Oncologic results of laparoscopic D3 lymphadenectomy for male sigmoid and upper rectal cancer with clinically positive lymph nodes

BACKGROUND

Many Japanese surgeons routinely perform extended D3 lymph node dissection for the treatment of advanced rectosigmoid cancer with a view to achieving better tumor control. However, the application of a laparoscopic approach to perform D3 lymphadenectomy has been challenging. This phase 2 prospective study aimed to explore the oncologic results of this surgical approach.

METHODS

The study was conducted during a 6-year period, in consideration of median follow-up time being >3 years. The study subjects were tumor, node, metastasis system stage III rectosigmoid cancer staged by clinical images. The extent of D3 dissection and the postoperative lymph node mapping were according to the guidelines of the Japanese Society for Cancer of the Colon and Rectum. Patients were stratified according to the histopathologically proved highest level of involved lymph nodes and placed into N0, N1, N2, and N3 groups. The primary end points of the study were the estimated time to recurrence and 5-year recurrence rate of cancer after laparoscopic D3 dissection.

RESULTS

The estimated 5-year recurrence rate (20% in the N0 group [n = 10]; 25% in N1 [n = 44]; 33.3% in N2 [n = 30]; and 42.8% in N3 [n = 14]), time to recurrence (mean [95% confidence interval] 59.8 [42.6-76.9] months in the N0 group; 56.8 [48.3-65.2] months in N1; 46.8 [37.5-56.1] months in N2; and 43.9 [28.3-59.4] months in N3), and recurrence patterns were without significant difference (all P values >.05) among N0, N1, N2, and N3 groups. Therefore, by laparoscopic wide anatomic dissection, patients with lymph node involvement could be treated as well as those without lymph node metastasis. Laparoscopic D3 dissection facilitated the collection of more lymph nodes (mean +/- standard deviation, 27.4 +/- 4.2) for histopathologic examination. Mapping of dissected lymph nodes showed that 18.2% (16 of 88) patients had skip lymph node metastasis. D3 dissection facilitated upstaging of cancer (from N0 to N3) in five patients (5.1%). However, this procedure resulted in transient voiding dysfunction in 77.5% patients and loss of ejaculatory function in 91.7%. By laparoscopic approach, the D3 lymph node dissection was safely performed through small wounds, resulting in quick functional recovery and only moderate blood loss (324.8 +/- 44.5 mL), but at the expense of a long operation time (294.4 +/- 34.8 minutes).

CONCLUSIONS

The good short-term oncologic results and quick convalescence mean that the laparoscopic D3 dissection may be recommended for patients with stage III rectosigmoid cancer who could accept the genitourinary dysfunction.

Laparoscopic Prophylactic Oophorectomy Plus N3 Lymphadenectomy for Advanced Rectosigmoid Cancer

BACKGROUND

The primary aim of the present retrospective study was to evaluate the feasibility and efficacy of laparoscopic prophylactic oophorectomy plus N3 lymph node dissection for patients with rectosigmoid cancer. The secondary aim was to explore the clinicopathologic features of ovarian micrometastasis from rectosigmoid cancer.

METHODS

We performed 244 laparoscopic resections of rectosigmoid cancer in women during a 6-year period. In them, 34 patients (13.9%) were subjected to prophylactic oophorectomy plus N3 lymphadenectomy in addition to the standard anterior or low anterior resection of rectosigmoid cancer, because the patients presented with ovarian cystic lesions, tethering of the ovary to the primary rectosigmoid tumor, and/or pelvic ascites accumulation, which were postulated as the indicative findings for the synchronous ovarian micrometastasis. The surgical procedures are detailed in the attached video. The surgical outcomes were compared between patients with (n = 34) and without (n = 210) these two additional procedures. In analyzing the clinicopathologic features of ovarian micrometastasis, we included both cases of laparoscopic (n = 34) and traditional open surgery (n = 30), whose prophylactic oophorectomy was performed by the same surgical indications.

