Pyloroplasty in gastric replacement of the esophagus after esophagectomy: one-layer or two-layer technique?

Pyloroplasty is our routine drainage procedure performed when the stomach is used as the esophageal substitute after esophageal resection for cancer. The technique of pyloroplasty varies among surgeons and effectiveness has not been studied. Thirty-four patients with a gastric conduit whose pyloroplasty was constructed with a one-layer technique (group 1) were compared with a historical cohort of 31 patients treated with a two-layer method (group 2). Patients who had an abnormal pyloroduodenal region were excluded from the study. Perioperative morbidity and post-operative gastrointestinal symptoms within the first 6 months were evaluated. Patient demographics and the types of surgical procedures did not differ between the two groups. The median daily output from the nasogastric tube was 119 mL in group 1 and 115 mL in group 2 (p = 0.49). In 40 out of 65 patients (62%), the nasogastric tube was removed at a median of 3 days after the operation in both groups. There was no leakage from the pylorus or the esophagogastric anastomosis in this study. In both groups, the patients could resume a semisolid diet at a median of 8 days after surgery. One patient in group 1 and two patients in group 2 developed gastroparesis clinically. No patient, however, required reoperation. There was no significant difference in cardiopulmonary complications attributable to the technique of pyloroplasty. The incidence of gastrointestinal symptoms within the first 6 months after surgery did not differ. Regurgitation was the most common symptom, affecting 10 patients in each group, 29% and 32% in group 1 and group 2 respectively (p = 1.0). Pyloroplasty was an effective gastric drainage procedure after esophagectomy whether the one or two-layer method was used. The authors prefer the one-layer method, which is safe and simple.

Treatment of inguinodynia after laparoscopic herniorrhaphy: a combined laparoscopic and fluoroscopic approach to the removal of helical tackers

Laparoscopic inguinal herniorrhaphy has become a popular operation for the treatment of inguinal hernia. However, injury and entrapment of the cutaneous nerves of the lumbar plexus by the staples or tackers used for mesh fixation have been described. Laparoscopic removal of the staples or tackers in the inguinal region has been attempted with variable success. The success of the laparoscopic approach for removal of helical tackers in particular is sometimes limited by the fact that the offending tackers are deeply embedded in the preperitoneal tissues and not readily located with a simple laparoscopic view. The authors report a case in which fluoroscopy was used to help identify tackers that could not be visualized laparoscopically. The neuralgia disappeared after successful removal of the offending tackers with no neurologic deficit. Liberal use of fluoroscopic guidance in the laparoscopic removal of helical tackers in similar cases is recommended.

Spinal anesthesia improves the early recovery profile of patients undergoing ambulatory knee arthroscopy

PURPOSE

We compared the recovery profiles, postoperative complications, perioperative OR utilization times, and times to discharge of patients undergoing ambulatory knee arthroscopy under spinal anesthesia (SA) or general anesthesia (GA).

METHODS

In this randomized, prospective study, 84 ASA I-II patients were randomized to receive either SA with 50 mg of 1% lidocaine, or a standardized GA. Postoperative pain, nausea and vomiting, sedation, OR utilization, postanesthesia care unit (PACU), and ambulatory surgical unit (ASU) recovery were compared.

RESULTS

Patients in the GA group had more pain in the PACU than the SA group (61% vs 15%, P <0.01), and a higher incidence of PACU analgesic use (59% vs 7.5%, P <0.01). Patients in the SA group were able to drink and eat sooner than the GA group (83 +/- 23 vs 95 +/- 22 min, P <0.05 and 88 +/- 27 vs 105 +/- 29 min, P <0.01, respectively). The times to sit, walk, and void were similar. The length of PACU and ASU stay between the GA and SA groups were similar (67 +/- 17 vs 60 +/- 19 min, P >0.05 and 122 +/- 27 vs 127.9 +/- 31 min, P >0.05, respectively). The incidence of backache was higher in the SA group (35 vs 13.6%, P <0.05) than the GA group. However, the incidence of sore throat was higher in the GA compared to the SA group (25% vs 2.5%, P <0.01).

