The role of MIB-1 index in the prognosis of resectable pancreatic head cancer

BACKGROUND/AIMS

Cell kinetics are important indicators of the biological behavior of various human tumors. In this study, we evaluated the prognostic values of the proliferative factors including MIB-1 index, DNA ploidy and S-phase fraction, and further determined the independent prognostic factors in pancreatic head cancer after pancreatoduodenectomy.

METHODOLOGY

Patients with pancreatic head cancer undergoing pancreatoduodenectomy were included. Cell proliferative parameters including MIB-1 index, DNA ploidy and S-phase fraction measured by flow cytometry were evaluated and compared with the conventional clinicopathologic factors.

RESULTS

There were 21 resectable pancreatic head cancers. By univariate analysis MIB-1 index, cell differentiation and lymphovascular invasion were significant prognostic factors. The 5-year survival rate was 22.2% for overall patients and 29.2% for patients with MIB-1 < or = 11%, while it was 0% for MIB-1 index > 11%, p=0.011. Tumors without lymphovascular invasion had significantly better prognosis than those with lymphovascular invasion (median survival: 38 vs. 10 months, p=0.009). The median survival was significantly longer for well-differentiated cancers than for moderately and poorly differentiated cancers (44 vs. 11 and 9 months, p=0.038). There was no correlation between the MIB-1 index and the other 2 conventional prognostic factors. After multivariate analysis, only the MIB-1 index emerged as the independent prognostic factor.

CONCLUSIONS

MIB-1 index played a significant role in the prognosis of the resectable pancreatic head cancer and could potentially complement the conventional factors in predicting the prognosis and determining the optimal treatment strategy. MIB-1 index was also an important independent prognostic factor.

The antiplatelet activity of Escherichia coli lipopolysaccharide is mediated through a nitric oxide/cyclic GMP pathway

In this study, Escherichia coli LPS dose-dependently (100-500 microg/ml) and time-dependently (10-60 min) inhibited platelet aggregation in human and rabbit platelets stimulated by agonists. LPS also dose-dependently inhibited the intracellular Ca2+ mobilization in human platelets stimulated by collagen. In addition, LPS (200 and 500 microg/ml) significantly increased the formation of cyclic GMP but not cyclic AMP in platelets. LPS (200 microg/ml) significantly increased the production of nitrate within a 10-min incubation period. Furthermore, LPS also dose-dependently inhibited platelet aggregation induced by PDBu (30 nmol/l), a protein kinase C activator. These results indicate that the antiplatelet activity of E. coli LPS may be involved in the activation of a nitric oxide/cyclic GMP pathway in platelets, resulting in inhibition of platelet aggregation. Therefore, LPS-mediated alteration of platelet function may contribute to bleeding diathesis in septicemic and endotoxemic patients.

Factors affecting morbidity, mortality and survival after pancreaticoduodenectomy for carcinoma of the ampulla of Vater

BACKGROUND/AIMS

The aim of this paper is to reevaluate the factors responsible for hospital morbidity, mortality and post-operative survival following pancreaticoduodenectomy for ampullary cancer.

METHODOLOGY

Peri-operative data on 132 patients undergoing pancreaticoduodenectomy for ampullary cancer were correlated with post-operative morbidity, mortality and long-term survival.

RESULTS

Three factors were found to correlate well with post-operative morbidity; however, only intraabdominal or wound sepsis was an independently significant variable. Four parameters correlated well with hospital mortality, while multivariate analysis revealed age > 75 y/o, positive blood culture and albumin < or = 3.0 g% to be independently significant in predicting post-operative mortality. Univariate analysis identified seven significant factors: 1) age < or = 75 y/o, 2) hematocrit > 30%, 3) blood urea nitrogen < 20 mg%, 4) earlier TNM staging, 5) smaller tumor size, 6) negative nodal status and 7) well-differentiated tumors, which were associated with longer survival. However, multivariate analysis disclosed nodal status and hematocrit to be the two most significant independent variables.

CONCLUSIONS

Although radical resection for ampullary cancer can be performed with a low mortality in recent years, the justification for performing this major operation in a patient over 75 years of age should be reevaluated for prohibitively high mortality (10x) and shorter survival (median 6.0 months). Pre-operative nutritional support and careful surgical technique to prevent post-operative sepsis are mandatory to reduce operative morbidity and mortality. Correction of anemia and adequate lymph node dissection will clarify the patient's survival benefit following this operation.