RESULTS

Although the operation time was significantly longer (264.2 +/- 24.5 vs. 192.5 +/- 24.2 minutes, P < .0001) in patients with prophylactic oophorectomy and N3 lymphadenectomy, there was no significant difference between patients with and without the two additional procedures in blood loss, wound length, postoperative complications, diverting ileostomy, and mortality. Although flatus passage, hospitalization, postoperative pain, and return to partial activity were statistically different between the study groups, they were deemed clinically unimportant because the difference of mean was very small. Foley removal was delayed in patients with N3 lymphadenectomy by 2 days. With respect to surgical efficacy, we found that patients undergoing the two additional procedures could collect significantly more lymph nodes (22.0 +/- 4.0 vs. 14.4 +/- 2.4, P < .0001) for pathologic staging and facilitated upstaging of nodal status in three patients (8.8%). Patients undergoing prophylactic oophorectomy plus N3 lymphadenectomy could achieve good oncologic outcome, with the estimated 5-year survival rate of 62.5% and 69.2% in patients with and without ovarian micrometastasis, respectively. Clinicopathologically, patients with ovarian micrometastasis (n = 15) tended to have vascular invasion of tumor cells, as compared with those without (n = 49). However, ovarian micrometastasis was not related to menstrual status of patients, tumor location, tumor size, morphology, differentiation, mucin production, T stage, nodal invasion, and level of carcinoembryonic antigen.

CONCLUSIONS

Laparoscopic surgical techniques could be safely applied to perform prophylactic oophorectomy plus N3 lymphadenectomy with acceptable efficacy in a highly selected subset of patients with rectosigmoid cancer.

Comparison of functional and surgical outcomes of laparoscopic-assisted colonic J-pouch versus straight reconstruction after total mesorectal excision for lower rectal cancer

BACKGROUND

To compare the functional and surgical outcomes of colonic J-pouch and straight anastomosis in the context that both reconstruction procedures were performed laparoscopically.

METHODS

The present study was a randomized prospective clinical trial. Patients with lower rectal cancer requiring laparoscopic total mesorectal excision were equally randomized to either laparoscopic-assisted colonic J-pouch reconstruction or laparoscopic straight end-to-end anastomosis. The techniques of the laparoscopic-assisted colonic J-pouch reconstruction are shown in the attached video. The primary end point was the comparison of functional results in both reconstruction methods. The secondary end points included the safety (surgical morbidity and mortality), surgical efficiency, and postoperative recovery.

RESULTS

A total of 48 patients were recruited within 2-year periods, in consideration of statistical power of 90% for comparison. There was no marked difference between patient groups undergoing colonic J-pouch surgery (n = 24) and straight anastomosis (n = 24) in various demographic and clinicopathogic parameters. The anorectal function of patients by colonic J-pouch were better than those by straight anastomosis in 3 months after operation, as evaluated by stool frequency (mean +/- standard deviation: 4.0 +/- 2.0 vs. 7.0 +/- 2.4 times/day, P < .001); use of antidiarrheal agents (29.2% [n = 7] vs. 75.0% [n = 18], P = .004); and perineal irritation (45.8% [n = 11] vs. 79.2% [n = 19], P = .037). Because of the relatively better bowel function in immediate postoperative period, patients by colonic J-pouch reconstruction were less disabled after surgery and had quicker return to partial activity (P = .039), full activity (P < .001), and work (P < .001). Both reconstruction methods were performed with similar amounts of blood loss, complication rates, and postoperative recovery. However, the operation time was significantly longer in the colonic J-pouch group (274.4 +/- 34.0 vs. 202.0 +/- 28.0 minutes, P < .001).

CONCLUSIONS

Because laparoscopic-assisted creation of a colonic J-pouch achieved better short-term functional results of the anorectum and did not increase surgical morbidity, as compared with laparoscopic straight anastomosis, this reconstruction procedure could be recommended to patients with lower rectal cancer requiring laparoscopic total mesorectal excision.

Pediatric Crohn disease: clinical and genetic characteristics in Taiwan

OBJECTIVES

Crohn disease (CD) is a heterogeneous disorder. The nucleotide oligomerization domain 2/caspase activating recruitment domain 15 (NOD2/CARD15) gene located at 16q12 is strongly associated with susceptibility to CD in white people but is absent in adult Asian patients, whereas the role of Toll-like receptor 4 (TLR4) polymorphisms has also been reported. Because clinical and genetic data in Asian children with CD are lacking, the aim of this study was to elucidate the clinical and genetic characteristics of Taiwanese children with CD.

PATIENTS AND METHODS

All of the children hospitalized at the National Taiwan University Hospital between January 2000 and July 2005 who fulfilled the diagnostic criteria for CD were enrolled. Their clinical characteristics were recorded, and genomic DNA was extracted from their white blood cells. After polymerase chain reaction was performed, direct sequencing was done to detect the 4 NOD2 hotspot mutations (P268S, R702W, G908R, 1007fs) and TLR4 polymorphisms (Asp299Gly, Thr399Ile).