CONCLUSIONS

SA with 50 mg of 1% lidocaine provides an improved recovery profile for ambulatory knee arthroscopy. Discharge times were similar, and with the exception of backache and sore throat, the incidence of complications was similar.

American ginseng (Panax quinquefolius L.) attenuates postprandial glycemia in a time-dependent but not dose-dependent manner in healthy individuals

BACKGROUND

We previously showed that 3 g American ginseng administered 40 min before an oral glucose challenge significantly reduces postprandial glycemia in subjects without diabetes. Whether this effect can be replicated with doses <3 g and administration times closer to the oral glucose challenge is unclear.

OBJECTIVE

Our objective was to study the dosing and timing effects of American ginseng on postprandial glycemia.

DESIGN

In a random crossover design, 12 healthy individuals [X +/- SEM age: 42 +/- 7 y; body mass index (BMI; in kg/m2): 24.1 +/- 1.1] received 16 treatments: 0 (placebo), 1, 2, or 3 g American ginseng at 40, 20, 10, or 0 min before a 25-g oral glucose challenge. Capillary blood was collected before administration and at 0, 15, 30, 45, 60, and 90 min after the start of the glucose challenge.

RESULTS

Two-way analysis of variance showed that the main effects of treatment and administration time were significant (P < 0.05). Glycemia was lower over the last 45 min of the test after doses of 1, 2, or 3 g ginseng than after placebo (P < 0.05); there were no significant differences between doses. The reductions in the areas under the curve for these 3 doses were 14.4 +/- 6.5%, 10.6 +/- 4.0%, and 9.1 +/- 6%, respectively. Glycemia in the last hour of the test and area under the curve were significantly lower when ginseng was administered 40 min before the challenge than when it was administered 20, 10, or 0 min before the challenge (P < 0.05).

CONCLUSIONS

American ginseng reduced postprandial glycemia in subjects without diabetes. These reductions were time dependent but not dose dependent: an effect was seen only when the ginseng was administered 40 min before the challenge. Doses within the range of 1-3 g were equally effective.

Endovascular stenting of superficial femoral artery stenosis and occlusions: results and risk factor analysis

PURPOSE

To determine the early and midterm results of femoro-popliteal angioplasty with adjunctive stenting and to identify factors affecting early and continuing success.

METHODS

Sixty-nine consecutive balloon angioplasty procedures on the superficial femoral artery (SFA) were performed in 60 limbs and 55 patients in the operating theater. Fifty-two percent of lesions were occlusions, and 87% involved the distal half or the whole segment of the SFA. Immediate endovascular stenting was used in all procedures, involving the placement of 105 stents, with a mean stented length of 13.8 cm. Twenty-nine procedures (43%) were performed for critical ischemia. Three-monthly duplex ultrasound was used for follow up assessment, with stenosis of > 50% defined as the endpoint for failure. The patient demographic and biochemical data, and procedural details were correlated with success criteria according to Society of Vascular Surgery standards.

RESULTS

Initial technical success by intent to treat was 92%, with four procedure-related complications and no deaths. Initial success by anatomic, hemodynamic and clinical criteria were 98.3, 96.7 and 93.3% respectively (92.2, 90.6 and 87.5% by intent to treat). Cumulative primary patency at 6, 12, and 24 months was 73.1, 62.6 and 53.8%, and secondary patency 84.9, 72.1 and 72.1% correspondingly. Significant factors relating to inferior patency were occlusions, stented segment length > 10 cm, procedure in claudicants, and the use of the Memotherm stent.

CONCLUSIONS

Angioplasty and stenting of the superficial femoral artery has acceptable primary and secondary patency rates even in the presence of long stenosis and occlusions. A duplex surveillance program is recommended for early detection and timely treatment of restenosis.

Anomalous overexpression of p27(Kip1) in sporadic pancreatic endocrine tumors

BACKGROUND

Little is known about the cellular defects and molecular mechanisms leading to pancreatic endocrine tumors (PETs). p27(Kip1) is a universal cyclin-dependent kinase inhibitor (CDKI), which acts as a tumor suppressor and a negative regulator of cell cycle. From previous reports, quiescent cells show high levels of p27(Kip1) expression while neoplastic and proliferating cells show no detectable p27(Kip1) expression. We hypothesize that in malignant sporadic PETs, p27(Kip1) expression would be decreased compared with benign PETs and normal pancreatic tissue.

