Anterior and posterior musculotendinous anatomy of the supraspinatus

The objective of this study was to quantitatively describe the supraspinatus musculotendinous architecture. After supraspinatus muscles were harvested from 25 embalmed shoulders, each muscle was divided into an anterior and posterior muscle belly on the basis of muscle fiber insertion. Pennation angles and musculotendinous dimensions were measured, and the physiologic cross-sectional area was calculated for each muscle belly. The physiologic cross-sectional areas of the anterior and posterior bellies were calculated to be 140 +/- 43 mm2 and 62 +/- 25 mm2, respectively, whereas their tendon cross-sectional areas were 26.4 +/- 11.3 mm2 and 31.2 +/- 10.1 mm2, respectively. The average anterior-to-posterior ratios for the muscle physiologic cross-sectional area and the tendon cross-sectional area were 2.45 +/- 0.82 and 0.87 +/- 0.30, respectively. Thus, a larger anterior muscle pulls through a smaller tendon area. These data suggest that physiologically, anterior tendon stress is significantly greater than posterior tendon stress and that rotator cuff tendon repairs should incorporate the anterior tendon whenever possible, inasmuch as it functions as the primary contractile unit.

Surgery after downstaging of unresectable hepatic tumors with intra-arterial chemotherapy

BACKGROUND

This retrospective study was performed to assess the outcome among patients who underwent hepatic resection or tumor ablation after hepatic artery infusion (HAI) therapy down-staged previously unresectable hepatocellular carcinoma (HCC) or liver metastases from colorectal cancer (CRC).

METHODS

Between 1983 and 1998, 25 patients with HCC and 383 patients with hepatic CRC metastases were treated with HAI therapy for unresectable liver disease. We retrospectively reviewed the records of 26 (6%) of these patients who underwent subsequent surgical exploration for tumor resection or ablation.

RESULTS

At a median of 9 months (range 7-12 months) after HAI treatment, four patients (16%) with HCC underwent exploratory surgery; two underwent resection with negative margins, and the other two were given radiofrequency ablation (RFA) because of underlying cirrhosis. At a median postoperative follow-up of 16 months (range 6-48 months), all four patients were alive with no evidence of disease. At a median of 14.5 months (range 8-24 months) after HAI therapy, 22 patients with hepatic CRC metastases underwent exploratory surgery; 10 underwent resection, 6 underwent resection and RFA or cryotherapy, and 2 underwent RFA only. At a median follow-up of 17 months, 15 (83%) of the 18 patients with CRC who had received surgical treatment had developed recurrent disease; the other 3 died of other causes (1 of postoperative complications) within 7 months of the surgery. One patient in whom disease recurred underwent a second resection and was disease-free at 1 year follow-up.

CONCLUSIONS

Hepatic resection or ablation after tumor downstaging with HAI therapy is a viable option for patients with unresectable HCC. However, given the high rate of recurrence of metastases from CRC, hepatic resection or ablation after downstaging with HAI should be used with caution.

Malvidin 3-rutinoside as the pigment responsible for bract color in Curcuma alismatifolia

Malvidin 3-rutinoside was the only anthocyanin identified from pink bracts of Curcuma alismatifolia cultivars. The concentration of malvidin 3-rutinoside in three cultivars increased as the intensity of the pink color in the bracts increased.

Thenar insertion of abductor pollicis longus accessory tendons and thumb carpometacarpal osteoarthritis

Although the etiology of osteoarthritis of the thumb carpometacarpal (CMC) joint remains unclear, some theories have focused on variations in the local anatomy of the abductor pollicis longus tendon insertion. This cadaver study of 68 specimens analyzed the relationship between a thenar insertion of an accessory abductor pollicis longus tendon and the presence and severity of thumb CMC osteoarthritis. The joint cartilage surfaces were visually graded for degenerative changes. Thirty-five of 68 specimens (51%) had a thenar insertion, most frequently inserting on either the abductor pollicis brevis or opponens pollicis fascia or muscle belly. No significant association between a thenar insertion and thumb CMC arthritis was observed. Conversely, increasing age was noted to have a significant association with degenerative joint disease. Thus, these findings indicate that a thenar slip of the abductor pollicis longus tendon does not correlate with the presence or severity of CMC osteoarthritis.

