss during the operation (BL). P-IL-6 and P-IL-8 were significantly correlated with OT (P-IL-6; r = 0.67, P < 0.001: P-IL-8; r = 0.59, P < 0.001) and BL (P-IL-6; r = 0.61, P < 0.001: P-IL-8: r = 0.48, P < 0.01). P-IL-8 was significantly correlated with P-IL-6 (r = 0.68, P < 0.001) and there was a positive correlation between GE and P-IL-8 (r = 0.37, P < 0.05). These findings indicate that IL-8 might activate granulocytes in the peritoneal cavity after elective abdominal surgery and that assaying P-IL-6 and P-IL-8 is useful in assessing the host's response to surgical stress.

Molecular properties, substrate specificity and regulation of DNA-dependent protein kinase from Raji Burkitt's lymphoma cells

A double-stranded DNA-dependent protein serine/threonine kinase (DNA-PK) was purified from a nuclear extract of Raji Burkitt's lymphoma cells by a three-step column-chromatographic procedure. The main silver-stained band visualized after SDS/PAGE corresponded to an autophosphorylated polypeptide of about 350-kDa that represents the catalytic component. The existence of Ku DNA-binding protein as a regulatory component in the purified enzyme was revealed by Western blot/enzyme immunoassay and direct inhibition test with anti-Ku sera from the autoimmune patients. The DNA-PK catalyzed phosphorylation of synthetic peptides corresponding to Myc and RB proteins in a DNA-dependent manner, indicating that DNA-PK may recognize a second core-sequence motif Pro-Ser/Thr- in addition to the putative consensus sequences of -Ser/Thr-Gln. The level of enzyme activity was significantly higher in DMSO-induced G0/G1-arrested Raji cells as well as in the cells after release from DMSO than in the log-phase cells.

Liver regeneration is enhanced by omeprazole in rats following partial hepatectomy

The effect of omeprazole on liver regeneration was studied in rats following partial (65 per cent) hepatectomy. Omeprazole 0.2 mg/kg increased the relative liver weight (weight of liver as a proportion of body-weight) and mitotic index (P < 0.05). There was no difference in food and water intake. The serum gastrin concentration was significantly higher in animals receiving omeprazole 0.2 mg/kg than in controls (P < 0.05). Omeprazole administration induced an increase in the level of serum alkaline phosphatase (P < 0.05) but had no effect on serum albumin, glutamic-pyruvic transaminase and total bilirubin levels. Omeprazole stimulates liver regeneration after partial hepatectomy and this regeneration may be mediated by gastrin.

OK432 inhibits experimental hepatic metastasis of colon adenocarcinoma ACL-15 in F344 rats

The effect of OK432 on hepatic metastasis, induced by inoculating 1 x 10(6) ACL-15 cells from a rat colon adenocarcinoma cell line into the ileocolic vein of male F344 rats, was investigated in this study. Metastases were detected 14 days after inoculation in the control rats, however, pretreatment 3 days prior to the tumor cell inoculation with an anti-asialoGM1 antibody, which eliminates natural killer (NK) cell activity in vitro, increased the number of hepatic metastases, shortened the survival time, and decreased the NK activity of the nonparenchymal liver cells (NPC). In contrast, pretreatment with OK432 2 days prior to tumor inoculation significantly decreased the number of hepatic metastases, prolonged the survival time, and augmented the NK activity of the NPC, although treatment with OK432 3 or 7 days after inoculation did not decrease the number of hepatic metastases. Moreover, NPC from the OK432-pretreated rats had a marked antitumor effect against ACL-15 cells in the Winn's neutralization test. The results of this study indicate that pretreatment with OK432 before tumor cell inoculation inhibits hepatic metastasis in this experimental model, possibly by augmentating liver-associated NK activity.

Stimulation of DNA-dependent protein kinase activity by high mobility group proteins 1 and 2

After incubation of high mobility group (HMG) proteins 1 and 2 with DNA-dependent protein kinase (DNA-PK) and [gamma-32P]ATP in the presence of double-stranded DNA, not only phosphorylation of HMG proteins but also enhancement of autophosphorylation of the catalytic polypeptide of 350 kDa in DNA-PK was observed. DNA-PK activity determined with a synthetic peptide and alpha-casein as substrates was stimulated several-fold by HMG1, HMG2, and the DNA-binding domains. The stimulation was decreased at higher concentrations of HMG proteins, and DNA-PK activity was inhibited by histone H1. Electrophoretic mobility shift analysis suggests that HMG proteins facilitate the binding of DNA-PK to DNA.

