Bromodeoxyuridine uptake by early liver metastases in rats: a comparison of the hepatic artery and portal vein infusion routes

Liver metastases generated by the intraportal inoculation of ascites hepatoma cells in Donryu rats were labeled with bromodeoxyuridine (BrdU) through the hepatic artery, or through the portal vein with or without ligation of the hepatic artery, 3, 6, or 9 days after tumor inoculation. The distribution of BrdU-labeled cells was evaluated in 174 metastases, 110-1640 microm in diameter, by immunohistochemical methods. When a dual blood supply from the portal vein and hepatic artery existed, the BrdU-labeled cells were diffusely found in the metastases regardless of their size and the route of BrdU infusion. When blood supply to metastases larger than 610 microm in diameter was from a single source, namely the portal vein, the BrdU-labeled cells were located within 90-290 microm from the margin of the metastases. These results indicate first, that drug uptake by the inner part of the early metastatic liver tumors is achieved through the hepatic artery, and second, that drug uptake by early liver metastases through the portal vein is limited to within the extent of portal diffusion regardless of the size of the metastases. Thus, we conclude that prophylactic treatment against liver metastases would be more effective when given via the hepatic artery route rather than via the portal vein route.

[Intra-arterial infusion chemotherapy for unresectable or recurrent breast cancer]

Epirubicin and 5-FU were administered through an indwelling catheter inserted into the internal mammary artery and/or subclavian artery employing an implantable infusion port system for the treatment of unresectable advanced breast cancer and recurrent breast cancer. Intraarterial infusion chemotherapy proved to be an effective treatment modality for unresectable advanced breast cancer and recurrent breast cancer.

[Adjuvant chemotherapy with UFT or UFT with OK-432 to patients with gastric and colorectal cancer. Kanto Adjuvant Study Group]

In Japan, long-term oral therapy with tegafur in combination with immunopotentiators is commonly used as adjuvant therapy after curative resection of gastric or colorectal can for gastric and colorectal cancer. When the outcome was analyzed in terms of the relative performance (R.P.) and the individual dose intensity (I.D.I.) of OK-432, gastric cancer patients with a R.P. of 0.5 or higher tended to have a better survival curve. There were no marked differences in lymphocytes subsets, except that the Leu 7 level at 3 months after gastric cancer resection was significantly higher (p < 0.05) in group B than in group A. Thus, no inhibition of the anticancer effect of UFT was noted during long term combination therapy with UFT and an immunopotentiator as postoperative adjuvant therapy for patients who underwent curative resection of gastric or colorectal cancer. The results suggest that UFT combined with long-term OK-432 maintenance therapy may contribute to improve survival rates in gastric cancer patients.

[A case report of neoadjuvant intra-arterial injection chemotherapy combined with peripheral blood stem cell reinfusion in an advanced breast cancer patient]

A seventy-one year-old woman suffered from Stage IIIb advanced breast cancer complicated with direct thoracic invasion and skin eruption. An indwelling intra-arterial catheter was inserted into the subclavian artery for the administration of anti tumor agents. After three courses of neoadjuvant chemotherapy combined with G-CSF and/or PBSCT reinfusion, the breast cancer revealed a remarkable size reduction and was absent from direct thoracic and pectoral muscle, invasion within the physical status and visual analysis by CT scan. Thereafter, the patient underwent a radical mastectomy. In the pathological findings of the operation specimen, despite a remarkable tumor collapse, the microscopic invasion remained in the shallow layer of the pectoral muscle. Thus, the patient should be given additional postoperative irradiation. The patients has had six months of stable tumor-free survival since the mastectomy.

Oral vancomycin hydrochloride therapy for postoperative methicillin-cephem-resistant Staphylococcus aureus enteritis

The postoperative development of methicillin-cephem-resistant Staphylococcus aureus (MRSA) enteritis can be fatal unless it is detected at an early stage and treated with effective antibacterial agents. We report herein a Japanese multicenter collaborative clinical study on the efficacy and safety of oral vancomycin hydrochloride (VCM) in the treatment of MRSA enteritis. A total of 49 patients who had been diagnosed as having, or were strongly suspected of having, MRSA enteritis during the early postoperative period, were given oral VCM as four standard doses of 0.5 g per day. The VCM concentrations in the blood, urine, and feces were then measured. No side effects were observed and the clinical efficacy of oral VCM in the 31 evaluable patients was excellent. There was a 100% clinical response rate and a 95.8% bacterial elimination rate in the feces. The clinical complete response (CR) rate to oral VCM differed significantly between patients in whom MRSA was detected only in the feces (100%) and those in whom MRSA was isolated from an additional source (57%) (P < 0.01). Although VCM concentrations in the stools were extremely high, the levels in the blood and urine were very low. These results demonstrate that oral VCM should be the treatment of choice for postoperative MRSA enteritis due to its safety and efficacy.

