Hepatic encephalopathy and reversible cortical blindness

We report a case of recurrent hepatic encephalopathy accompanied by transient cortical blindness. The patient with cryptogenic liver cirrhosis had six attacks of hepatic encephalopathy of grades II to III during 1 yr after admission. In the beginning of each episode of encephalopathy, when the patient was conscious, a complete loss of vision occurred, but with a normal pupillary reflex to light. At the same time, the visual evoked potential recorded the second negative wave with a prolonged latency and a diminished amplitude. His sight completely returned, and the electroencephalogram tracing and the visual evoked potential response normalized after treatment for the encephalopathy. The loss of vision was thought to be cortical blindness accompanied by hepatic encephalopathy. Thus, in rare cases of hepatic encephalopathy, the visual cortex may be affected, and cortical blindness may occur before the loss of consciousness.

[Assessment of interaction between the left and right ventricles using pressure-volume loops in various heart diseases]

To assess the interaction and interdependence of left and right ventricular function, ECG-gated radionuclide angiocardiography was performed immediately after cardiac catheterization during right atrial pacing for 11 patients with old myocardial infarction (MI), two with non-obstructive hypertrophic cardiomyopathy, one with aortic stenosis (AS), two with pulmonary infarction (PI), and one with neurocirculatory asthenia (NCA). Absolute left ventricular (LV) volume curves were obtained by the count-based method with attenuation factor corrections. Biventricular pressure and volume curves were digitized and synchronized to end-diastole, and pressure-volume (P-V) loops were constructed throughout a cardiac cycle. The stroke work index (SWI), the work index per min (WI/M) and the contractility index (CNTI) were calculated from the P-V loops. In a patient with NCA, LV end-diastolic volume decreased during rapid pacing, but no significant change in the LV end-systolic P-V relation was recognized. However, the entire right ventricular (RV) P-V loop was shifted toward the left during rapid pacing. In a patient with AS, the LV P-V loop was markedly enlarged and every parameter of LV function was much greater than that of the right ventricle due to increased LV afterload. The areas of RV P-V loops in two patients with PI were larger than those of other patients, because RV pressure was relatively high, and RV volume was increased. It is suggested that RV pressure and volume overloads prevail in patients with PI. In four MI patients with three vessel disease and having collateral circulation, the LV end-systolic P-V relationship was shifted toward the lower right, and every parameter (SWI, WI/M, CNTI) of LV function decreased by rapid pacing. Myocardial ischemia may be induced by rapid pacing stress, causing decreased LV contractility. It was concluded that the P-V loops obtained by RNA and catheterization are clinically useful for estimating the interaction and interdependence between right and left ventricular hemodynamics.

Carcinogenic potential of the noncancerous epithelium in patients with oesophageal cancer

Detailed histopathological examination of serial blocks and subserial sections of the entire resected oesophagus in 63 patients operated upon for oesophageal cancer revealed 11 associated minute superficial cancers, independent and apart from the main tumours, in 10 patients (15.9 per cent). Only one of these eleven lesions was diagnosed preoperatively, and only three of the eleven lesions were detected macroscopically on the resected specimens. The high incidence of such coexisting independent lesions may indicate a possible increased multicentric carcinogenic potential in the non-cancerous epithelium of patients who have had an antecedent oesophageal cancer. These results emphasize the need for careful attention to the choice of margins during surgical resection of the oesophagus.

Experimental studies of the effects of local hyperthermia on blood flow, oxygen pressure and pH in tumors

The heat-induced environmental changes in tumor tissues are considered to influence the antitumor effect of hyperthermia or hyperthermochemotherapy, which is believed to complement the direct lethal effect of heat on tumor cells. The effects of local hyperthermia on the blood flow, oxygen pressure and pH in tissues were investigated using AH-100B tumor bearing rats, by immersing the tumor in a water bath at 41 degrees, 43 degrees and 45 degrees C. These parameters were measured in the marginal and deeper sites of the tumor mass, and in the normal muscle adjacent to the tumor. During immersion at 41 degrees C, blood flow in the tissue was increased at each site, and during immersion at 43 degrees C, tissue blood flow increased initially at each site, but decreased with time to rates below that of the unheated tissue. During immersion at 45 degrees C, the blood flow decreased markedly in each tissue. The changes in oxygen pressure and pH in each tissue were similar to those observed in the blood flow during localized heating at 41 degrees, 43 degrees and 45 degrees C. In local thermochemotherapy, the initial stage of hyperthermic treatment seems to be the most suitable time for administering carcinostatics, since it is the time when tumor blood flow has not yet decreased.