RESULTS

CD was diagnosed in 10 children (6 boys and 4 girls; age range at diagnosis, 14 months to 13 years; median age, 11.1 years). There were 5 children with ileocolonic region involvement, 3 with colonic region involvement, 2 with ileal region involvement, 4 with additional upper gastrointestinal tract involvement, and 2 with additional perianal fistula. Half of the children had growth retardation at diagnosis. Neither NOD2/CARD15 mutations nor TLR4 polymorphisms were found in the 10 patients.

CONCLUSIONS

Ileocolonic location and inflammatory behavior constitute the most frequent phenotype of CD in Taiwan. Mutations in the NOD2/CARD15 and TLR4 genes that are common in the West are not associated with CD in Taiwanese children.

Laparoscopic Pelvic Autonomic Nerve-Preserving Surgery for Patients with Lower Rectal Cancer after Chemoradiation Therapy

OBJECTIVE

This is a phase II study, the aim of which is to determine if a laparoscopic approach can be used in pelvic autonomic nerve-preserving surgery for patients with lower rectal cancer following chemoradiation therapy.

METHODS

Patients with T3 lower rectal cancer treated by preoperative chemoradiation were recruited and subjected to laparoscopic pelvic autonomic nerve-preserving surgery with total mesorectal excision and a sphincter-saving procedure. This study was performed with the approval of the ethics committee of National Taiwan University Hospital. Because the quality of a surgical trial is highly dependent on the skill of the surgeon with respect to the technique under study, it is imperative that a surgical trial only be implemented after the surgical technique has been judged to be mature. Before the start of this clinical trial, we gained a sound knowledge of surgical anatomy through conventional open surgery for rectal cancer and mastered the related laparoscopic skills from other sound and proven laparoscopic approaches, including right hemicolectomy, left hemicolectomy, among others. We determined that the learning curve for this surgical technique necessitated that colorectal surgeons carry out at least 20 such procedures. At this point we conducted this clinical trial. The details of the surgical procedures have been shown in the attached video. Briefly, the dissection commences at the pelvic promontory with exposure and preservation of the superior hypogastric plexus. The pre-aortic plexus and inferior mesenteric plexus are preserved by sparing the pre-aortic connective tissue and leaving a 1- to 2-cm-long stump of the inferior mesenteric artery in situ. Subsequently, the "holy plane" at the transition of the mesosigmoid to the mesorectum is meticulously dissected to progressively displace the hypogastric nerves dorsally and laterally and, therefore, preserving them. Following adequate dorsal and lateral dissection down to the floor of the pelvis, the so-called lateral ligament is reached at which the mesorectum appears to be adherent, anteriorly and laterally, to the inferior hypogastric plexus (at roughly 10:00-2:00 O'clock or within an angle of 60 degrees about symphysis on both sides). The ligaments are divided immediately at the endopelvic fascia of the mesorectum to avoid damage to the inferior hypogastric plexus (pelvic plexus). Finally, great care was taken to dissect the lateral border of Denonvilliers' fascia where the inferior hypogastric plexus joins the neurovascular bundle described by Walsh. Postoperatively, only patients successfully operated on by total pelvic autonomic nerve-preserving surgery were included in the statistical analysis of surgical outcomes. Preoperatively, all patients were screened for their genitourinary function by a questionnaire-based interview. Patients with abnormal preoperative baseline functional data were excluded from further postoperative assessment of sexual or urinary function. The male sexual function was evaluated by potency and ejaculation. In female patients, the sexual function was assessed by vaginal lubrication, dyspareunia, sexual arousal, and orgasm. The reason for these four parameters is because the influence of pelvic autonomic nerve damage on female sexual function has been ambiguous but would most likely result in impairment of vaginal lubrication and congestion of the genitals. We evaluated sexual function at 6 months postoperatively, when the temporary colostomy had been closed and the patients were completely recovered from surgical disability. In evaluating urinary function, the duration between initial voiding trial and spontaneous voiding was recorded. The questionnaire used for the assessment of urinary dysfunction was based on the International Prostate Symptom Score and the following parameters from this Score were used: incomplete emptying, frequency, intermittency, urgency, week stream, straining, and nocturia. Any voiding problems recovered within 3 months after the operation were considered to be transient bladder voiding dysfunction; all other voiding problems were deemed persistent. The interview and scoring of the questionnaire were done by the research assistant blinded to operation procedures. The genitourinary function was ranked as good, fair (decreased), and poor (impaired).