METHODS

Western analysis was performed on 28 PETs (7 malignant, 21 benign), 2 nonendocrine cell lines, and 5 endocrine cell lines. Signal intensities were quantitated using densitometry and standardized to normal pancreas.

RESULTS

Unexpectedly, increased p27(Kip1) expression as compared with control was seen in both benign and malignant tumors, as well as in all four pancreatic islet tumor cell lines, but not fibroblast or pituitary cell lines, evaluated. There was no difference in p27(Kip1) level between benign and malignant tumors.

CONCLUSION

This represents the first report of anomalous p27(Kip1) overexpression in sporadic PETs, and is part of a growing literature describing the paradoxical overexpression of p27(Kip1) in human tumors that includes other endocrine tumors. These studies suggest a unique molecular pathway leading to endocrine tumorigenesis.

Laparoscopic versus open bowel resection for Crohn's disease

BACKGROUND

Laparoscopic bowel resection is an alternative to open surgery for patients with Crohn's disease requiring surgical resection. The present report describes a seven-year experience with the laparoscopic treatment of Crohn's disease compared with the open technique in a tertiary Canadian centre.

PATIENTS AND METHODS

A retrospective analysis of 61 consecutive patients undergoing elective resection for Crohn's disease was carried out between October 1992 and June 1999. This analysis included 32 laparoscopic resections (mean age 33 years) and 29 open resections (mean age 42 years). Patient demographics were compared, as well as short and long term outcomes after surgery (mean follow-up 39 months).

RESULTS

Patients in the laparoscopic group were younger and had fewer previous bowel surgeries than patients who had open resections. Indications for surgery and operative times were similar between the groups. Patients who underwent laparoscopic resections required fewer doses of narcotic analgesics. The resumption of bowel function after surgery, and tolerance of a clear liquid and solid diet was quicker in the laparoscopic group. Patients who underwent laparoscopic resections had significantly shorter hospital stays than those who underwent open resections. Fifteen patients (48.4%) in the laparoscopic group experienced recurrence of disease compared with 13 patients (44.8%) in the open group. In both groups, the most common site of recurrence was at the anastomosis. The disease-free interval was the same length for both groups (23.9+/-17.3 months for the laparoscopic resection patients compared with 23.9+/-20.2 months for the open resection patients; P=1.00).

CONCLUSIONS

Laparoscopic resection for Crohn's disease can be performed safely and effectively. Quicker resumption of oral feeds, less postoperative pain and earlier discharge from hospital are advantages of the laparoscopic method. No differences in the recurrence rate or the disease-free interval were noted.

Automated chemical synthesis: from resins to instruments

Solid-phase organic synthesis is now a prevalent activity in drug discovery. In keeping with this keen interest is the need to develop reliable automated synthesis instrumentation as well as polymeric supports and linkers suitable for the full range of organic synthesis applications. In this paper, we review our activities in the development of new and enabling tools for automated chemical synthesis, including the following: (i) new solid supports such as ArgoGel (PS-PEG-based) and Argo-X203 (PS-based); and (ii) the Nautilus 2400 system, a fully closed and inert automated chemistry development workstation. Selected chemistry optimization and synthesis examples performed on the Nautilus and new solid supports will be described.

Adjunctive donepezil in attention deficit hyperactivity disorder youth: case series

Despite well-documented improvement in attention deficit hyperactivity disorder (ADHD) in youths with the available single and combined pharmacologic agents, a number of youths remain with residual symptomatology causing impairment in multiple domains. Recent work has suggested a potential cognitive-enhancing role of cholinergic agents in ADHD. We describe five cases of ADHD youths aged 8-17 years being treated for ADHD with the acetylcholinesterase inhibitor donepezil (Aricept), all of whom demonstrated improvement.

Liver transplantation in rats using small-for-size grafts: a study of hemodynamic and morphological changes

BACKGROUND

Damage to a small-for-size liver graft after reperfusion is frequently observed but the mechanism of injury remains unclear.