The effects of diet on the residual small intestine following massive resection

The midportions of rat small intestines were resected by 90 per cent, and the residual intestines studied for the effects of diet on mucosal morphology, nutrition and gastrointestinal hormones. Groups of rats were fed chow, an elemental diet (ED), or an ED + dietary fiber (EDF) for 1 or 3 weeks. Nonresected rats which were fed chow or ED for 3 weeks were used as controls. Nutritional parameters, such as concentrations of serum total protein, albumin and transferrin were favorable but gain in body weight was not. The parameters indicated that resected rats fed EDF fared better than resected rats fed ED. Mucosal villous height in the residual jejunum, similar in all the resected groups after 1 week, was significantly increased in the resected rats fed chow or EDF after 3 weeks, but did not differ between 1 and 3 weeks in the resected rats fed ED. Changes in the number of villous epithelial cells and villous width were also examined. The level of plasma enteroglucagon was high in the rats fed chow or EDF after both 1 and 3 weeks, and was positively correlated with the increases in villous height. Levels of serum gastrin were not affected by dietary change. Luminal nutrients were significantly associated with the adaptive changes in the mucosa of the residual intestine, and mucosal morphology was also considerably influenced by dietary change.

[Gastrointestinal carcinoma with skin diseases from the standpoint of surgery]

We encountered 21 patients with gastrointestinal carcinoma accompanied with skin diseases such as acanthosis nigricans, dermatomyositis, pemphigoid, erythrodermia, ichthyosis vulgaris, herpes zoster, Leser-Trélat's sign, Recklinghausen's disease and Gardner's syndrome. We have discussed such cases from the standpoint of surgery. There were 16 cases (76%) with gastric carcinoma, which were almost in the far advanced stage. Carcinomas of the other patients were seen in the esophagus, liver, pancreas, small intestine and rectum. Although skin lesions appeared before the onset of gastrointestinal symptoms in almost all cases, detection of carcinomas was very difficult until the symptoms emerged. In 6 of 21 patients (29%), carcinomas were detected by only skin manifestation, and they proved to be gastric cancer in all cases. Although the relationship of gastrointestinal carcinoma and skin diseases was unclear, we presented a 70-year-old woman with acanthosis nigricans accompanied with gastric cancer, whose skin manifestation was reduced by the therapy for gastric cancer. Therefore, some of these skin manifestation may be a symptom of the biological characteristics of the gastrointestinal carcinoma.

[Clinical results and problems of total-body thermochemotherapy]

The clinical results and problems of extracorporeally-induced total-body thermochemotherapy (TBHT) for recurrent cancer are presented. A total of 127 hyperthermic treatments were performed in 45 patients who had undergone unsuccessful conventional systemic anticancer chemotherapy. Partial response was observed in 11 of 34 evaluable patients (32%). In analysing the anticancer effects of TBHT according to cancer site, a high efficacy was observed in patients with their main tumor in the lung, liver and lymph nodes. The anticancer effects were most enhanced when TBHT was performed in combination with cisplatin and 5-fluorouracil. In order to augment the anticancer effects of TBHT, the choice of combined agents and administration timing are important. A useful method for determining the thermochemosensitivity of individual cancer cells to agents selected for drug treatment is the human tumor clonogenic assay. Furthermore, the usefulness of angiotensin II-induced hypertensive chemotherapy during TBHT for augmenting selective drug delivery to cancer tissue is stressed.