Intraoperative radiofrequency ablation or cryoablation for hepatic malignancies

BACKGROUND

The majority of patients with primary or metastatic malignancies confined to the liver are not candidates for resection because of tumor size, location, multifocality, or inadequate functional hepatic reserve. Cryoablation has become a common treatment in select groups of these patients with unresectable liver tumors. However, hepatic cryoablation is associated with significant morbidity. Radiofrequency ablation (RFA) is a technique that destroys liver tumors in situ by localized application of heat to produce coagulative necrosis. In this study, we compared the complication and early local recurrence rates in patients with unresectable malignant liver tumors treated with either cryoablation or RFA.

PATIENTS AND METHODS

Patients with hepatic malignancies were entered into two consecutive prospective, nonrandomized trials. The liver tumors were treated intraoperatively with cryoablation or RFA; intraoperative ultrasonography was used to guide placement of cryoprobes or RFA needles. All patients were followed up postoperatively to assess complications, treatment response, and local recurrence of malignant disease.

RESULTS

Cryoablation was performed on 88 tumors in 54 patients, and RFA was used to treat 138 tumors in 92 patients. Treatment-related complications, including 1 postoperative death, occurred in 22 of the 54 patients treated with cryoablation (40.7% complication rate). In contrast, there were no treatment-related deaths and only 3 complications after RFA (3.3% complication rate, P<0.001). With a median follow-up of 15 months in both patient groups, tumor has recurred in 3 of 138 lesions treated with RFA (2.2%), versus 12 of 88 tumors treated with cryoablation (13.6%, P<0.01).

CONCLUSIONS

RFA is a safe, well-tolerated treatment for patients with unresectable hepatic malignancies. This study indicates that (1) complications occur much less frequently following RFA of liver tumors compared with cryoablation of liver tumors, and (2) early local tumor recurrence is infrequent following RFA.

Effect of tuftsin on human Kupffer cell

BACKGROUND/AIMS

Kupffer cells are the most important category of reticuloendothelial cells which are critical for host defense in the liver. We investigated the effects of tuftsin (Thr-Lys-Pro-Arg) on human Kupffer cells.

METHODOLOGY

Human Kupffer cells were obtained from the livers of patients with colon cancer. Phagocytosis assay was done by microscopic counting of the number of Kupffer cells that engulfed fluorescent particle(s), and the number of the particles engulfed per Kupffer cell when Kupffer cells were incubated with and without tuftsin. Effect of tuftsin on the release of tumor necrosis factor from Kupffer cells was also studied.

RESULTS

Phagocytosis was enhanced significantly by tuftsin. The greatest effect on percentage of phagocytic cells was observed at 1.0 microg/ml of tuftsin. The mean number of particles engulfed per Kupffer cell was also increased with tuftsin 1.0 microg/ml. Tumor necrosis factor release was also significantly increased; the greatest effect was observed at 1.0 microg/ml of tuftsin.

CONCLUSIONS

Tuftsin enhances phagocytic activity and tumor necrosis factor release of human Kupffer cells, which are advantageous for host defense against invading microorganisms and tumor cells.

Repeat hepatic resection as effective treatment of recurrent colorectal liver metastases

BACKGROUND

Approximately 20-40% of patients who undergo liver resection for colorectal metastases develop recurrent disease confined to the liver. The goals of this study were to determine whether the survival benefit of repeat hepatic resection justified the potential morbidity and mortality.

METHODS

A retrospective review was performed on all patients who underwent liver resection for colorectal cancer metastases between 1983 and 1995 (N = 202). Repeat liver resections were performed on 23 patients for recurrent metastases.

RESULTS

There were no operative deaths in the 23 patients, and the postoperative morbidity rate was 22%. The 5-year actuarial survival rate after repeat resection was 32%, with a median length of survival of 39.9 months. There were three patients who survived for > 5 years after repeat resection. Sixteen patients (70%) developed recurrent disease at a median interval of 11 months after the second resection; 10 of these 16 patients (62%) had new hepatic metastases. No clinical or pathological factors were significant in predicting long-term survival.

CONCLUSIONS

Repeat liver resection for recurrent colorectal metastases (a) can be performed safely with acceptable mortality and morbidity rates and (b) may result in long-term survival in some patients.