Prognostic value of MIB-1 index and DNA ploidy in resectable ampulla of Vater carcinoma

OBJECTIVE

To evaluate the prognostic value of the proliferative factors, MIB-1 index, DNA ploidy, and S-phase fraction, and further to determine the independent prognostic factors in ampulla of Vater carcinoma after pancreaticoduodenectomy.

SUMMARY BACKGROUND DATA

Cell kinetics are important indicators of the biologic behavior of various human tumors, but only a few authors have reported the application of cell proliferative factors in ampulla of Vater carcinoma.

METHODS

Patients undergoing pancreaticoduodenectomy for ampulla of Vater carcinoma were included. Proliferative factors, MIB-1 index, and DNA contents, measured by flow cytometry, were evaluated and compared with the conventional clinicopathologic factors.

RESULTS

Ninety resectable ampulla of Vater carcinomas were included. By univariate analysis, MIB-1 index, DNA ploidy, S-phase fraction, stage, and lymph node status were significant prognostic factors. The 5-year survival rate was 40.7% for tumors with MIB-1 index < or =15% and 0% for those with MIB-1 index >15%. Diploid tumors had a significantly better prognosis than aneuploid. Outcomes of stage I and II tumors were more favorable than those of stage III and IV. After multivariate analysis, MIB-1 index, DNA ploidy, and stage remained as the independent prognostic factors. Among the three independent prognostic factors, MIB-1 index was the most powerful.

CONCLUSIONS

Both MIB-1 index and DNA ploidy provide important prognostic value and potentially complement the conventional prognostic factors in resectable ampulla of Vater carcinoma. MIB-1 index is the most powerful independent prognostic factor.

Diagnostic and prognostic values of CA 19-9 and CEA in periampullary cancers

BACKGROUND

The roles of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) in periampullary cancers have not been clearly established. Diagnostic and prognostic values of these two tumor markers were clarified in this study.

STUDY DESIGN

Preoperative serum levels of CEA and CA 19-9, and clinicopathologic features were retrospectively reviewed in 143 surgical patients with periampullary cancer from 1989 to 1997.

RESULTS

There were 86 resectable and 57 unresectable periampullary cancers. CA 19-9 demonstrated significantly higher sensitivity in detecting these cancers than CEA. The cancer with unresectable lesion, total bilirubin >7.3 mg/dL, or tumor size >2 cm tended to associate with higher CA 19-9 level. CEA level was significantly higher in the tumor >2 cm, not in the tumor < or =2 cm. CA 19-9 was a significant prognostic factor in both resectable and unresectable periampullary cancers, but CEA was significant only in the resectable group. Multivariate analysis revealed that independent prognostic factors included CA 19-9, resectability, primary tumor, and stage, and CA 19-9 was the most important one.

CONCLUSION

CA 19-9 provided more important diagnostic and prognostic values than CEA in periampullary cancers and was the most important independent prognostic factor for periampullary cancers. This study recommends serum CA 19-9 as an adjunct in detecting periampullary cancers, in evaluating resectability, and in predicting prognosis.

Noninvasive evaluation of blunt abdominal trauma: prospective study using diagnostic algorithms to minimize nontherapeutic laparotomy

A prospective study was performed to investigate the feasibility and benefit of evaluating blunt abdominal trauma (BAT) without diagnostic peritoneal lavage (DPL) or other invasive methods. Diagnostic algorithms were designed by using ultrasonography (US) as a screening method. For unstable patients, a free fluid >/= 2 mm thickness on US images over any one of the intraperitoneal spaces (bilateral subphrenic, Morrison, and Douglas pouch) was used as an indicator for laparotomy. For stable patients, any intraabdominal free fluid detected by US was used as an indicator for further investigations. Computed tomography served as a principal complementary method. To further clarify the clinical results, the rate of nontherapeutic laparotomy (NTL) was compared with that from a previous 5-year review done before this study. During studying period of 1 year, 170 patients were consecutively enrolled. There was no delayed diagnosis, and 66 patients were found to have BAT; 17 patients were initial unstable, among whom 15 had free fluid shown by US and 13 patients had confirmed BAT. Eight of the unstable patients with free fluid on US were saved from NTL, of whom six had retroperitoneal hematoma. There was no NTL in unstable patients. Twenty-two patients underwent laparotomy. Two laparotomies done for a suspicion of bowel injury turned out to be NTL. The rate of NTL in the present study was significant lower than that in a previous review (9.1% vs. 32.2%, p = 0.025). Hence following well designed algorithms, noninvasive evaluation of BAT can proceed with safety, and NTL is minimized.