Physiological significance of fetal blood gas changes elicited by different delivery postures

We performed umbilical blood gas analysis for 130 pregnant women in sitting and for 50 in supine position immediately after their deliveries. To elucidate whether fetal blood gas changes were attributed to the maternal postures, we also carried out the maternal blood gas analysis during delivery (n = 145) and prior to the onset of labor (n = 100) in both positions. Blood gas values of the umbilical vein and artery in the sitting group were significantly higher in pH, PO2, base excess (BE) and oxygen saturation (SO2), and lower in PCO2 than those in the supine group. In contrast, maternal blood gas values (pH, PaCO2, PaO2 and SaO2) did not show significant differences between these two groups in both during delivery and before the onset of labor. Thus, the sitting delivery position can elicit physiologically more beneficial blood gas aspects in fetus compared with the conventional supine delivery position. Umbilical blood gas improvements induced by sitting delivery position do not appear to be a result of the maternal blood gas alteration, but appear to be mediated by other factors.

Effects of insulin, dexamethasone and glucagon on the production of apolipoprotein A-I in cultured rat hepatocytes

Cultured rat hepatocytes were used to study the effects of hormones on the production of apo A-I. In addition, we compared these effects with the production of albumin. Hepatocytes were isolated from normal adult rat livers and cultured in MEM, as nearly confluent monolayers. In the absence of hormones, apo A-I and albumin accumulated in the culture medium almost linearly for periods up to 24 h. The rates of accumulation of apo A-I and albumin in the medium were 22 ng/mg cell protein per h and 1.2 micrograms/mg cell protein per h, respectively. During the incubations the cellular contents of apo A-I remained constant. Insulin stimulated the production of albumin at concentrations over 10(-10) M, but inhibited the production of apo A-I at concentrations over 10(-8) M. Dexamethasone showed no significant effects on albumin production but stimulated apo A-I production at concentrations over 10(-6) M. Glucagon inhibited the production of albumin and apo A-I dose-dependently at concentrations over 10(-10) M. Thus, the production of albumin and apo A-I are presumably controlled by different regulatory mechanisms.

[Hyperthermia adjunct to surgery in the treatment of scirrhous carcinoma of the stomach]

In approximately 80% of patients with scirrhous carcinoma of the stomach, recurrence of cancers occurs even after potentially curative resection, and recurrence most frequently occurs in the form of peritoneal metastasis. Such recurrence may be attributable to possible intraperitoneal dissemination of malignant cells already present at the time of surgery. We performed intraoperative peritoneal cytology on patients with scirrhous carcinoma of the stomach. Free cancer cells were demonstrated in the Douglas cavity in 16 of 32 (50%) patients who underwent potentially curative gastrectomy. The postoperative 5-year survival rate was 23% in patients without detectable free cancer cells in the peritoneal cavity, compared with only 9% in patients with microscopic evidence of intraperitoneal free cancer cells. Therefore, we have applied hyperthermic continuous peritoneal perfusion (CHPP) on patients with scirrhous carcinoma of the stomach in order to develop a surgical adjuvant therapy effective for the prevention of recurrence of peritoneal involvement. The results obtained so far from our study have shown an increased 3-year survival rate of patients undergoing potentially curative gastrectomy, but no improvement of therapeutic outcome in terms of postoperative 5-year survival.

Serum zinc and copper changes after gastrectomy in aged patients with gastric cancer

Serum zinc and copper levels were evaluated in patients with gastric cancer who had undergone gastrectomy. These patients were divided into two age categories; namely, the aged group, comprising 39 patients over the age of 70 years, and the younger group, comprising 23 patients younger than 50 years. The data before and after surgery were compared between the two groups. Serum zinc levels in the aged group were significantly lower than those in the younger group, both before and after surgery. Serum copper levels, however, did not differ significantly between the two groups. The serum Cu/Zn ratio was also analyzed according to the histological stages of cancer (stages I to IV), and compared between the two age-classified groups. The aged group showed a higher Cu/Zn ratio at all stages, whereas in the younger group, the ratio was significantly higher at stage IV than in the earlier stages. Preoperative serum zinc, copper, and the Cu/Zn ratio were studied in relation to the complication of anastomotic leak after surgery. The Cu/Zn ratio in the aged patients with this complication was significantly higher than that in the aged patients without it. These results suggest that the Cu/Zn ratio may be an important factor in determining nutritional parameters in the aged.