RESULTS

Between June 2003 and December 2005, a total of 98 patients (stage II: n = 44; stage III: n = 54; male: n = 50; female: n = 48) were enrolled in this study. Technically, although the dissection plane is a little blurred by preoperative chemoradiation therapy, the laparoscopic pelvic nerve-preserving procedure with total mesorectal excision was successfully performed in 89 (90.8%) patients with an acceptable operation time (284.4 +/- 44.8 minutes; mean +/- standard deviation) and little blood loss (114.5 +/- 24 ml). The number of dissected lymph nodes was 16.4 +/- 4.0. With respect to scrutiny of surgical specimens, the distal safety margin was adequate (mean: 2.4 cm; range: 1.2-5.6 cm), and the circumferential resection margins were free of tumor invasion (mean: 8.6 mm; range: 2-18 mm). A total of 74 patients completed the evaluation of urinary function. For these 74 patients, the median duration of training for the Foley catheter was 7 days (range: 4-64 days). The voiding function after removal of the Foley catheter were good in 53 (71.6%) patients, fair in 17 (23.0%), and poor in four (5.4%). Of the 17 patients with fair bladder function, eight were transient dysfunction and recovered thereafter. Thirty-two male and 28 female patients who were sexually active before the operation responded to the assessment of sexual function. In male patients, the ejaculation was good in 18 (56.3%) patients, fair (decrease in ejaculatory amounts) in six (18.7%), and poor (retrograde ejaculation, failure to ejaculate) in eight (25%). The potency was good in 20 (62.5%) patients, fair in five (15.6%), and poor in seven (21.9%). In female patients, the sexual function was good in 15 (53.6%) patients, fair in four (14.3%), and poor in nine (32.1%). Specific sexual problems in women included lubrication (46.6%, n = 13), dyspareunia (39.2%, n = 11), sexual arousal (28.6%, n = 8), and orgasm in (32.1%, n = 9).

CONCLUSIONS

By the laparoscopic approach, total preservation of pelvic autonomic nerves without compromise of the radical extirpation of tumor is technically feasible in the vast majority of patients with lower rectal cancer who have undergone concurrent chemoradiation therapy, thus facilitating the retention of genitourinary function in a significant proportion of such patients.

Pancreaticobiliary Anomalies is the Leading Cause of Childhood Recurrent Pancreatitis

BACKGROUND/PURPOSE

To explore the etiology, age and gender distribution, complications, and prognosis of recurrent pediatric pancreatitis.

METHODS

Between 1993 and 2005, 92 children were hospitalized at the National Taiwan University Hospital with pancreatitis. Only 25 diagnosed with recurrent pancreatitis, based on two or more episodes of pancreatitis, elevated serum amylase and/or lipase levels > or = 3 times the upper limit of normal, radiographic evidence, and clinical symptoms, were enrolled.

RESULTS

A total of 85 episodes of pancreatitis in 25 patients (16 girls, 9 boys; mean age, 9.5 +/- 4.4 years; 3.4 +/- 1.9 episodes per person) were documented. The recurrence rate of pediatric pancreatitis was 27.2%. Recurrent pancreatitis was associated with pancreaticobiliary structural anomalies (n = 7), biliary stones or sludge (n = 4), hyperlipidemia (n = 3), pseudopapillary tumor of the pancreas (n = 2), trauma (n = 2), hypoxic encephalopathy with recurrent bacteremia and sepsis (n = 1), and idiopathic (n = 6). The age and gender distribution according to etiologies were not different (p = 0.301 for age, p = 0.137 for gender). Complications included cholangitis or cholestasis (16%), pancreatic necrosis (16%), pseudocyst formation (12%), shock (8%), hemorrhagic pancreatitis (4%), and diabetes mellitus (4%). No patient died of recurrent pancreatitis. Long-term morbidity after recurrent pancreatitis presented as gout, diabetes mellitus, non-alcoholic steatohepatitis, and chronic pancreatitis.

CONCLUSION

For children who suffer from recurrent pancreatitis, pancreaticobiliary structural anomalies should be considered first.

Clinicopathological features and prognosis in resectable synchronous and metachronous colorectal liver metastasis

INTRODUCTION

Hepatic resection may offer long-term survival for patients with colorectal metastases. However, controversies exist regarding the prognostic factors. Herein, the impact of synchronicity of liver metastasis on patient clinicopathological features and prognosis was evaluated.