Comparison of pylorus-preserving and classic pancreaticoduodenectomy

BACKGROUND

The authors present their recent experience with the treatment of periampullary lesions to compare the surgical technique, safety and prognosis between pylorus-preserving pancreaticoduodenectomy (PPPD) and classic pancreaticoduodenectomy (CPD).

METHODS

Prospective data from 100 patients with periampullary lesions treated with either PPPD or CPD between January, 1991, and June, 1997, were evaluated, including demographic data, surgical technique, surgical risk and prognosis.

RESULTS

There were 35 patients treated with PPPD and 65 treated with CPD. The operating time was significantly shorter in the PPPD group (9.3 +/- 0.3 hours) than in CPD (10.4 +/- 0.3 hours). The average overall blood loss was 1,275 +/- 71 ml, with no statistical difference between PPPD and CPD groups. The overall complication rate was 56%, with 54% in the PPPD group and 57% in the CPD group (p = 0.755). The overall mortality was 4%, with 0% in the PPPD group and 6.2% in CPD (p = 0.655). There was no statistical difference in survival time for overall periampullary cancers between the PPPD and CPD groups (median = 28.0 vs 26.5 months, p = 0.393). The difference in survival time was still of no significance between the PPPD and CPD groups when the periampullary cancers were further stratified into pancreatic head cancer and nonpancreatic periampullary cancer.

CONCLUSIONS

Morbidity and mortality of PPPD did not exceed that of CPD, and the prognosis after PPPD was not compromised in patients with periampullary cancer. PPPD, with a shorter operating time, can be a safe and effective alternative to CPD in the treatment of periampullary lesions.

Triflavin potentiates the antiplatelet activity of platelet activating factor receptor antagonist on activated neutrophil-induced platelet aggregation

In this study, specific platelet activating factor (PAF) receptor antagonist ginkgolide B (BN52021) was tested for its antiplatelet activity in zymosan activated polymorphonuclear neutrophil-induced platelet aggregation. Triflavin was also tested for its antiplatelet activity compared with PAF receptor antagonist. Triflavin, an Arg-Gly-Asp-containing disintegrin purified from venom peptide inhibited platelet aggregation by interfering with the interaction of fibrinogen with the glycoprotein IIb/IIIa complex. Furthermore, we also report an efficient high resolution method for quantitative analysis of PAF using high-performance capillary electrophoresis (HPCE). The supernatant of polymorphonuclear neutrophils after their activation by opsonized zymosan induces the aggregation of washed rabbit platelets. In rabbit platelets, BN52021 (100-1000 microM) only partially inhibited activated polymorphonuclear neutrophil-induced platelet aggregation, and its maximal inhibition was estimated to be about 79%. Triflavin also partially inhibited platelet aggregation about 82% induced by activated polymorphonuclear neutrophils. Furthermore, after treatment with a combination of triflavin (0.26 microM) with various concentrations of BN52021 (4-1000 microM), the inhibitory effect of platelet aggregation was almost completely. This inhibition was greater than that produced by the individual drugs alone. These results indicate that a combination of glycoprotein IIb/IIIa complex and PAF receptor antagonist could completely inhibit activated polymorphonuclear neutrophil-induced platelet aggregation. In addition, the amount of PAF released from zymosan (6 mg/ml)-activated polymorphonuclear neutrophils was accurately calculated about 11.8+/-1.5 ng/10(6) cells, and did not further increase even at a high concentration of zymosan (10 mg/ml). These results suggest that PAF play a major role in the interaction between platelets and polymorphonuclear neutrophils. This interaction may be important in the pathogenesis of thrombosis and inflammatory diseases. Our present findings support the hypothesis that combination therapy with glycoprotein IIb/IIIa complex antagonists and PAF receptor antagonists may represent a new approach to the treatment of ischemic disorders.

Superoxide production of neutrophils after severe injury: impact of subsequent surgery and sepsis

To evaluate the early variations of superoxide production of neutrophils (SPN) in injured patients, SPN was serially measured on the first, third, and seventh day after severe injury (injury severity score of >16). For patients receiving subsequent surgery, SPN was measured again on the first postoperative day. Eighteen patients were studied. Six had subsequent surgery within 1 day (early operation); 6 had surgery 3 days after injury (late operation); 6 did not have surgery (nonoperation). SPN increased on the first day and recovered from the third day after injury in all three groups. In patients who had surgery, SPN did not significantly increase on the first postoperative day. Eight patients developed sepsis, 4 of whom had early multiple organ dysfunction (EMOD). On the last measurement, mean SPN was suppressed in septic patients with EMOD, whereas it was elevated in septic patients without EMOD. Patients with EMOD also had a higher injury severity score. In conclusion, subsequent surgery after injury has no effect on the priming of neutrophils. While late priming of neutrophils in injured patients coincides with the development of sepsis, suppression of SPN is found in septic patients with EMOD that frequently results from severe injury.