Prophylactic therapy for peritoneal recurrence of gastric cancer by continuous hyperthermic peritoneal perfusion with mitomycin C

Continuous hyperthermic peritoneal perfusion (CHPP) with a solution that contains mitomycin C (CHPP-M) has been clinically introduced as a prophylactic treatment for peritoneal recurrence of gastric cancer with serosal invasion. Two studies, each with a treated and a control group, were performed. In the historical control study the postoperative 3-year survival rate of patients (73.7%) in the treated group (n = 38) was significantly higher than the survival rate (52.7%) of those in the control group (n = 55) (P less than 0.04). In the random control study the survival rate (83%) of patients in the treated group (n = 26) was also higher than that (67.3%) of those in the control group (n = 21) in the 30 months that followed gastric surgery. However, there was no significant difference. In the historical control study with respect to the postoperative complications, anastomotic leak was observed in 8.5% of patients who were given CHPP-M and 12.8% patients who did not have CHPP-M. In the random control study anastomotic leak was observed in 3.1% of patients who had CHPP-M and 7.1% of patients who did not have CHPP-M. The incidence of adhesive ileus in patients having CHPP-M did not increase in historical or random control groups. Postoperative prolonged intestinal paresis or chemical peritonitis were not induced by CHPP-M. These results indicate that CHPP-M is a simple, safe, and readily available prophylactic therapy for peritoneal recurrence that may follow gastric cancer surgery.

Prophylactic therapy for peritoneal recurrence of gastric cancer by continuous hyperthermic peritoneal perfusion with mitomycin C

Continuous hyperthermic peritoneal perfusion (CHPP) with a solution that contains mitomycin C (CHPP-M) has been clinically introduced as a prophylactic treatment for peritoneal recurrence of gastric cancer with serosal invasion. Two studies, each with a treated and a control group, were performed. In the historical control study the postoperative 3-year survival rate of patients (73.7%) in the treated group (n = 38) was significantly higher than the survival rate (52.7%) of those in the control group (n = 55) (P less than 0.04). In the random control study the survival rate (83%) of patients in the treated group (n = 26) was also higher than that (67.3%) of those in the control group (n = 21) in the 30 months that followed gastric surgery. However, there was no significant difference. In the historical control study with respect to the postoperative complications, anastomotic leak was observed in 8.5% of patients who were given CHPP-M and 12.8% patients who did not have CHPP-M. In the random control study anastomotic leak was observed in 3.1% of patients who had CHPP-M and 7.1% of patients who did not have CHPP-M. The incidence of adhesive ileus in patients having CHPP-M did not increase in historical or random control groups. Postoperative prolonged intestinal paresis or chemical peritonitis were not induced by CHPP-M. These results indicate that CHPP-M is a simple, safe, and readily available prophylactic therapy for peritoneal recurrence that may follow gastric cancer surgery.

Thermochemosensitivity: augmentation by hyperthermia of cytotoxicity of anticancer drugs against human colorectal cancers, measured by the human tumor clonogenic assay

Thermochemosensitivity was examined in vitro by a human tumor clonogenic assay (HTCA) using specimens obtained surgically from 43 patients with colorectal cancer. We found that the percentages of patients whose cells showed higher sensitivity (greater than 70% inhibition of colony formation) to hyperthermia alone were 29.6 and 55.6% at 42 and 43 degrees C each for 1 h, respectively. Similarly, percentages of patients whose cells were sensitive to drugs alone were 13.8, 24.1 and 48.3%, for cis-diamminedichloroplatinum(II), 5-fluorouracil and mitomycin C, respectively. These sensitivities were augmented when hyperthermia was combined with administration of anticancer agents. Even in tumor cells that were insensitive to anticancer drugs alone or to hyperthermia alone, sensitivity was enhanced when administration of drugs was combined with hyperthermia. Our results demonstrate that HTCA of tumor cells, obtained from suitable patients, may be useful as a predictive test for application of thermotherapy and for individualization of chemotherapy.

[Chronological trends in gastric cancer surgery in Japan]

The development of surgery for gastric cancer in Japan was reviewed. Recently, favorable long-term results have been obtained in surgically treated gastric cancer patients. This success has been mainly attributable to the performance of extended lymph node removal since the 1960s and of active total gastrectomy since the 1950s. Furthermore, gastrectomy combined with the resection of other organs since the 1960s, has resulted in an improvement of resectability. On the other hand, modified lymph node removal for early gastric cancer has been promoted in the 1980s. With the progress of anticancer chemotherapy since the 1970s, the concept of reduction surgery has been introduced into cancer surgery, and active palliative gastrectomy has been performed. Despite the advances made in gastric cancer surgery, however, there is a definite limit to the surgical treatment of gastric cancer. For this reason, multidisciplinary therapy combined with surgery should be considered.