Improved survival after resection of colorectal liver metastases

BACKGROUND

The goal of this study was to determine if staging with intraoperative ultrasound (IOUS), assessment of porta hepatis lymph nodes, and evaluation of resection margins can improve selection of patients likely to benefit from resection of colorectal liver metastases.

METHODS

A retrospective evaluation was performed on patients undergoing celiotomy with intent to resect colorectal liver metastases. Patients were considered unresectable if extrahepatic disease was identified by peritoneal exploration or if IOUS demonstrated greater than four lesions or the inability to achieve negative margins. Tumor-negative margins were confirmed by pathologic evaluation. Actuarial 5-year survival was calculated using the method of Kaplan and Meier.

RESULTS

Median follow-up is 25 months. Of the 151 patients undergoing operative exploration, 107 (71.0%) underwent liver resection (all margins tumor negative). Three operative deaths occurred in this group (2.8%). The disease of 30 patients (19.8%) was considered unresectable due to extrahepatic involvement, and that of 14 patients (9.2%) was demonstrated by IOUS to be unresectable. Five-year actuarial survival was 44% for the resected group and 0% for the unresectable patients (p < 0.0001).

CONCLUSIONS

IOUS, portal node assessment, and pathologic margin evaluation improves the selection of patients likely to benefit from resection of colorectal liver metastases.

Perineal reconstruction using single gracilis myocutaneous flaps

Bilateral gracilis myocutaneous flaps were originally used as part of a technique for creating a neovagina following total pelvic exenteration. Based upon this experience, we began using single flaps for primary repair and closure of large surgical defects in the perineal area that require alternate tissue sources to replace lost skin, mucosa, or adjacent deep tissues. Eighteen single gracilis flaps were used for major vulvovaginal reconstructions in 17 women during the past 5 years. Women undergoing unilateral flap reconstructions included 6 with anorectal cancers and 11 with vulvovaginal tumors. Most patients were being treated for recurrence after failed primary therapy (n = 7) or were receiving multimodal treatment for advanced local disease (n = 7). All cases involved complex resections followed by simultaneous reconstruction: mean total operative time was 377 min with a mean estimated blood loss of 1010 cc. Reconstruction involved external flap placement on the vulva or perineum in 7 cases and internal placement to replace excised portions of the vagina in the other 11. Mean flap size was 6.6 x 11.4 cm. Necrosis of flap skin occurred in 3 patients; minor wound separations or flap edge necrosis was seen in 5 cases. Hospital stay averaged 18.4 days. Nine women had recurrent disease and died over 4-30 months; the remaining 8 are alive and disease free with a median follow-up of 25 months. The single gracilis flap provides a versatile method for providing anatomic reconstruction of large perineal defects in women who have undergone extensive resection.

Stimulation of phagocytic activity of murine Kupffer cells by tuftsin

Tuftsin (Thr-Lys-Pro-Arg) is a natural immunomodulating peptide. We have investigated for the presence of a specific tuftsin receptor on murine Kupffer cells using fluorescein-labeled tuftsin, which retains full biological activity. After incubation with fluorescein-labeled tuftsin, Kupffer cells displayed clear binding of this compound on the plasma membrane. Excess tuftsin inhibited this binding, indicating the presence of specific tuftsin receptors on the Kupffer cells. We then investigated the effect of tuftsin on the phagocytic activity of these cells. Phagocytosis assays were performed on 24-well plates between murine Kupffer cells and fluorescent microspheres. The greatest stimulatory effect of tuftsin on percent phagocytic cells over the control value was observed when the cells were incubated with particles at 1 microgram/ml tuftsin for 15 min at 37 degrees C with a particle-to-Kupffer cell ratio of 50:1. Tuftsin also markedly increased the number of particles engulfed by Kupffer cells under the same conditions. These results indicate that Kupffer cells have specific tuftsin receptors; thus tuftsin can stimulate phagocytic activity of Kupffer cells, which constitute the majority of macrophages in the host and are situated strategically in the liver for host defense.