Development of fungal mycelia as skin substitutes: effects on wound healing and fibroblast

In this study, Sacchachitin membrane, prepared from the residue of the fruiting body of Ganoderma tsugae, was estimated for its effects on wound healing and the proliferation and migration of fibroblast cells. Two mirror-image wounds were made on the back of female guinea pigs by dissecting a 1.5 x 1.5 cm2 skin surface of full thickness. Sacchachitin membrane was placed randomly on one of the wounds and gauze or Beschitin on the other. Changes in the wound area were measured and photographed after a predetermined amount of time postoperatively. Histological examination of the wound and surrounding tissue was also performed to reveal any interaction of tissue with the dressing. The results showed that the wound area covered with Sacchachitin membrane was statistically smaller than that covering with gauze on day 10, whereas there was no significant difference in the wound size compared to that with Beschitin. Fibroblast cells from the dermis layer of guinea pigs were used. The number of fibroblast cells were counted on the predetermined days in the culture suspended with or without 0.01% w/v dressing materials. By layering on DMEM plates, the number of fibroblast cells migrating across the center line or outside of the central hole were counted after five days. All the results indicated that both 0.01% w/v of Sacchachitin and chitin significantly enhanced the proliferation and migration of fibroblast cells.

Ultrasound measurement of the fetal cavum septi pellucidi

OBJECTIVES

To establish normative data for the width of the fetal cavum septi pellucidi at various gestational ages.

SUBJECTS AND METHODS

A total of 608 consecutive fetuses between 19 and 42 gestational weeks were included in this prospective study. The largest width of the cavum septi pellucidi was measured by two-dimensional ultrasound. Piecewise regression analysis was used to study the relationships between the width of the fetal cavum septi pellucidi, gestational age and biparietal diameter.

RESULTS

The fetal cavum septi pellucidi width increased gradually between 19 and 27 weeks of gestation and then plateaued between 28 weeks and term. Regression analysis revealed significant associations between cavum septi pellucidi width and gestational age, and cavum septi pellucidi width and biparietal diameter.

CONCLUSIONS

The present study provides normative data for fetal cavum septi pellucidi width and useful information about the development of the midline brain structure in the fetus.

The antiplatelet activity of rutaecarpine, an alkaloid isolated from Evodia rutaecarpa, is mediated through inhibition of phospholipase C

In this study, the mechanism involved in the antiplatelet activity of rutaecarpine in human platelet suspensions was investigated. In platelet suspensions (4.5 x 10(8)/ml), rutaecarpine (100 and 200 microM) did not influence the binding of FITC-triflavin to platelet glycoprotein IIb/IIIa complex. Additionally, rutaecarpine (200 microM) did not significantly change the fluorescence of platelet membrane labeled with diphenylhexatriene (DPH). On the other hand, rutaecarpine (50 and 100 microM) dose-dependently inhibited the increase in intracellular free Ca2+ of Fura 2-AM loaded platelets stimulated by collagen. Moreover, rutaecarpine (100 and 200 microM) did not significantly affect the thromboxane synthetase activity of aspirin-treated platelet microsomes. Furthermore, retaecarpine (100 and 200 microM) significantly inhibited [3H]arachidonic acid released in collagen-activated platelets but not in unactivated-platelets. Nitric oxide (NO) production in human platelets was measured by a chemiluminesence detection method in this study. Rutaecarpine (100 and 200 microM) did not significantly affect nitrate production in collagen (10 microg/ml)-induced human platelet aggregation. On the other hand, various concentrations of rutaecarpine (50, 100, and 200 microM) dose-dependently inhibited [3H]inositol monophosphate formation stimulated by collagen (10 microg/ml) in [3H]myoinositol-loaded platelets at different incubation times (1, 2, 3, and 5 minutes). It is concluded that the antiplatelet activity of rutaecarpine may possibly be due to the inhibition of phospholipase C activity, leading to reduce phosphoinositide breakdown, followed by the inhibition of thromboxane A2 formation, and then inhibition of [Ca2+]i mobilization of platelet aggregation stimulated by agonists.