Cocarcinogenic activity of bile acids in the chemical transformation of C3H/10T1/2 fibroblasts in vitro

We have performed a series of experiments to determine directly whether bile acids influence carcinogenesis, using a C3H/10T1/2 cell transformation system in vitro. Treatment of the cells with the carcinogen, 3-methylcholanthrene (MCA), followed by the addition of lithocholic acid (LCA), produced a marked increase in the number of transformed foci as compared to the number induced by MCA alone. Simultaneous treatment with MCA and bile acid did not increase the number of transformed foci except in the case of MCA in combination with LCA. When cultured cells were exposed to MCA soon after removal of cholic acid or LCA, a statistically significant increase in the number of transformed foci was noted. When cultured cells were replated after continuous exposure to test compounds and then treated with MCA, no enhancement of the rate of formation of transformed colonies was observed. From these results, it appears that bile acids act as not only promoting but also as co-carcinogenic agents under certain circumstances.

Comparative study of gastric cancer in young and aged patients

Clinical and pathological findings of gastric cancer in patients of less than 30 years of age were compared with those in aged patients of over 75 years of age. These were 10 males and 24 females, and the rate of gastric cancer for females in the younger group was extremely high. There were marked differences between both groups in the pathological findings of gastric cancer, and consequently in the progressive pattern of the disease, perhaps as the result of differences in the matrix of cancer development and the influence of sex hormones. Gastric cancer at an advanced stage and delayed surgery in younger patients are attributable to negligence on the part of the patient in scheduling a medical examination and careless diagnosis by the physician. However, the prognosis of gastric cancer was not unfavorable in the younger patients when curative surgery was performed.

[Evaluation of the system performance and clinical images of the single photon emission computed tomography for head using ring arranged detector]

To evaluate the system performance, several preoperational fundamental tests of single photon emission computed tomography (SPECT) were carried out. Spatial resolutions (FWHM) measured with the point-spread functions of a 99mTc line source were 12.5 mm with a high resolution (HR) collimator and 17.2 mm with a high sensitivity (HS) collimator respectively. Slice thicknesses (FWHM) obtained from the profile curves of slice images were 17.5 mm (HR) and 29.0 mm (HS) at the center of rotation. System sensitivities were 5.4 kcps/slice (HR) and 27.8 kcps/slice (HS). Uniformities calculated from the SPECT images of a pool phantom were 4.7% (HR) and 2.7% (HS) at the condition of 3,000 kcounts to be acquired. SPECT images of the HEADTOME SET-031 were considered very useful to diagnose the cerebrovascular disease.

[Bone disorder in long-term survival after gastrectomy with reference to bone mineral content]

To investigate post-gastrectomy metabolic bone disorder, the radial bone mineral content (BMC) was measured with 125I-photon absorptiometry in 131 long-term survivors, the postoperative periods ranged 3 to 30 years. Sixty-eight patients (52 per cent) showed abnormally low BMC levels compared with healthy controls. The 43 patients with total gastrectomy manifested a higher incidence of decreased BMC levels than did the other 88 patients with partial gastrectomy. In females, patients subjected to the Billroth II procedure manifested low BMC values. The extent of the decline in BMC was much higher in females than in males, and higher in totally gastrectomized patients than in partial gastrectomy group. At more than 10 years postoperatively many patients manifested markedly low BMC levels; in totally gastrectomized patients this finding was made at less than 5 years postoperatively. A significant correlation was found between the extent of the decreased BMC levels and the postoperative periods. Of the patients with decreased BMC values, 30 per cent of them gave histories of osseous symptom after gastrectomy, however, 70 per cent of patients were asymptomatic. Based on the results, in long-term survival treated by total or partial gastrectomy, many patients present an osteopenic status, however, the number of those with clinically manifested bone disease such as osteomalacia may be low.