HYPOTHESIS

Injury to a small-for-size liver graft is related to the changes of portal pressure and blood flow.

MAIN OUTCOME MEASURES

Survival rates, portal hemodynamics, microcirculatory changes, and morphological changes (by light microscopy and electron microscopy).

SETTING

A rat model of nonarterialized orthotopic liver transplantation comparing 2 groups of rats transplanted with whole grafts (100% of recipient liver weight) and small-for-size grafts (30% of recipient liver weight).

RESULTS

Median survival of the rats with small-for-size grafts was 30 hours (range, 27-37 hours). During the first 15 minutes after reperfusion, mean arterial pressure of the small-for-size graft group was significantly lower than that of the whole graft group (10-minute: 100 vs 132 mm Hg, P =.04; 15-minute: 96 vs 127 mm Hg, P =.04). Portal pressure (in centimeters of water) of the small-for-size graft group was significantly higher in the first 20 minutes after reperfusion than the level before the anhepatic phase (5-minute: 15.1 vs 9.3, P =.02; 10-minute: 16.1 vs 9.3, P =.03; 15-minute, 13.5 vs 9.3, P =.03; 20-minute: 13.4 vs 9.3, P =.03) and was significantly higher than that of the whole graft group in the first 10 minutes after reperfusion (5-minute: 15.1 vs 9.6, P =.02; 10-minute: 16.1 vs 10.3, P =.04). Hepatic microcirculatory blood flow (in milliliters per minute per 100 g) was also significantly higher in the small-for-size graft group during the first 40 minutes after reperfusion (5-minute: 16.3 vs 9.3, P =.02; 10-minute: 14.9 vs 6.6, P =.02; 15-minute: 14.8 vs 5.5, P =.02; 20-minute: 13.1 vs 7.0, P =.02; 30-minute: 13.2 vs 8.8, P =.04; 40-minute: 14.6 vs 7.1, P =.02). Light and electron microscopy showed normal morphological features of whole graft up to 24 hours after reperfusion. The small-for-size graft, however, showed sinusoidal congestion, tremendous swelling of mitochondria of hepatocytes, irregular large gap of sinusoidal lining cells, and collapse of the space of Disse.

CONCLUSIONS

In a rat model, the portal hemodynamic changes in small-for-size grafts are transient. Progressive damage of the graft may result from microcirculatory failure due to irreversible endothelial injury after reperfusion.

Novel demonstration of a physiologic/pharmacologic role of insulin-like growth factor-1 in ovulation in rats and action on cumulus oophorus

Gonadotropins are well known to be the most important stimulus for ovarian follicular development. More recently, there is indirect evidence that insulin-like growth factor-1 (IGF-1) is also a very important autocrine/paracrine factor in folliculogenesis. We had access to an analog of IGF-1, LR3IGF-1, which binds very poorly to IGF-1 binding proteins and therefore was shown by previous investigators to have biologic effects. We studied rats that were superovulated with the use of gonadotropins. We showed that the addition of LR3IGF-1 by infusion further increased the ovulation rate (statistically significant) and increased the ovarian weight in two of three strains of rats. We demonstrated that infusion of LR3IGF-1 or injection of equine chorionic gonadotropin or a combination of these two were associated with oocytes with reduced number of cumulus cells (statistically significant). We conducted an experiment to determine whether in vitro culturing with varying dosage of IGF-1 may stimulate cumulus cell replication to improve the quality of oocyte cumulus complex. IGF-1 did not show any change in this respect. Through these physiologic (pharmacologic) studies, we have shown that IGF-1 (analog) can further increase the ovulation rate induced by gonadotropins.

Analysis of reduced death and complication rates after esophageal resection

OBJECTIVE

To identify factors that have contributed to reduced rates of death and complications after esophageal resection in a 17-year period at a tertiary referral center.

SUMMARY BACKGROUND DATA

There has been an evolving refinement in surgical technique and perioperative management of patients undergoing esophageal resection at Queen Mary Hospital during the past two decades. As of the end of 1998, there had been no hospital deaths among the last 105 consecutive resections performed for esophageal squamous cancer.