Surgical management of hepatoma

For the majority patients with HCC, the prognosis is poor. Only a fraction of patients will be resectable at the time of their diagnosis. For the oncologic surgeon caring for such patients, the challenges are multifaceted. First, he or she must have a familiarity with current imaging techniques and reliable support from a radiologist to determine whether a given patient can be technically resectable. We rely most heavily upon the initial diagnostic CT scan followed by the staging CTAP in order to define the resectable patient as clearly as possible. Additionally, the risk of postoperative hepatic failure must be assessed. Careful physical exam, blood chemistries, and volumetric analysis of CT scans demand much judgment on the part of the surgeon. While some patients are clearly capable of undergoing a resection, and others are clearly inoperable due to poor hepatic function, a large group of patients exist in a "gray area" where resection can be entertained but the risk of hepatic failure looms large. In this group the use of the ICG retention test or the 14C-aminopyrine breath test are occasionally useful. Further research into better assessment of hepatic reserve is clearly needed. Once a laparotomy is undertaken, IOUS is a key component of intraoperative staging and the final determinant of resectability. Resection itself must be performed with three goals: Resection of all disease with negative surgical margins, retention of as much hepatic parenchyma as possible in keeping with oncologic principles, and maintenance of hemodynamic stability with minimal transfusion requirements in an effort to minimize the stress of surgery. The combination of vascular control and the porta hepatis (and IVC where necessary), segmental hepatic resection where appropriate, and ultrasonic dissection can accomplish these goals. Intrahepatic recurrence, despite adequate resection, can be expected in many patients, and few will be candidates for a second resection. For this reason, and because most patients are unresectable at presentation, the oncologic surgeon must be familiar with palliative options available for his patients, as well as the surgical management of operable tumors. Close collaboration with one's colleagues in medical oncology, invasive radiology, and gastroenterology are critical to the optimal care of this difficult patient population.

Adjuvant hepatic arterial infusion chemotherapy after curative resection of colorectal liver metastases

We performed a prospective study of adjuvant hepatic arterial infusion chemotherapy after resection of colorectal liver metastases. We placed hepatic arterial infusion ports in 20 consecutive patients undergoing curative resection of colorectal liver metastases. The chemotherapy regimen was a weekly bolus of 5-fluorouracil (15 mg/kg) for 6 months. The median follow-up has been 33 months. Nine of the 18 evaluable patients (50%) have developed recurrent colorectal cancer. The liver was the only site of failure in 3 of 18 patients (17%), and extrahepatic recurrences occurred in 6 of 18 patients (33%). All patients without recurrence are alive. The median survival of the patients without recurrent disease is 39 months, compared with 27 months for those with recurrent metastatic disease (p < 0.01). In patients who received adjuvant hepatic arterial infusion chemotherapy compared with historical controls treated with surgery alone, we have observed a decreased incidence of recurrent disease after liver resection for metastases. We recommend that patients who undergo hepatic resection for colorectal metastases be considered for postoperative adjuvant chemotherapy to decrease the likelihood of recurrence and to improve survival.

Technical considerations and complications associated with the placement of 180 implantable hepatic arterial infusion devices

BACKGROUND

Treatment regimens with hepatic arterial chemotherapy infusion are being investigated in an attempt to improve survival and quality of life for patients with primary and metastatic liver malignancies. The successful delivery of chemotherapeutic drugs through an implantable hepatic arterial infusion device depends on the surgeon's understanding of hepatic arterial anatomy, the proper cannulation technique, and the operative measures necessary to prevent misperfusion of drug.

METHODS

Between January 1, 1987, and December 31, 1991, we placed implantable hepatic arterial infusion devices in 180 patients. The records of these patients were review to determine (1) the incidence and surgical management of variant hepatic arterial anatomy and (2) the complications associated with surgical placement of these devices.

RESULTS

Variant hepatic arterial anatomy requiring ligation of the variant vessel or nonstandard cannulation was seen in 66 patients (36.7%). Treatment response rates and duration of treatment were no different for these 66 patients than for the 114 patients with standard hepatic arterial anatomy (p = 0.94). There were no operative deaths in this series. Operative or early postoperative (within 30 days) complications occurred in 10 patients (5.5%). However, late complications or device-related malfunctions developed in 52 patients (28.8%).