Enhanced hepatic portal blood flow induced by prostaglandin E1 following liver transplantation in pigs

Portal venous blood flow (PVF), hepatic arterial blood flow (HAF), and systemic arterial pressure (SAP) were examined after prostaglandin E1 (PGE1) was injected into the vena cava superior (VCS) of liver-transplanted pigs. The injection of PGE1 at 0.2 micrograms/kg/min for 2 min on the day of transplantation and 3 days later produced an increase in PVF without causing any change in HAF or SAP, the response in PVF being dose-dependent. However, no reliable change in PVF, HAF, or SAP was seen when the same dose of PGE1 was administered 7 days after transplantation. Furthermore, no significant difference was noted among the values for PVF and total hepatic blood flow (THF) during the experimented days, although the HAF value had increased markedly 3 days after transplantation. These findings suggest that PGE1 is effective in increasing PVF in the liver transplanted condition; however, the hepatic circulatory improvement attributed to this agent would be limited to the first few days following transplantation.

[Thyroid function abnormalities during interferon therapy]

One hundred and twenty patients with chronic hepatitis C were treated with a 6-month course of recombinant alpha-interferon (a daily dose of 6 MU i.m. for the first two weeks and 6 MU or 3 MU i.m. three times weekly thereafter). Serum levels of thyroxine (T4), triiodothyronine (T3), thyroid-stimulating hormone (TSH), antithyroglobulin antibody (TGHA) and antimicrosomal antibody (MGHA) were measured before and three month after treatment. Ten of 106 patients with normal thyroid function test before therapy developed thyroid dysfunction; five with hyperthyroidism, four with hypothyroidism and one with positive MCHA. Fourteen patients had thyroid function disorder before treatment. Seven of eight patients with positive MCHA, showed a rise in the titer during the treatment. These data showed that a small proportion of patients treated with interferon developed thyroid dysfunction during the treatment. The interferon-induced thyroid dysfunction appears to be caused via the immune system but also by acting directly on the thyroid gland.

Endothelin-1 stimulates bile acid secretion and vesicular transport in the isolated perfused rat liver

The effects of endothelin (ET) on portal pressure and bile secretion were examined using isolated perfused rat liver and rat hepatocyte preparations. ET-1 raised portal pressure dose dependently; administration at a high dose (10(-9) mol) induced a > 200% increase along with reduced bile flow and decreased secretion of bile acid and phospholipids. However, a low dose (10(-10) mol) of ET-1 brought about a < 100% portal pressure rise, enhanced both bile flow and excretion of bile acid and phospholipids, and significantly increased transfer of preadministered horseradish peroxidase (HRP) into bile. In addition, values for Ca2+ concentrations, examined by indo 1 fluorescence, were elevated in isolated hepatocytes after administration of ET-1. Papaverine suppressed the low-dose ET-1 stimulation effects on both portal pressure and bile secretion. Moreover, it also reduced the HRP excretion and suppressed intracellular Ca2+ release. This study demonstrated that ET-1 stimulates vesicular transport, probably via promotion of intracellular Ca2+ release, and, as a result, increases bile acid-dependent bile flow.

Inhibition of ethanol-induced inositol phosphate formation and Ca(2+) mobilization by okadaic acid in rat hepatocytes: evidence for a role of protein phosphatases in the modulation of phospholipase C by ethanol

The effect of the protein phosphatase inhibitor okadaic acid on phospholipase C (PLC)-linked signal transduction processes was investigated in intact hepatocytes. A short (5 min) pretreatment of the hepatocytes with okadaic acid (1 mu M) markedly inhibited a subsequent stimulation of PLC by ethanol as well as by receptor-mediated stimuli (vasopressin and phenylephrine). Okadaic acid inhibited the agonist-induced hydrolysis of polyphosphoinositides, the accumulation of inositol trisphosphate (InsP(3)) and the increase in cytosolic Ca(2+) concentrations. The inhibition could be overcome by high concentrations of vasopressin or ethanol, but only partly so with phenylephrine. A comparison of the sensitivity of different agonists at similar rates of InsP(3) accumulation and Ca(2+) mobilization indicated that ethanol-induced PLC activation was more resistant to the effects of okadaic acid than the hormonal agonists. Moreover, the stimulation of PtdInsP kinase by ethanol, which accompanies PLC activation, was refractory to okadaic acid treatment. These findings suggest that receptor-mediated PLC activation is subject to multiple controls by phosphorylation-dephosphorylation, not all of which affect the actions of ethanol on this signal transduction system.

The association between extrahepatic biliary carcinoma and the junction of the cystic duct and the biliary tree

OBJECTIVE

To establish accurately the sites of primary extrahepatic biliary carcinomas, so that optimal treatment may be given.

DESIGN

Retrospective study.

SETTING

University department of surgery.

SUBJECTS

120 patients with 121 primary extrahepatic biliary carcinomas.