Differentiation of genuines and counterfeits of Cordyceps species using random amplified polymorphic DNA

For identification of genuine and counterfeit samples of Cordyceps sinensis, an RAPD (random amplified polymorphic DNA) analysis was performed. In the study, twelve samples were collected, of which six were genuine and six were counterfeit samples. Genuine samples of Cordyceps sinensis contain two parasitic larvae produced from each of the three provinces, Sichuan (SC), Chinghai (CH), and Tibet (TB). The counterfeits contain two products of each of the three species, Cordyceps hawkesii, Stachys geobombycis, and Stachys sieboldii. In the RAPD analysis, twenty arbitrary decamer primers were screened to obtain primers appropriate for differentiating the genuine and counterfeit samples. The result of twelve RAPD markers generated from four primers, OPT-08, OPT-12, OPT-13, and OPT-17, were selected. The primers can easily distinguish between genuine and counterfeit samples of Cordyceps sinensis.

Severe colonic complications in acute pancreatitis

BACKGROUND

Colonic complications in patients with acute pancreatitis may be very severe and have rarely been analyzed in Chinese patients.

METHODS

We retrospectively evaluated 1,637 patients with acute pancreatitis who were admitted to the Veterans General Hospital-Taipei from January 1986 to December 1995 in order to identify those with severe colonic complications. The clinical, radiologic and pathologic features and surgical findings in these patients are reviewed.

RESULTS

Eight of 1,637 patients with acute pancreatitis had severe colonic complications. Six of them were diagnosed between two and eight weeks after the onset of clinical pancreatitis. All had a Ranson's score of at least 3. Four patients, including one with hematochezia, had a strong positive reaction for occult blood in stool specimens. Computed tomography (CT) revealed necrotizing pancreatitis and colonic wall swelling in all eight patients. Colonic involvement was discovered by CT in two patients prior to surgery, one with colocutancous fistula and the other with colonic perforation. The other six patients were found to have colonic involvement incidentally at the time of laparotomy. All of the colonic involvements were located near the splenic flexure. In addition to necrosectomy, three patients underwent segmental hemicolectomy and the remaining five patients had simple closure of the perforation. Diverting loop ileostomy or colostomy was also carried out in all patients. Three patients (34%) died of overwhelming sepsis superimposed on the subsequent multiple organ failure between 44 and 122 days after the onset of pancreatitis.

CONCLUSIONS

Severe colonic complications of acute pancreatitis are rare. Although preoperative diagnosis is difficult, CT may be helpful to make an early diagnosis. These complications should be suspected in patients with severe acute pancreatitis when acute lower gastrointestinal hemorrhage or positive stool occult blood is found two to eight weeks after the onset of pancreatitis or when CT reveals necrotizing pancreatitis and colonic wall swelling; this will allow early surgical intervention.

Alternations of surface antigens on leukocytes after severe injury: correlation with infectious complications

OBJECTIVE

To investigate the alternations of surface antigens of leukocytes after severe injury and the correlation with clinical outcome.

SETTING

Emergency Department and Intensive Care Unit of a university hospital.

PATIENTS

Patients with severe trauma (injury severity score > 16) were enrolled. Those who were transferred or had critical injuries were excluded.

MEASUREMENTS AND RESULTS

Polymorphonuclear cells (PMN) and mononuclear cells (MN) were isolated from patients on the 1st, 3rd and 7th day following injury. The mean fluorescent expressions of CD11b and CD16 of PMN, and CD25 of MN were measured and compared with those obtained from paralleled controls. Sixteen injured patients were included. The CD11b expressions of PMN increased on the 1st day and were still high on the 7th day. The CD16 expressions decreased on the 1st day and CD25 decreased on the 3rd day; both were still low on the 7th day. Six patients developed infectious complications. CD11b expression remained high and CD16 expression remained low on three measurements of the infectious patients, whereas both expressions recovered on the last measurement of non-infectious patients. CD25 expression remained low in both groups. Three infectious patients with pneumonia died from multiple organ failure.

CONCLUSIONS

Phenotypic alternations of leukocytes develop early after severe injury. The alternations may represent a state of activation of PMN and subsequent suppression of IL-2 related immunity. Persistent activation of PMN with enhanced CD11b and attenuated CD16 expression indicates the development of infectious complications and a poor prognosis can be anticipated if the infectious sites can not be controlled early.