CONCLUSIONS

An understanding of regional arterial anatomy is required to surgically place a catheter to achieve bilobar hepatic arterial perfusion and avoid gastroduodenal misperfusion of drug. Placement of hepatic arterial infusion devices has a low rate of early morbidity, but surgeons should be aware of late complications that may develop in patients undergoing hepatic arterial chemotherapy infusion through an implantable device.

Mechanisms of Kupffer cell cytotoxicity in vitro against the syngeneic murine colon adenocarcinoma line MCA26

We have previously demonstrated that in vivo activation or inhibition of Kupffer cell (KC) cytotoxic function can reduce or enhance, respectively, the hepatic tumor burden in a syngeneic murine colon adenocarcinoma (MCA26) tumor model. In the current study, we have performed in vitro experiments to define the possible mechanisms of KC cytotoxicity against MCA26 cells. Addition of either anti-tumor necrosis factor (TNF) or anti-interleukin-1 alpha (IL-1 alpha) antisera reduced KC cytotoxicity in coculture against MCA26 targets in a dose-dependent fashion; addition of these sera together resulted in approximately additive inhibition, suggesting the existence of parallel pathways for these effector molecules. Nitric oxide as a mediator of cytotoxicity by KCs in coculture with MCA26 cells was evaluated by two approaches. Activated KCs produced detectable levels of nitric oxide; however, activated KC exerted cytotoxicity against MCA26 targets in the absence of exogenous free L-arginine. Thus, TNF and IL-1 play major roles in producing murine KC cytotoxicity against MCA26 colon cancer cells in vitro, whereas reactive nitric oxides do not.

Arterial complications from long-term hepatic artery chemoinfusion catheters: evaluation with CT

OBJECTIVE

The purpose of this study was to define CT changes in the common hepatic artery and the porta hepatis caused by complications of long-term placement of a catheter in the hepatic artery for infusion of chemotherapeutic agents via a surgically implanted pump or port.

MATERIALS AND METHODS

We retrospectively reviewed abdominal CT scans of 115 patients before and after placement of a catheter into a hepatic artery for chemoinfusion, with special attention to the common hepatic artery and the porta hepatis. The changes seen on CT scans were correlated with clinical findings and other imaging findings (arteriography and radionuclide scanning) in patients who had symptoms related to catheters and pumps, including pain during treatment, persistent pain without apparent cause, or occlusion of the catheter.

RESULTS

CT scans of 20 patients (17%) showed changes along the common hepatic artery. Five had rounded, low-density fluid collections around the tip of the catheter, believed to be caused by extravasation of chemotherapeutic agents or heparin. Five had well-defined soft-tissue densities along the hepatic artery, where the tip of the catheter was located; these were thought to be caused by dissection of the artery with periarterial fibrosis. Ten had poorly defined areas of low density along the vessel, which may have been caused by periarterial edema, arteritis, or extravasation of the chemotherapeutic agents. Two patients had pain on injection through the device, but no changes were seen on CT scans. Fourteen of 16 patients who had symptoms related to infusion catheters had CT changes in the porta hepatis.

CONCLUSION

Fluid collections and soft-tissue densities around the tip of the catheter and along the hepatic artery seen on CT scans of patients who had surgical placement of catheters for chemoinfusion should be recognized as possible complications from the treatment and lead to further study to confirm the diagnosis.

Increase in activity and level of pp60c-src in progressive stages of human colorectal cancer

Activation of the tyrosine kinase of the c-src gene product, pp60c-src, has been shown to occur in nearly every primary colorectal carcinoma, and is found as early as in polyps of high malignant potential. However, no studies have addressed potential pp60c-src changes which occur during progression. To examine this question, we have studied kinase activity and protein levels in 7 colonic polyps, 19 primary lesions, and 19 liver metastases relative to normal colonic mucosa. Significant increases in tyrosine kinase activity were seen as early as in colonic polyps of high malignant potential. Further increases were observed in activity and level in primary tumors. However, the greatest increases in activity and protein levels were observed in liver metastases. Additionally, six metastatic lesions were obtained in which synchronous primary tumor was resected. In each of these liver metastases, pp60c-src activity and level were significantly increased relative to the corresponding primary tumor, as well as to normal colonic mucosa. Our results demonstrate that progression of colon primary tumors to liver metastases correlates with increased pp60c-src kinase activity and protein level.