METHODS

The results of esophageal resection for squamous cell carcinoma were analyzed using a prospective esophageal database. A longitudinal study was performed to compare and analyze rates of death and complications for three consecutive time periods.

RESULTS

The study group comprised 710 patients who underwent one-stage esophageal resection between 1982 and 1998. A transthoracic esophagectomy was the preferred approach in 590 patients (83%). The overall hospital death rate was 11%. The leading causes of hospital death were pulmonary complications (45.5%) and progression of malignant disease (21.5%); anastomotic leakage accounted for 9% of deaths. During the study period, the hospital death rate decreased from 16% to 3.2%, and the incidence of postoperative respiratory failure decreased from 15.5% to 6.5%. Perioperative factors that correlated with the decreased death rate over time were the increased postoperative use of epidural analgesia and bronchoscopy (for clearance of pulmonary secretions), a decrease in history of smoking, and a decrease in surgical blood loss of more than 1,000 mL.

CONCLUSIONS

In this series of predominantly transthoracic esophagectomies, there has been a decline in the hospital death rate to less than 5%. These results are largely attributable to factors aimed at reducing postoperative pulmonary complications.

Clinical implications of circulating angiogenic factors in cancer patients

PURPOSE

Angiogenesis, a process fundamental to tumor growth, is regulated by angiogenic factors. This article reviews prognostic and other clinical implications of circulating angiogenic factors in cancer patients.

METHODS

A MEDLINE search of literature was performed using the names of various angiogenic factors as the key words. Studies pertaining to circulating angiogenic factors in cancer patients were reviewed. Pertinent literature regarding tumor expression of common angiogenic factors and their prognostic relevance in human cancers were also examined.

RESULTS

A substantial number of studies have demonstrated a strong association between elevated tumor expression of vascular endothelial growth factor (VEGF) and advanced disease or poor prognosis in various cancers. This supports the pivotal role of VEGF in regulating tumor angiogenesis. More recently, there is mounting evidence that the level of circulating VEGF in patients with different types of cancer may be predictive of tumor status and prognosis. Preliminary data also suggest that circulating VEGF may be useful in predicting and monitoring tumor response to anticancer therapies and in follow-up surveillance for tumor relapse. There are reports supporting the prognostic value of other circulating angiogenic factors such as basic fibroblast growth factor, platelet-derived endothelial cell growth factor, transforming growth factor-beta, and angiogenin, but their clinical significance is less conclusive because of limited data.

CONCLUSION

Circulating VEGF seems to be a reliable surrogate marker of angiogenic activity and tumor progression in cancer patients. Evaluation of circulating angiogenic factors is a promising novel approach of prognostication in cancer patients that has the advantages of being convenient and noninvasive, and it may provide new prognostic information that is not afforded by conventional clinicopathologic prognostic indicators.

Intra-abdominal hypertension and abdominal compartment syndrome

BACKGROUND

The effects of increased intra-abdominal pressure in various organ systems have been noted over the past century. The concept of abdominal compartment syndrome has gained more attention in both trauma and general surgery in the last decade. This article reviews the current understanding and management of intra-abdominal hypertension and abdominal compartment syndrome.

METHODS

Relevant information was gathered from a Medline search of the English literature, previous review and original articles, references cited in papers, and by checking the latest issues of appropriate journals.

RESULTS AND CONCLUSION

Akin to compartment syndrome in extremities, the pathophysiological effects of increased intra-abdominal pressure developed well before any clinical evidence of compartment syndrome. These effects include cardiovascular, pulmonary, renal and intracranial derangement, reduction of intestinal and hepatic blood flow, and reduction of abdominal wall compliance. Although abdominal compartment syndrome is more commonly noted in patients with abdominal trauma, it is now evident that non-trauma surgical patients could also develop the condition. Early initiation of treatment for intra-abdominal hypertension is currently advocated in view of the possibility of subclinical progress to the full-blown abdominal compartment syndrome.

What is appropriate treatment for carcinoma of the thoracic esophagus?