Triflavin inhibits platelet-induced vasoconstriction in de-endothelialized aorta

Triflavin, a 7.5-kD cysteine-rich polypeptide purified from Trimeresurus favoviridis snake venom, belongs to a family of Arg-Gly-Asp-(RGD)-containing peptides, termed disintegrins. In this study, aggregating human platelets dose-dependently induced vasoconstriction in de-endothelialized isolated rat thoracic aortas. At 5x10(7) cells per milliliter, platelets induced a peak tension averaging 65 +/- 7.2% of the tension induced by phenylephrine (10 mumol/L). The relative effectiveness of RGD-containing peptides (including venom peptides triflavin and trigramin, small RGD synthetic peptides Gly-Arg-Gly-Asp-Ser [GRGDS], Gly-Arg-Gly-Asp-Phe [GRGDF], and Gly-Arg-Gly-Asp-Ser-Pro-Lys [GRGDSPK]) was examined by testing the inhibitory effect on aggregating platelet-induced vasoconstriction in de-endothelialized aorta. Triflavin (1 mumol/L) significantly inhibited the platelet-induced vasoconstriction, whereas neither trigramin (10 mumol/L) nor small RGD peptides (2 mmol/L) (i.e., GRGDS, GRGDF, and GRGDSPK) showed any significant effect. The release of serotonin and the formation of thromboxane A2 from aggregating platelets were both significantly inhibited by triflavin (2 mumol/L), whereas trigramin and small RGD-containing peptides showed no significant effect. On scanning electron micrographs of de-endothelialized aorta, aggregating platelets adhered to the subendothelium, with loss of their discoid shape, to form irregular spheres with pseudopod extensions. Triflavin (2 mumol/L) markedly reduced the adhesion of platelets to the subendothelium in the same aorta. Furthermore, RGD-containing peptides (including triflavin, trigramin, and small RGD-containing peptides) inhibited the adhesion of 10 micrograms/mL collagen-activated platelets to extracellular matrices (i.e., fibronectin, vitronectin, and von Willebrand factor). It is concluded that the marked ability of triflavin to inhibit aggregating platelet-induced vasoconstriction in de-endothelialized aorta compared with other RGD-containing peptides (including trigramin), may be due at least partly to triflavin's efficiently preventing the activation of platelets subsequent to inhibition of serotonin release and thromboxane A2 formation. However, the different abilities of triflavin compared with other RGD-containing peptides was not related to the ability to inhibit adhesion of platelets to extracellular matrices. Therefore, from the results of this study, it appears that triflavin may be a useful therapeutic agent for the treatment of thromboembolism and its associated angiospasm.

Tumor necrosis factor-alpha gene polymorphism in chronic bronchitis

Airway inflammation is an important pathologic feature in chronic bronchitis, and we hypothesized that individuals with greater inflammatory responses may be more likely to acquire the disease. A polymorphism at -308 position of the tumor necrosis factor-alpha (TNF-alpha) gene has been described, with the rarer allele, TNF2, demonstrated to have higher inducibility in vitro. We investigated the distribution of this polymorphism in a case-control study. The genotype was determined in 42 male patients with chronic bronchitis, 42 sex-, age-, and smoking index-matched control subjects, and 99 random-sampled schoolchildren. We report here that the TNF2 allele is overrepresented in the patient group. The allele frequency of TNF2 is 5.1% in the schoolchildren, 2.4% in the control group, and 19% in the bronchitis group (p < 0.01). Carriage of the TNF2 allele confers a higher risk to the development of chronic bronchitis (odds ratio = 11.1, 95% CI = 2.89-42.57). The results demonstrate the important pathologic role of TNF-alpha in chronic bronchitis and suggest that greater inflammatory response may predispose an individual to this disease.

Fungal mycelia as the source of chitin and polysaccharides and their applications as skin substitutes

A wovenable skin substitute (Sacchachitin) made from the residue of the fruiting body of Ganoderma tsugae was developed in this study. Chemical analysis revealed that the treated residue was a copolymer of beta-1,3-glucan (ca 60%) and N-acetylglucosamine (ca 40%) with a filamental structure of mycelia form, as demonstrated by both optical and scanning electron microscopy. The pulp-like white residue was then woven into thin, porous sheets 7.0 cm in diameter and 0.1-0.2 mm in thickness by filtration and lyophilized for use as a skin substitute. The wound area produced by dissecting rat skin of full thickness was found to almost completely heal on the side covered with Sacchachitin, whereas the control side covered with cotton gauge was around 6.0 cm2 on the 28th day. Furthermore, the wound healing effects of the chitin sheet from crab shell (Beschitin) and Sacchachitin were not found to be significantly different.

Response of resuscitation in multiple trauma with pelvic fracture

BACKGROUND

The early management of patients with pelvic injury remains a great challenge for emergency physicians and trauma surgeons. A retrospective study was performed in this hospital to identify the clinical significance of different responses in the resuscitation of pelvic injury.

METHODS

From March 1989 to May 1995, 75 patients with pelvic ring injury who had initially had unstable hemodynamic status were studied. They were divided into four groups as "good response" (GR), "delayed response" (DR), "poor response" (PR) and "no response" (NR) according to the time when hemodynamics became stable after immediate resuscitation.