Murine Kupffer cells and hepatic natural killer cells regulate tumor growth in a quantitative model of colorectal liver metastases

This investigation aimed to develop a biologically relevant murine model of colorectal liver metastases and determine if Kupffer cells (KC) and hepatic natural killer cells (hNKC) regulate tumor growth. The model involves the injection of murine colon adenocarcinoma 26 (MCA 26) tumor cells into the portal vein of female-specific pathogen-free BALB/c mice. Metastases developed in all animals, and the growth was limited entirely to the liver. To determine if KC and hNKC control the development of liver metastases, the in vivo function of these hepatic effector cells was modulated. Tumor growth was quantitated by the uptake of 125I into tumor DNA. Stimulation of the KC and hNKC produced a significant (P less than 0.01) dose-dependent decrease in 125I uptake in the liver in both treatment groups, which was associated with a significant improvement in survival (P less than 0.05). The in vivo cytotoxic function of the liver was inhibited with an intravenous injection of gadolinium chloride (for KC) or asialo GM1 antiserum (for hNKC). Inhibition of KC and hNKC cytotoxic function led to a significant (P less than 0.01) increase in 125I uptake in the liver and a significant decrease in survival (P less than 0.05).

Current strategies for the treatment of hepatocellular carcinoma

Although hepatic resection for hepatocellular carcinoma is the only known modality that offers an opportunity for cure, the practicing oncologist must be aware of alternative modes of therapy. A multidisciplinary approach between surgeon, medical oncologist, and invasive radiologist is necessary in exploring all potential therapeutic options. The oncologist must not only consider the stage of the tumor, but must also take into account the functional reserve of the nontumor-bearing liver in selecting appropriate therapy. More recently, hepatic transplantation has been recognized as a potential curative modality for specific tumor types and stages. Percutaneous ethanol injection and chemoembolization are excellent palliative measures. However, it remains clear that new and innovative techniques are necessary in the therapeutic, adjuvant, and palliative settings in the comprehensive care of the patient with hepatocellular carcinoma.

Human Kupffer cells are cytotoxic against human colon adenocarcinoma

Colorectal liver metastases are a common clinical problem and require more effective therapy. Kupffer cells (KC) perform many important homeostatic functions within the liver and may also possess the ability to mediate tumor cytotoxicity. We investigated the ability of human KC to mediate cytotoxicity against human colon adenocarcinoma targets (HT 29) in vitro. Unstimulated human KC were cytotoxic against the HT 29 targets at all effector/target ratios tested. This cytotoxicity was increased significantly (p less than 0.05) when the KC were stimulated with interferon-gamma and lipopolysaccharide. Human KC produced tumor necrosis factor (TNF), and KC stimulation significantly (p less than 0.05) increased secretion of this monokine. The addition of anti-TNF antibody to the KC-HT 29 cocultures completely neutralized all of the available TNF yet cytotoxicity was not affected, suggesting the participation of a membrane-bound form of TNF or other mechanisms.

Hepatic artery infusion pumps: cannulation techniques and other surgical considerations

Long term hepatic artery chemotherapy for metastatic disease to the liver has been made practical by technologic advances in pumps and catheters. The surgical placement of these pumps and catheters can be associated with a significant morbidity unless careful attention is given to variations in hepatic arterial anatomy and to eliminating collateral arterial supply to the distal stomach and duodenum. Gastroduodenal devascularization should be performed in all patients and should be confirmed both with intra-operative fluorescein injection and postoperative scintigraphy scanning. Routine cholecystectomy avoids the complication of chemical cholecystitis. Exact placement of the catheter tip at the junction of the gastroduodenal artery and the hepatic artery with fixation of the catheter in this position by placement of bidirectional ligatures around the catheter bead will reduce the incidence of hepatic artery thrombosis and catheter migration. Intrahepatic arterial collateralization in most patients allows for ligation of variant lobar vessels with total liver perfusion through the remaining lobar arterial supply. This again can be confirmed intra-operatively with fluorescein injection and postoperatively with scintigraphy scanning. Strict attention to these technical details will allow continued use of this important therapeutic modality in the treatment of hepatic metastases and by minimizing surgical complications will encourage continued trials to improve the efficacy of long term hepatic arterial chemotherapy.