Recent advances in the treatment of esophageal cancer have yielded a variety of new options for management of this highly lethal disease. Various approaches to surgical resection have been proposed. Chemotherapy and radiotherapy with or without surgery have been tested in numerous trials, the results of which are often conflicting and confusing for clinicians. The changing epidemiology of the disease between East and West adds to the controversy. In this review, the authors address some of the more controversial debates. The following questions are asked: What is the appropriate approach for surgical resection? What is the appropriate extent of resection? Is multimodality treatment appropriate for esophageal cancer?

Liver transplantation in Asian patients with chronic hepatitis B using lamivudine prophylaxis

OBJECTIVE

To report the results of liver transplantation in 31 Asian patients with chronic hepatitis B using lamivudine prophylaxis in an open-label study.

SUMMARY BACKGROUND DATA

Chronic hepatitis B is a prevalent cause of end-stage liver disease in Asia, but the results of liver transplantation in these patients are poor.

METHODS

Thirty-one Asian patients with chronic hepatitis B underwent liver transplantation using lamivudine prophylaxis (100 mg daily). Twenty-three (74%) patients had detectable serum hepatitis B envelope antigen (n = 18) or hepatitis B virus DNA (n = 11) before treatment, and seven had associated hepatocellular carcinoma. Lamivudine was continued indefinitely after transplantation, and hepatitis B immune globulin was not used.

RESULTS

The actuarial patient and graft survival rates were 84% and 81%, respectively. Five patients died of causes unrelated to hepatitis B, and 26 patients were alive at a median follow-up of 16 months (range 6-47) after transplantation. One (3.8%) patient developed recurrent hepatitis B resulting from viral breakthrough at week 53 and survived after retransplantation using adefovir and hepatitis B immune globulin treatment. The remaining 25 surviving patients had no biochemical or histologic evidence of recurrent hepatitis, and serum hepatitis B virus DNA remained negative by polymerase chain reaction. In six patients, hepatitis B surface antigen (HBsAg) persisted or reappeared in serum. Among 19 patients who became negative for HBsAg from 5 to 431 days after transplantation, 13 developed anti-HBsAb that lasted a median of 6 months (range 1-21). None of the seven patients with hepatocellular carcinoma developed recurrent tumor.

CONCLUSIONS

Asian patients with chronic hepatitis B may achieve a good outcome after liver transplantation using lamivudine prophylaxis.

Post-operative recovery: day surgery patients' preferences

Due to the growing importance of quality assurance and cost containment in healthcare, eliciting patients' preferences for post-operative outcomes may be a more economical and reliable method of assessing quality. Three hundred and fifty-five day surgery patients completed a pre-operative written questionnaire to identify patients' preferences for avoiding 10 particular post-operative symptoms: pain, nausea, vomiting, disorientation, shivering, sore throat, drowsiness, gagging on the tracheal tube, thirst and a normal outcome. The two scoring methods used to evaluate preferences were priority ranking and relative value scores. The effects of age, gender, previous health status, type of surgery and previous experience of anaesthesia on patients' preferences were also examined. Avoiding post-operative pain, gagging on the tracheal tube and nausea and vomiting are major priorities for day-case patients. Anaesthetists should take patients' preferences into consideration when developing guidelines and planning anaesthetic care.

Coexistent cutaneous Aspergillus and cytomegalovirus infection in a liver transplant recipient

Cutaneous infections are a significant cause of morbidity in solid organ recipients. These infections may be complex with multiple pathogens occurring in the same lesion. We describe the unusual association of cutaneous Aspergillus and cytomegalovirus (CMV) infections in a liver transplant recipient. Cutaneous CMV infection is rare and often indicates severe systemic involvement, whereas Aspergillus is a frequent cause of opportunistic cutaneous fungal infection. Seven weeks after liver transplantation, our patient had hemorrhagic, eroded plaques develop on his arms. The results of routine histology, immunoperoxidase staining for CMV antibody, and fungal culture revealed coexistent cutaneous Aspergillus flavus and CMV infections. The patient was treated with ganciclovir, amphotericin B, and topical terbinafine cream; however, 2 weeks after the development of the cutaneous lesions, the patient died.