RESULTS

Motor vehicle accidents (MVA) had a higher incidence than other causes in the trauma mechanism. The fracture types of pelvis had no correlation with the response to resuscitation. The injury severity score (ISS) was higher in the PR group (41.7 +/- 18.3) than in the GR (17.5 +/- 8.6) or DR (19.5 +/- 17.0). The incidence of extrapelvic hemorrhage (EPH) and of mortality rates was higher in the PR group (38% and 75%, respectively), and the DR group (25% and 13%, respectively), than in the GR group (6% and 2%, respectively).

CONCLUSIONS

The responses of resuscitation is a valuable parameter in the management of multiple trauma with pelvic injury. Nonoperative treatment may be tried in patients of good response to resuscitation with EPH. In those patients with poor or delayed response, delayed extrapelvic bleeding (especially from abdominal injury) must be ruled out besides aggressive management for pelvic injury. Poor prognosis can also be expected in those patients with poor response.

Hepatolithiasis associated with cholangiocarcinoma

BACKGROUND

Intrahepatic stone is common in East Asia. Hepatolithiasis is a risk factor for cholangiocarcinoma but it is difficult to make an accurate diagnosis before operation. The effect of intrahepatic stone on diagnosis, treatment and survival in patients with coexistent cholangiocarcinoma was investigated.

METHODS

Between 1981 and 1994, 33 patients with hepatolithiasis and associated cholangiocarcinoma were identified and compared respectively to 18 patients with intrahepatic cholangiocarcinoma alone.

RESULTS

Patients with intrahepatic stones had a significantly longer duration of symptoms, a higher frequency of previous biliary surgery but a lower rate of preoperative diagnosis. Surgical resection was the treatment of choice and was performed in 18 of 33 patients with cholangiocarcinoma and stones and in nine of 18 with intrahepatic cholangiocarcinoma alone. Significantly inferior 5-year survival rates were found in patients with hepatolithiasis: two of 32 versus four of 14 for all cases and two of 17 versus four of nine for resectable cases (P < 0.05).

CONCLUSION

These survival differences may be attributed to delayed diagnosis, lower diagnostic rate and relatively fewer curative resections in the patients with stone-containing cholangiocarcinoma.

Randomized trial of three types of gastrojejunostomy in unresectable periampullary cancer

BACKGROUND

A gastrojejunostomy with duodenal partition was designed to clarify whether so-called circulus vomiting exists and, if so, its clinical significance, by comparing it with two other types of gastrojejunostomy commonly used for gastric bypass in unresectable periampullary cancer.

METHODS

Forty-five patients with unresectable periampullary cancer complicated by gastric outlet obstruction (GOO) were recruited into this study between May 1992 and November 1995. They were randomized to receive one of the three types of gastrojejunostomy. The anastomosis in type I gastrojejunostomy was performed at the jejunum 20 cm distal to the ligament of Treitz. Type II was similar to type I except that in type II a duodenum partition was done by linear stapler 1 cm beyond the pylorus. Type III gastrojejunostomy was performed at the Roux-limb jejunum 60 cm distal to biliojejunostomy.

RESULTS

"Food reentry" was noted in three (21%) of the type I patients, as determined by upper gastrointestinal (UGI) study. Of the three, one patient had severe circulus vomiting, one had anorexia, and one had no major symptoms. When patients were evaluated immediately after oral diet intake resumed, the incidence (27%) of clinical GOO symptoms and mean value of gastric emptying time (GET1/2, 118.1 +/- 39.2 min) were significantly lower in type II patients than in types I and III patients. When evaluated I month after operation, the incidence (7% and 17%, respectively) of clinical symptoms of GOO and mean value of GET1/2 (42.0 +/- 23.0 and 35.6 +/- 5.4 min, respectively) were significantly lower in both type II and type III patients than in type I patients. The type II patients resumed oral diet after operation 3.5 days earlier than type I patients, p < 0.05.

CONCLUSIONS

Circulus vomiting induced by food reentry does exist if the gastrojejunostomy is performed as the type I gastrojejunostomy in this study. The newly designed type II gastrojejunostomy with duodenal partition is an easy, safe, and effective gastric bypass and avoids the problem of food reentry.