Hepatic resection for colorectal liver metastases

Colorectal liver metastases are a frequent and lethal complication of cancer. Hepatic resection is an effective treatment for patients with colorectal liver metastases and can provide a 25 to 35 per cent 5-year survival rate. All potential resection candidates should undergo extensive preoperative testing to exclude extrahepatic metastases and local recurrence. Contraindications to resection are the presence of (1) positive portal/celiac lymph nodes, (2) extrahepatic discontiguous disease, and (3) four or more lesions. At surgery all patients should undergo a detailed examination of the lymph nodes (periportal, retroperitoneal, regional), peritoneal surfaces, and the liver. Every resection candidate should have an intraoperative ultrasound examination of the liver. This modality will identify the presence of small, nonpalpable lesions and define the tumor-vessel relationship. Many types of resections can be performed and are classified as anatomic or nonanatomic (segmental). Preference should be given to segmental resections, because these procedures reduce blood loss, shorten operating time, and lower morbidity and mortality. Unfortunately, not all patients undergoing resection will be cured of the disease; many will develop extrahepatic disease. Effective systemic chemotherapy is necessary to improve survival in patients with colorectal cancer.

Surgical therapy of early rectal carcinoma

Radical surgical resection is the "gold standard" treatment for rectal carcinoma. Results indicating that radiation therapy reduces the incidence of local recurrence and that combined modality radiation therapy and chemotherapy reduce the rate of local and distant failures, as well as improving survival, has produced interest in adjuvant therapy. Conservative procedures to treat rectal cancer are also gaining support because of reduced morbidity and mortality, avoidance of colostomy, and excellent survival figures in selected patients. The key phrase continues to be "in selected patients" because current data support conservative procedures as attempts for cure only in patients with small, histologically favorable tumors. The combination of local excision and adjuvant external beam irradiation holds promise for improved control of local disease in patients with early rectal carcinoma. Further prospective evaluation with long-term follow-up of patients with early rectal carcinoma treated with conservative procedures is needed to assess the efficacy of conservative management.

Direct stimulation of the adrenal cortex by interleukin-1

The impact of human recombinant beta-interleukin-1 (IL-1) on adrenocortical stimulation was investigated. This study asked three questions: Does IL-1 increase the corticosterone levels of rat serum? Is there a direct effect on the adrenal cortex? What is the mechanism of this effect? The intraperitoneal injection of IL-1 (70 micrograms) in anesthetized male Fisher rats resulted in elevated corticosterone levels at 30 minutes and reached a maximum at 180 minutes (94 +/- 12 versus 34 +/- 4 micrograms/dl, p less than 0.01). Next, the adrenal glands from separate animals were perfused in situ. Corticosterone secretion was significantly increased (p less than 0.01) 90 minutes after a single arterial bolus of 35 micrograms of IL-1. The response to IL-1 was dose dependent, beginning at 3.5 micrograms and reaching a maximum at 35 micrograms. The addition of indomethacin (3 mumol/L) completely abolished the stimulatory effect of IL-1. This study demonstrates that IL-1 increases rat serum corticosterone levels, IL-1 directly stimulates the adrenal cortex, and the stimulation may be mediated through prostaglandin synthesis. This is the first evidence that IL-1 has a direct stimulatory effect on the adrenal cortex.