Serum vascular endothelial growth factor predicts venous invasion in hepatocellular carcinoma: a prospective study

OBJECTIVE

To evaluate the correlation between serum vascular endothelial growth factor (VEGF) level and the clinicopathologic features in patients with hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

VEGF is an important angiogenic factor regulating tumor angiogenesis. A high serum VEGF level has been shown to be associated with tumor progression and metastasis in several human cancers, but its significance in HCC is unclear. The correlation between serum VEGF level and tumor pathologic features in patients with HCC has not been studied before.

METHODS

Preoperative serum samples and tumor specimens were prospectively collected in 100 patients undergoing resection of HCC. Serum VEGF level was measured by enzyme-linked immunosorbent assay, and tumor VEGF expression was assessed by immunohistochemical study. Histopathologic examination was performed by a pathologist without prior knowledge of the serum VEGF level or tumor VEGF expression.

RESULTS

Preoperative serum VEGF levels ranged from 15 to 1,789 pg/mL (median 269). When serum VEGF levels were compared between groups categorized by different clinicopathologic variables, significant correlation was found between a high serum VEGF level and absence of tumor capsule, presence of intrahepatic metastasis, presence of microscopic venous invasion, and advanced stage. There was a positive correlation between the serum VEGF level and tumor expression of VEGF as well as platelet count. When the 75th percentile serum VEGF level (500 pg/mL) was used as a cutoff level, the frequency of venous invasion in patients with a high serum VEGF level was significantly greater compared with patients with a low serum VEGF level. By multivariate analysis, a serum VEGF level of more than 500 pg/mL and tumor size more than 5 cm were independent preoperative factors predictive of microscopic venous invasion. During a median follow-up of 11.6 months, 48% of patients with a serum VEGF level of more than 500 pg/mL and 27% of those with a serum VEGF level of 500 pg/mL or less developed postoperative recurrence.

CONCLUSIONS

These results show that a high preoperative serum VEGF level is a predictor of microscopic venous invasion in HCC, suggesting that the serum VEGF level may be useful as a biologic marker of tumor invasiveness and a prognostic factor in HCC.

Laparoscopic cholecystectomy and exploration of common bile duct in a patient with situs inversus

Situs inversus is a rare anomaly with a genetic predisposition. We report a patient with situs inversus, cholelithiasis, and choledocholithiasis who was treated successfully with laparoscopic cholecystectomy and laparoscopic exploration of the common bile duct. We believe this to be the first such case reported in the literature.

Localization of needle tip with color doppler during pericardiocentesis: In vitro validation and initial clinical application

This study evaluates a new device that uses color Doppler ultrasonography to enable real-time image guidance of the aspirating needle, which has not been possible until now. The ColorMark device (EchoCath Inc, Princeton, NJ) induces high-frequency, low-amplitude vibrations in the needle to enable localization with color Doppler. We studied this technique in 25 consecutive patients undergoing pericardiocentesis, and in vitro, in a urethane phantom with which the accuracy of color Doppler localization of the needle tip was compared with that obtained by direct measurement. Tip localization was excellent in vitro; errors axial to the ultrasound beam (velocity Doppler -0.13 +/- 0.90 mm, power Doppler -0.05 +/- 1.7 mm) were less than lateral errors (velocity -0.36 +/- 1.8 mm, power -0.02 +/- 2.8 mm). In 18 of 25 patients, the needle was identified and guided into the pericardial space with the ColorMark technique, and it allowed successful, uncomplicated drainage of fluid. Initial failures were the result of incorrect settings on the echocardiographic machine and inappropriate combinations of the needle puncture site and imaging window. This study demonstrates a novel color Doppler technique that is highly accurate at localizing a needle tip. The technique is feasible for guiding pericardiocentesis. Further clinical validation of this technique is required.