MAIN OUTCOME MEASURES

Site of tumour (primary site being geometric centre of tumour) and distance from junction of cystic duct and the biliary tree on histological examination of the resected specimen.

RESULTS

64 of the tumours (53%) were within 5 mm of the junction; 14 were proximal to the junction, 32 distal, and 18 within the cystic duct itself.

CONCLUSIONS

Over half the primary extrahepatic biliary tumours were within 5 mm of the junction of the cystic duct and the rest of the biliary tree. Further investigations are required to find out if any particular aetiological factor can be identified.

Major hepatectomy and pancreatoduodenectomy for advanced carcinoma of the biliary tract

Seven patients with advanced carcinoma of the extrahepatic biliary tract, including two with cancer of the gallbladder, underwent major hepatectomy with concomitant pancreatoduodenectomy. The mean hepatic volume resected was 64 (range 35-81) per cent. Postoperative complications occurred in all patients and accounted for two hospital deaths. Two patients with gallbladder carcinoma survived without recurrence for 22 and 58 months. Three of five patients with bile duct cancer survived operation, although all three subsequently died from recurrent disease at 8, 10 and 27 months. Combined major hepatectomy and pancreatoduodenectomy may be appropriate in selected patients with advanced cancer of the gallbladder. Further evaluation is necessary before this approach can be recommended for those with advanced bile duct carcinoma.

Carcinoma of the gallbladder: CT evaluation of lymphatic spread

PURPOSE

To clarify the computed tomographic (CT) characteristics of positive nodes and to assess the ability of CT to demonstrate lymphatic spread.

MATERIALS AND METHODS

CT findings of lymph nodes in 51 patients with histologically proved gallbladder carcinoma were correlated with pathologic findings retrospectively.

RESULTS

Thirty-one of 51 patients (61%) had a total of 157 positive nodes, 60 (38%) of which were depicted at CT. A positive node was defined at CT as a soft-tissue mass with an anteroposterior dimension of at least 10 mm that showed ringlike or heterogeneous enhancement. These criteria had a positive predictive value of 75% for cystic nodes, 90% for pericholedochal nodes, 100% for posterosuperior pancreatoduodenal nodes, 100% for retroportal nodes, 88% for right celiac nodes, 100% for hepatic nodes, 100% for superior mesenteric nodes, and 83% for interaortocaval nodes.

CONCLUSION

CT does not reliably demonstrate all regional nodes of gallbladder carcinoma, but the criteria of size and pattern of enhancement reliably indicate lymphatic spread, which has an important bearing on disease staging and treatment planning.

Expression of active human DNA ligase I in Escherichia coli cells that harbor a full-length DNA ligase I cDNA construct

A recombinant plasmid for expression of full-length human DNA ligase I (phLig-I) was constructed in a plasmid/phage chimeric vector, pTD-T7N, which was derived from pUC118 by oligonucleotide-directed mutagenesis. The insert contained a 2757-base pair coding sequence for a whole human DNA ligase I and an extra ACC codon adjacent to the ATG initiation codon. This ACC codon was required for achieving high levels of expression of full-length DNA ligase I in Escherichia coli strain BL21. The recombinant plasmid, which was designed to exploit the T7 late promoter and the ATG initiation codon for beta-galactosidase was transfected into E. coli BL21 cells that express T7 RNA polymerase. The recombinant clone produced relatively high levels of DNA ligase I with a molecular mass of 130 kDa, as estimated by SDS-polyacrylamide gel electrophoresis. The DNA ligase was purified to near-homogeneity by the two-step column chromatographic procedure from BLphLig-I cells that had been induced with isopropyl beta-D-thiogalactoside. The specific activity, chromatographic behavior, kinetic properties, molecular mass, and antigenicity of the recombinant human DNA ligase I were indistinguishable from those of purified mammalian DNA ligase I. Metabolically labeling experiments with 32P(i) indicate that the recombinant DNA ligase I was present as an enzyme-AMP reaction intermediate, but not as a phosphoprotein, in the E. coli cells.

Expression of non-hepatic-type S-adenosylmethionine synthetase isozyme in rat hepatomas induced by 3'-methyl-4-dimethylaminoazobenzene

It is known that a high incidence of hepatocellular carcinoma in rat liver can be induced by such azo dye carcinogens as 3'-methyl-4-dimethylaminoazobenzene (3'-MeDAB). Mammalian S-adenosylmethionine (AdoMet) synthetase exists as two isozymes, non-hepatic-type and liver-type enzymes, which are the products of two different genes. We have examined the expression of two AdoMet synthetase isozyme proteins and mRNAs in rat hepatomas induced by 3'-Me-DAB. The levels of non-hepatic-type enzyme protein and mRNA are clearly induced by 3'-Me-DAB feeding. On the other hand, the levels of liver-type enzyme protein and mRNA are nearly the same or slightly decreased during hepatocarcinogenesis. These results indicate that the expression of the non-hepatic-type isozyme gene is obviously influenced with the progression of carcinogenesis and that the non-hepatic-type isozyme is useful as a oncodevelopmental marker in the liver.

Percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis

The effectiveness and long-term results of percutaneous cholecystostomy for acute acalculous cholecystitis are evaluated. Fifteen patients with acute acalculous cholecystitis were treated prospectively by this procedure, using a pigtail catheter successfully placed under ultrasonographic and fluoroscopic guidance. Prompt relief of the signs and symptoms of cholecystitis was achieved in 14 patients. One required emergency cholecystectomy for uncontrolled bleeding after drainage. Another patient underwent prophylactic cholecystectomy before further chemotherapy for leukaemia. The remaining 13 patients required no further surgery. Morbidity and mortality rates were 13 per cent and nil respectively. Long-term follow-up showed no recurrence of cholecystitis after removal of the catheter. Percutaneous cholecystostomy is a safe, effective and usually definitive procedure for the treatment of acute acalculous cholecystitis.

A new brain-specific 14-kDa protein is a phosphoprotein. Its complete amino acid sequence and evidence for phosphorylation

We previously reported a new brain-specific protein with a molecular mass of 14 kDa, specifically present in synapses around neurons but not in glial cells [Nakajo, S., Omata, K., Aiuchi, T., Shibayama, T., Okahashi, I., Ochiai, H., Nakai, Y., Nakaya, K. & Nakamura, Y. (1990) J. Neurochem. 55, 2031-2038]. In the present study, we determined the primary structure of this protein, found that it is phosphorylated in vitro and in vivo, and designated it phosphoneuroprotein 14 (PNP 14). The protein is a single polypeptide with 134 amino acid residues (molecular mass = 14122 Da), and it contains a hydrophobic region at the center of the molecule. The carboxy-terminal region has all seven proline residues, and is rich in glutamic acid, which contribute to the acidic property of the protein. The amino-terminal region possesses four unique repetitive motifs, Glu(Ser)-Lys-Thr-Lys-Glu(Gln)-Gly(Gln)-Val(Ala). When a cytosolic fraction prepared from rat cerebral cortex was incubated with [gamma-32P]ATP, 32P was incorporated into PNP 14. Phosphorylated PNP 14 was immunoprecipitated from rat brain synaptosomes labeled metabolically with [32P]orthophosphate. Injection of [32P]orthophosphate into the third ventricle of rat brain resulted in incorporation of radioactive phosphate into PNP 14. We have also found that Ca2+, calmodulin-dependent protein kinase II phosphorylates serine residue(s) of PNP 14 in vitro. The results suggest that PNP 14 may be important to neuronal cells, but not to glial cells, and that its physiological functions may be controlled by the phosphorylation reaction.

High carrier rate after hepatitis B virus infection in the elderly

An outbreak of hepatitis B virus infection occurred in a nursing facility; it involved 31 patients with sequelae of cerebral vascular accidents (15 men and 16 women; mean age, 77.4 +/- 9.3 yr). HBsAg disappeared within 6 mo in 9 patients and persisted during an observation period of more than 6 mo in 13; the remaining 9 patients were lost to follow-up while they carried HBsAg. Thus 13 of 22 patients followed (59%) became HBsAg carriers. We amplified a part of the S gene (436 nucleotides) with polymerase chain reaction on hepatitis B virus DNA from 12 randomly selected patients. The sequences of nine patients were the same as that of a nursing assistant who was an HBsAg carrier and suspected as the source of infection; it differed by only 1 or 2 (< 0.5%) nucleotides from those of the remaining three patients. Between the group of nine patients with transient HBV infection and the 13 patients with persistent HBV infection, we found no differences in age or sex or in parameters of nutrition or immunocompetence. These results indicate a high incidence of HBV carrier state in the elderly.

Immunohistochemical analysis of rat S-adenosylmethionine synthetase isozymes in developmental liver

Mammalian S-adenosylmethionine (AdoMet) synthetase exists as two isozymes, liver-type and kidney(non-hepatic)-type enzymes. The developmental expression of these two isozymes proteins has been investigated in rat liver using immunohistochemical techniques. The liver-type AdoMet synthetase is expressed only in adult liver, but not in fetal liver. On the other hand, the kidney-type AdoMet synthetase is predominantly expressed in fetal liver and faintly detected in adult liver. It was also found that both isozymes were localized to the hepatocytes of rat liver. These results clearly show that AdoMet synthetase isozymes are developmentally regulated within hepatocytes. In addition, in rat kidney we have shown that the kidney-type AdoMet synthetase is predominantly localized to the distal tubule.