Hyperinsulinaemia accelerates accumulation of cholesterol ester in aorta of rats with transplanted pancreas

Hyperinsulinaemia may play a role in the development of atherosclerosis; however, the direct effect of endogenous insulin on the atherosclerotic process is not well understood. To clarify this situation we performed pancreas transplantation with systemic venous drainage in Wistar Shionogi (WS) and Spontaneous Hypertensive (SHR) rats. Both rats received syngeneic pancreaticoduodenal transplants from donor rats. SHR rats were used to observe the additive effects of both hypertension and hyperinsulinaemia on the atherosclerotic process. Peak blood insulin levels after a glucose load were approximately two times higher in transplanted rats than in non-transplanted WS and SHR rats. By contrast, there was no difference in plasma glucose responses between transplanted and non-transplanted rats. Hyperinsulinaemia was not related to dyslipidaemia and hypertension in transplanted rats. Nine months after transplantation, the cholesterol ester contents of the aortas of both WS and SHR transplanted rats were significantly higher than in the control rats (WS: 1.9 +/- 1.0 vs 3.8 +/- 2.1 mg/g dry tissue, p < 0.01; SHR: 1.7 +/- 1.3 vs 3.7 +/- 1.4 mg/g dry tissue, p < 0.05). No differences were demonstrated in the thickness of the intima or in the histology of the aortas of transplanted and control rats. To study the mechanism for cholesterol ester accumulation in the arterial wall, we measured neutral cholesterol ester hydrolase activities in vascular medial smooth muscle cells. Insulin significantly suppressed neutral cholesterol ester hydrolase activities in medial smooth muscle cells. Our results indicate that endogenous hyperinsulinaemia contributes to the development of atherosclerosis by accelerating cholesterol ester accumulation in the arterial wall.

[The history of the treatment for portal hypertension]

Until recently, the only effective treatment for bleeding esophageal varices was surgery, including portal-systemic shunts, nonshunting operations, and selective shunts. New operations were developed from the neccessity to find a better therapeutic modality for the treatment. This article describes the history of development of surgical treatment for portal hypertension as well as introducing the outline of several such procedures. The history of nonoperative treatments, especially endoscopic injection screlotherapy, is also described: Endoscopic sclerotherapy as a treatment for bleeding esophageal varices had been employed before many definitive surgical procedures. In accordance with the development of fiberoptic endoscopy, endoscopic sclerotherapy came into prominance. The less invasive treatment is appreciated and popularized even among surgeons today, who once believed that shunt operation (or nonshunting operation) was the best modality of treatment for esophageal varices. Finally, this article provides readers with a simplified guide to Japanese participation in the development of treatment for esophagogastric varices.

Hemodynamic analysis of findings in patients with portal hypertension: multicenter analysis in Japan. Japan Portal Hypertension Study Group

BACKGROUND/AIMS

A multicenter study was done to assess the pathophysiology of malcirculation with portal hypertension.

PATIENTS AND METHODS

Patients were admitted to 48 different institutes from 1990 to 1992.

RESULTS

Portal venous pressure was 345.9 +/- 72.1 mmH2O in patients with portal hypertension. In patients with liver cirrhosis, the diameter of the splenic artery, of the proper hepatic artery, of the left gastric artery and of the splenic vein was significantly larger (p<0.05) than seen in the controls without portal hypertension. In patients with idiopathic portal hypertension, the diameter of the splenic artery and of the vein was significantly larger (p<0.05) and that of the proper hepatic artery was significantly smaller (p<0.05) than seen in the cirrhotic patients. In the cirrhotic patients, blood flow volume was significantly larger (p<0.05) in the splenic vein. In patient with idiopathic portal hypertension, blood flow volume in the portal vein and splenic vein were significantly larger (p<0.05) and that of superior mesenteric vein showed an increasing tendency to enlarge.