Establishment and characterization of a new xenograft-derived human esophageal squamous cell carcinoma cell line SLMT-1 of Chinese origin

A new human esophageal cancer cell line, named SLMT-1, was established from a nude-mouse xenograft of a well-differentiated esophageal squamous cell carcinoma (ESCC) of the lower esophagus from a male Hong Kong Chinese patient. SLMT-1, passaged over 34 times and with a doubling time of 31 hours, has the microscopic features of epithelial cells with adherent growth as a monolayer. The general biologic properties of SLMT-1 cells were characterized by (1) a positive test of tumorigenicity obtained by injecting cells subcutaneously into athymic nude mice and observing their development into well-differentiated squamous cell carcinoma; (2) immunohistochemical staining using antibodies (AE1/AE3, CAM5.2 and MAK 6) which show the presence of cytokeratin intermediate filaments; and (3) electron microscopy demonstrating the morphologic features of epithelial cells with the presence of desmosomes. The cytogenetic abnormalities found in both the primary culture and SLMT-1 included der(1;14)(q10;q10), add(1)(p1?), +1, +2, del(3)(q11), +6, +7, i(8)(q10), +8, +10, +11, -13, -15, +16, +17, -18, -19, -Y and marker chromosomes. Additional changes observed in the 34th passage included gains as well as losses of both numerical and structural abnormalities. Comparative genomic hybridization (CGH) indicated copy number gains on chromosomal regions 3q32-qter, 5p, 8p12-p11.2, 11q13-q22 and 13q22-qter, and loss of the Y. The gains of 8p12-p11.2 in SLMT-1 cells are novel to ESCC. Based on its distinct and common characteristics, the SLMT-1 cell line serves as a useful tool for studying the molecular and genetic basis of the pathogenesis of ESCC.

Activation of NF-kappaB by double-stranded RNA (dsRNA) in the absence of protein kinase R and RNase L demonstrates the existence of two separate dsRNA-triggered antiviral programs

Double-stranded RNA (dsRNA) of viral origin triggers two programs of the innate immunity in virus-infected cells. One is intended to decrease the rate of host cell protein synthesis and thus to prevent viral replication. This program is mediated by protein kinase R (PKR) and by RNase L and contributes, eventually, to the self-elimination of the infected cell via apoptosis. The second program is responsible for the production of antiviral (type I) interferons and other alarmone cytokines and serves the purpose of preparing naive cells for the viral invasion. This second program requires the survival of the infected cell and depends on the expression of antiapoptotic genes through the activation of the NF-kappaB transcription factor. The second program therefore relies on ongoing transcription and translation. It has been proposed that PKR plays an essential role in the activation of NF-kappaB by dsRNA. Here we present evidence that the dsRNA-induced NF-kappaB activity and the expression of beta interferon and inflammatory cytokines do not require either PKR or RNase L. Our results indicate, therefore, that the two dsRNA-activated programs are separate and can function independently of each other.

Management of gallstone cholangitis in the era of laparoscopic cholecystectomy

HYPOTHESIS

The combined endoscopic and laparoscopic approach is safe and effective in managing gallstone cholangitis in the era of laparoscopic cholecystectomy (LC).

DESIGN

Retrospective case series.

SETTING

University teaching hospital.

PATIENTS

One hundred eighty-four consecutive patients with gallstone cholangitis treated between January 1995 and December 1998.

INTERVENTIONS

The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed.

MAIN OUTCOME MEASURES

Success of various interventions, morbidity and mortality, and long-term incidence of recurrent biliary symptoms.

RESULTS

Endoscopic retrograde cholangiopancreatography was successful in 175 patients (95%), with bile duct stones found in 147 (84%). Endoscopic stone clearance by ES was achieved in 132 patients (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After bile duct stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and 3 underwent LCBDE with 1 conversion and no morbidity. There was no operative mortality. Seventy-eight patients were managed conservatively after endoscopic clearance of bile duct stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (P =.001). In both groups, the most common recurrent symptom was cholangitis (n = 5 and n = 14, respectively). Gallbladder in situ (risk ratio, 4.16; 95% confidence interval, 1.39-12.50; P =.01) and small-size papillotomy (risk ratio, 2.94; 95% confidence interval, 1. 07-8.10; P =.04) were significant risk factors for recurrent biliary symptoms.

CONCLUSIONS

Endoscopic sphincterotomy for biliary drainage and stone removal, followed by interval LC, is a safe and effective approach for managing gallstone cholangitis. Patients with gallbladder left in situ after ES have an increased risk of recurrent biliary symptoms. Laparoscopic cholecystectomy should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.33333333333333333333333