Management of pancreatic lesions in von Hippel-Lindau disease

Twelve patients with von Hippel-Lindau disease were collected in our institute from 1981 to 1995. All had a family history of the disease. Eleven patients underwent abdominal computed tomography, sonography, or angiographic studies. Ten had pancreatic involvement that included cystic lesions in nine and a solid lesion in one. Seven patients were asymptomatic. Another three presented with obstructive jaundice or upper gastrointestinal (UGI) bleeding. Except for case 8, who died of a central nervous system complication soon after diagnosis of the pancreatic lesion, the other patients had been found to have pancreatic involvement for a variable period of time, ranging from 1 to 13 years (median 5 years). Serous cystadenoma was proved pathologically in two with cystic lesions, and pancreatic endocrine tumor was diagnosed in one with a solid mass. One patient (case 1) underwent biliary bypass due to obstructive jaundice and died of cholangitis and pneumonia 6 years later. One patient (case 3) had total pancreatectomy and lived well with good diabetic control for more than 5 years. The patient with a solid lesion was explored because of repeated UGI bleeding. Surgical resection was impossible owing to advanced tumor with vascular involvement, and a pancreatic endocrine tumor was diagnosed pathologically. He was followed for 1 year. The other seven patients remained asymptomatic during the successive follow-up period. From a literature review and our own experience, we suggest that conservative measures are adequate for the cystic lesions; however, aggressive resection is mandatory for a solid pancreatic lesion in von Hippel-Lindau disease.

Surgical management of primary retroperitoneal sarcoma

BACKGROUND

Retroperitoneal sarcoma is a rare and challenging group of diseases for surgeons, characterized by extensive growth and high recurrent rate. We analyzed data from our patients to identify the factors of survival.

METHODS

From 1971 to 1993, medical records of 40 patients with primary retroperitoneal sarcoma were reviewed. Clinical factors including age, sex, tumor size, histopathology, type of operation, disease-free interval, and number of operation were collected to correlate with patient's survival.

RESULTS

Most patients presented with huge abdominal mass. There were 22 liposarcomas, 8 leiomyosarcomas, 5 malignant fibrous histiocytomas, 2 fibrosarcomas, 2 malignant mesenchymomas and one rhabdomyosarcoma. Twenty-eight patients received complete resection and 12 had incomplete resection. The group with complete resection showed a better survival than incomplete resection group (p = 0.0001). Nineteen patients with complete resection had tumor recurrence. The recurrent rate was 68%. Patients having been disease-free for more than 12 months showed to have better survival than those less than 12 months (p = 0.005). Aggressive surgical resection was done in case of tumor recurrence. Patients who received more than 2 (> or = 3) operations also showed a better survival than those with less than 2 operations (p = 0.0247).

CONCLUSIONS

Complete surgical resection and aggressive repeated surgical intervention are the most effective treatment modality for better survival in patients with retroperitoneal sarcoma.

Adenomyomatosis of the gallbladder

BACKGROUND

Adenomyomatosis of the gallbladder in Chinese patients has rarely been analyzed.

METHODS

The clinical, radiological and pathological features of 18 patients with histologically-proven adenomyomatosis, collected during a 5-year period, were retrospectively analyzed.

RESULTS

According to the extent and site of involvement, adenomyomatosis of the gallbladder was conventionally classified into three types: localized, generalized and segmental. In our series, the disease was localized in 17 patients (15 in the fundus and 2 in the neck), generalized in one patient and segmental in none. Only 5 patients showed sonographic features correlative to pathologic findings, and 2 of them were correctly diagnosed before operation. Only mild nonspecific abnormalities of liver function test or urine analysis were noted in some patients with gallbladder adenomyomatosis. The clinical manifestations were not related to coincidental diseases in 11 patients. All these 11 patients, with gallstone in 9 and without in 2, complained of epigastralgia, right upper quadrant abdominal pain or dyspepsia, which relieved all after cholecystectomy.

CONCLUSIONS

Some patients with adenomyomatosis may be symptomatic and relieved by cholecystectomy. In patients with adenomyomatosis of the gallbladder and right upper quadrant pain of abdomen without other explanation, cholecystectomy may be considered. Infrequent accurate diagnosis in Chinese patients calls for a high suspicion of the disease entity in clinical practice.

Factors influencing postoperative morbidity, mortality, and survival after resection for hilar cholangiocarcinoma

OBJECTIVE; Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patient's survival also were re-evaluated.

SUMMARY BACKGROUND DATA

Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis.

METHODS

The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival.

RESULTS

There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that co-existent hepatolithiasis and lower serum asparate aminotransferase levels (<90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin > or = 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin > or = 10 mg/dL, curative resection, and histologic type as the three most significant independent variables.

CONCLUSIONS

Surgical resection provides the best survival for hilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3 g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well-differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.