Stimulatory effect of interleukin-1 upon hepatic metabolism

The liver plays an important role in the acute-phase response to sepsis and injury, and host survival often depends upon an adequate hepatic response. Many of the metabolic sequelae to sepsis and injury are mediated by interleukin-1. This study was undertaken to investigate the impact of interleukin-1 upon hepatic metabolism and whether this mediator acted directly upon the liver. Interleukin-1 (5 rabbit pyrogen dose units) was administered to male Fisher F344 rats (175 to 200 g), and hepatocytes were isolated at three time periods; 2 to 4, 6 to 10, and 12 to 14 hours following an intraperitoneal injection. Alanine transport, gluconeogenesis, nonsecretory protein synthesis, and oxygen consumption were measured simultaneously in freshly isolated hepatocytes. Interleukin-1 stimulated initial rates of alanine uptake over a four-minute period. Peak stimulation of gluconeogenesis occurred at six to ten hours (0.52 +/- .14 v 0.08 +/- .01 nmol alanine converted/10(6) cells/min, P less than 0.05); nonsecretory protein synthesis was significantly stimulated at 12 to 14 hours (2.1 +/- .7 v 0.7 +/- 0.1 nmol valine converted/10(6) cells/min, P less than 0.05). These enhanced metabolic processes were associated with an increased oxygen consumption, with peak oxygen utilization occurring at six to ten hours (69 +/- 2 v 25 +/- 7 nmol of oxygen consumed 10(6) cells/min, P less than 0.05). In order to examine if interleukin-1 exerted its effect directly upon the liver, hepatocytes from normal rats were incubated in vitro with this mediator for two hours. Under these experimental conditions, interleukin-1 did not reproduce the stimulatory effect obtained following in vivo administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated energy expenditure in hepatocytes from tumor-bearing rats

Mechanisms for the development of cancer cachexia are not well defined. Oxygen consumption and the capacity of the host liver to metabolize lactate were studied in isolated hepatocytes from sarcoma-bearing rats (TIH) and pair-fed controls (CH). Basal oxygen consumption (without exogenous substrate) is significantly increased by 65% in the TIH as compared to the CH. The addition of a physiologic concentration of lactate stimulated oxygen consumption over the already stimulated basal state by 13% in the TIH compared to 5% in the CH. When the hepatocytes are incubated with 1.5 mM of [U-14C]lactate, glucose production, lactate oxidation, and entry of lactate carbons into nonsecretory protein are significantly increased in the TIH. Associated with this stimulation is a significant decrease in lactate incorporation into glycogen and lipid in the TIH. This study suggests that the tumor-influenced liver utilizes lactate at an increased rate and its intermediary metabolism is directed toward energy utilization rather than energy storage. The enhanced metabolic processes in the tumor-influenced liver are associated with an increased oxygen consumption which may be a contributory factor to the negative energy balance, a characteristic of cancer cachexia.

Gluconeogenesis in tumor-influenced hepatocytes

The growth of a tumor leads to alterations in host carbohydrate metabolism. In this study we examined gluconeogenic capacity and amino acid transport in tumor-influenced and control rat hepatocytes. Serum glucose level decreased with increasing tumor burden and a significant correlation (r = -0.80) was observed. Hepatic glycogen content was similar in both groups after an overnight fast. Endogenous glucose production was 27% higher in tumor-influenced hepatocytes. The presence of 10mM of alanine led to 72% stimulation of gluconeogenesis in tumor-influenced hepatocytes as compared to 48% stimulation in control hepatocytes. The same trends were present when lactate was used as a substrate. Alanine transport into the cells was increased in tumor-influenced hepatocytes by 55% +/- 5% at a physiologic level of substrate. In conclusion, gluconeogenesis from alanine and lactate is significantly increased in tumor-influenced hepatocytes despite decreased serum glucose levels. This is associated with increased gluconeogenic capacity and accelerated alanine transport.

Blalock shunt: procedure of choice in infants

This report summarizes our experience in 39 infants less than three months of age who underwent a Blalock anastomosis. Mortality in the 16 infants under one week of age was 25% (4/16) and the overall mortality was 26% (10/39). Early patency was 87% (34/39) and late, 83% (24/29). No patient developed congestive heart failure or pulmonary hypertension. For the infant with diminished pulmonary blood flow, the Blalock shunt is the procedure of choice.

Esophageal variceal sclerosis

In one year, we have performed esophageal varix sclerosis upon 20 patients with portal hypertension and bleeding esophageal varices who were not candidates for portosystemic shunting. The flexible fiberoptic endoscope permits sclerosis of both gastric and esophageal varices and is less prone to serious complications than the rigid instrument. Repeated injections are necessary to control hemorrhage. Five of nine acute episodes were successfully controlled. Fifteen patients survived initial hospitalization and entered a chronic injection protocol. Sclerosis has controlled recurrent variceal bleeding in 13 of this group. We now use injection sclerosis as the primary form of therapy for patients who have bled from esophageal varices. Portosystemic shunting is reserved for those instances of sclerotherapy failures.