CONCLUSION

This study shows that a hyperdynamic state is present in patient with portal hypertension.

Healing process of sutureless choledochojejunostomy in an experimental model

The healing characteristics and morphological features of sutureless choledochojejunostomy were investigated in a rat experimental model. The common bile duct of 34 conditioned Wistar rats was exposed, divided transversely and a choledochojejunostomy constructed with only a vinyl chloride tube positioned between the common duct and jejunum. The animals were killed 4, 12 and 52 weeks after surgery. Cholangiographic evaluation of the anastomosis in all three groups showed wide openings with dilatation of the extrahepatic bile duct. Microscopic examination of the anastomosis showed hyperplastic changes of the bile duct epithelium. The epithelial defect was completely covered with proliferative epithelium 12 weeks after operation. At long-term follow-up of 52 weeks there were no biliary strictures after the sutureless technique. This surgical approach may be useful for patients in whom sutured anastomosis of the bile duct might lead to stricture, such as those with a normal thin-walled bile duct.

Extensive subcutaneous emphysema and hypercapnia during laparoscopic cholecystectomy: two case reports

We report two cases of marked hypercapnia of more than 60 mm Hg (PaCO2) and extensive subcutaneous emphysema noted during laparoscopic cholecystectomy. The first case, a 55-year-old man was diagnosed as having cholecystolithiasis and had hypercapnia up to 83.5 mm Hg (PaCO2) during laparoscopic cholecystectomy. The patient resumed spontaneous respiration under controlled ventilation accompanied by persistent bigeminal pulse. Soon after deflation, CO2 returned to normal range, and extensive subcutaneous emphysema was detected in the recovery room. The second patient, a 53-year-old woman, had cholecystolithiasis and also underwent laparoscopic cholecystectomy. Both hypercapnia rising to 61.1 mm Hg (PaCO2) and extensive subcutaneous emphysema appeared just before completion of resection of the gallbladder. Mild hypercapnia during pneumoperitoneum of about 50 mm Hg (PaCO2) has been reported previously. As compared with cases in the literature, the present cases suggest that hypercapnia is due to extensive subcutaneous emphysema. The large absorption surface area in the subcutaneous tissue and the large difference in the partial pressure cause the extensive gaseous interchange of CO2 between subcutaneous tissue and blood perfusing into it at the moment between peritoneal cavity and blood perfused the peritoneum.

General rules for recording endoscopic findings of esophagogastric varices (1991). Japanese Society for Portal Hypertension

The general rules made in 1980 for recording endoscopic findings of esophageal varices have widely been used in Japan and in other countries. However, since the development of endoscopic sclerotherapy and other modalities of endoscopic treatment, these 1980 rules were found to be insufficient for recording mucosal changes after treatment. The general rules as revised in 1991 recognize mucosal changes such as erosion, ulcer, scar, thrombosed varices, and bleeding signs. These new 1991 rules, which seem useful for recording initial evaluation of gastroesophageal varices and for describing mucosal changes after sclerotherapy as well, are described here.

Evaluation of long-term results of Caroli's disease: 21 years' observation of a family with autosomal "dominant" inheritance, and review of the literature

A 5-year-old girl underwent laparotomy in 1972 because of hepatomegaly and mottled radiopacities shown by cholangiography. Polycystic segmental dilatation of the intrahepatic bile ducts, typical of Caroli's disease, was found. Thereafter she remained in good health for over 21 years with careful medical management. In 1972 mottled radiopacities of the hepatic parenchyma were also demonstrated by cholangiography in her 9-year-old brother, who, however, remained asymptomatic until hematemesis due to esophageal varices suddenly occurred in 1993. At the time of the pre-operative evaluation for esophageal transection, his condition was definitively diagnosed as Caroli's disease. Their father was in good health, but in 1993 was shown by CT to have the same disease. The mode of inheritance is likely to be autosomal dominant, although Caroli's disease or congenital hepatic fibrosis is generally considered autosomal recessive (McKusick number 263200) (1). If we had not examined the father, this particular family would have been accepted as an example of autosomal recessive inheritance. We suggest that further family studies are needed to exclude the autosomal dominant mode of inheritance, and that at least some of the recessive cases in the literature are, in fact, autosomal dominant. Well-documented cases of "classical" Caroli's disease in the literature were reviewed with special reference to the long-term results. In addition, an international questionnaire aimed at establishing the further clinical course of the patient was sent to authors who reported cases after 1968.(ABSTRACT TRUNCATED AT 250 WORDS)

Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy

OBJECTIVE

The authors used prolamine (Ethibloc, Ethicon GmBH, Norderstedt, Germany) for segmental obstruction of the pancreatic duct to prevent pancreatic fistula development after distal pancreatectomy combined with total gastrectomy for gastric malignancies.

SUMMARY BACKGROUND DATA

Although the initial clinical application of prolamine was pancreatic duct obstruction for patients with pancreatitis and undergoing pancreatic transplantation and pancreaticoduodenectomy for pancreatic cancer, there are no reports on prevention of pancreatic fistula formation after distal pancreatectomy.

METHODS

Prolamine (0.2 mL) was injected into the distal segment of the main duct in the remaining pancreata of 51 patients. Small pancreatic ducts on the cut surface, from which prolamine extravasates, were closed by ligation, the main duct was ligated doubly, and the transected pancreatic margin was closed 15 minutes after phenylpropanolamine hydrochloride injection.

RESULTS

No patient developed a pancreatic fistula or the complication of arterial bleeding due to prolonged infection.

CONCLUSION

Segmental obstruction of the pancreatic duct with prolamine is useful for preventing pancreatic fistula development after distal pancreatectomy.

Morphometry of sinusoids and portal hypertension in non-alcoholic cirrhosis

To examine whether structural changes in hepatocytes and/or sinusoidal areas contribute to the portal hypertensive state in non-alcoholic cirrhosis, a new method of morphometric analysis using a computer-aided color image analyzer was performed in 16 patients with non-alcoholic cirrhosis, which allowed quantitative evaluation of various morphometric parameters of sinusoids and hepatocytes. The sinusoidal pressure gradient was estimated theoretically with these and clearance parameters using Poiseulle's equation and compared with the hepatic venous pressure gradient measure by hepatic vein cannulation. A significant relationship was found between the hepatic venous pressure gradient and sinusoidal volumetric ratio (r = -0.598, p < 0.05), but not between mean hepatocyte volume and sinusoidal volumetric ratio (r = 0.416, NS), or the hepatic venous pressure gradient (r = 0.371, NS). The estimated sinusoidal pressure gradient showed a significant relationship with the hepatic venous pressure gradient (r = 0.637, p < 0.01). However, the absolute values of the former were much lower than those of the latter. Therefore, in non-alcoholic cirrhosis, although sinusoidal stenosis not caused by hepatocyte swelling may lead to increased vascular resistance, other factors must also play a significant role.

Study of new prognostic factors of esophageal variceal rupture by use of image processing with a video endoscope

BACKGROUND

We studied new prognostic factors of esophageal variceal rupture by analyzing electronic video images of esophageal varices in 30 patients with portal hypertension.

METHODS

Fifteen of the patients were emergency or elective cases (bleeders), and the remaining 15 were prophylactic cases (nonbleeders). A comparison was made between the bleeders and nonbleeders in terms of endoscopic findings and the image processing data, especially variceal color tone and red color sign.

RESULTS

Endoscopic findings based on the general rules prepared by the Japanese Research Society for Portal Hypertension showed no significant difference between the two groups. However, with regard to the image processing data, both the ratio of red signal and the ratio of value were significantly lower in bleeders than in nonbleeders. In addition, the area ratio of red color sign was significantly higher in the former than in the latter. A follow-up study of nonbleeders also indicated that image processing data were more reliable than traditional endoscopic rules.

CONCLUSIONS

By adding these image processing data to the traditional general rules for recording endoscopic findings, it is possible to select patients with varices that have a higher risk of rupture.

Therapeutic efficacy and toxicity of sequential methotrexate and 5-fluorouracil in gastric cancer

The therapeutic efficacy and toxicity of sequential methotrexate and 5-fluorouracil in 64 inoperable gastric cancer patients are reported. An intermediate-dose treatment was given to 48 patients, and a low-dose treatment to 16 patients. In the intermediate-dose treatment, leukopenia was observed in 11 patients, nausea and vomiting in six patients and diarrhea and stomatitis in two patients each. In the low-dose treatment, no patient developed toxic symptoms of grade 3 or 4. All 9 responders had adenocarcinoma of the poorly differentiated type and the response rate in patients who belonged to this type was 32.1%.