METHODS

One hundred and fifty-five patients who underwent hepatectomy for colon cancer metastasis, from 1995 to 2004, were enrolled in this study. Patients were divided into two groups: synchronous and metachronous colorectal liver metastasis. Patient demographics, the nature of the primary and metastatic tumors, surgery-related complications, and long-term outcome were analyzed.

RESULTS

Patients included in the synchronous group tended to be younger than those in the metachronous group. Compared to the metachronous group, patients in the synchronous group showed more metastases (P = 0.008) and bilobarly distributed metastases (P = 0.016). Bile leakage was the most common surgical complication. The estimated 5-year disease-free and overall survival rates were 16.8 and 41.1%, respectively. Univariate analysis indicated that synchronous metastases, advanced stage of the primary tumor, bilobar distribution of the metastases, more than three metastases, and colonic versus rectal location of the primary tumor were prognostic factors of shorter disease-free survival, but not overall survival. Multivariate analysis revealed that synchronous metastases and the advanced stage of the primary tumor were indicators for a worse disease-free survival.

CONCLUSION

The synchronous presence of primary colon cancer and liver metastasis may indicate a more disseminated disease status and is associated with a shorter disease-free survival than metachronous metastasis. These patients may need more careful monitoring and aggressive chemotherapy following curative resection.

Oncologic results of laparoscopic versus conventional open surgery for stage II or III left-sided colon cancers: a randomized controlled trial

INTRODUCTION

Minimal invasive surgical approach can achieve quick functional recovery. However, the oncologic outcome for cancer is still a concern. This study aims to compare the oncologic outcome between laparoscopic and open methods in the curative resection of Stage II or III left-sided colon cancers.

METHODS

In consideration of statistical power up to 90%, 286 eligible patients with curable left-sided colon cancer (Tumor-Node-Metastasis Stage II and Stage III disease) requiring the takedown of colonic splenic flexure to facilitate a curative left hemicolectomy were recruited randomly and equally allocated to the laparoscopic and open group. The primary endpoint was time-to-recurrence of tumor. Data was analyzed according to intention-to-treat principle.

RESULTS

Postrandomization exclusion occurred because of metastatic disease detected intraoperatively occurred in 13 patients and because of patient withdrawal from trial in 4. Therefore, 135 and 134 patients actually comprised the laparoscopic and open group, respectively. The median follow-up of patient was 40 months (range: 18-72 months). The oncologic results were similar (P = 0.362, one-sided log-rank test) in laparoscopic and open group of patients, with the estimated cumulative recurrence rate of 13.2% (9/68) versus 17.2% (11/64) in Stage II disease and 20.9% (14/67) versus 25.7% (18/70) in Stage III disease, respectively. The recurrence patterns were similar between the two groups. Both open and laparoscopic groups were comparable in the number of dissected lymph node (15.6 +/- 3.0 vs. 16.0 +/- 6.0, P = 0.489), various demographic and clinicopathologic parameters.

CONCLUSIONS

The estimated cumulative recurrence rate for the surgery of Stage II or III left-sided colon cancers was the same between laparoscopic and open methods.

Validation of a computer-based bronchoscopy simulator developed in Taiwan

BACKGROUND/PURPOSE

Conventional training in bronchoscopy may increase patient's discomfort and procedure-related morbidity. Computer-based bronchoscopy simulator (CBBS) permits the acquisition and evaluation of the necessary skills through a realistic bronchoscopic experience. This study was conducted to validate the use of a CBBS system developed in Taiwan as a learning and assessment tool.

METHODS

Twenty novice bronchoscopists and 10 expert bronchoscopists were enrolled as subjects in this prospective study. The 20 novice bronchoscopists were randomized into two groups, which received conventional bronchoscopic training or CBBS training and then completed a satisfaction survey. Subsequently, the novices who received CBBS training underwent an observational performance trial and the results were compared with those of expert bronchoscopists. All 10 expert bronchoscopists completed a realism survey and observational trial after CBBS performance.

RESULTS

The satisfaction survey showed that the CBBS training program significantly increased participants' satisfaction (p = 0.002) and interest in learning (p < 0.001). The realism survey by the 10 expert bronchoscopists indicated that CBBS provides a favorable degree of realism with regard to the mechanical and visual parameters examined. Analysis of the performance results showed that the following parameters were capable of differentiating the participants by level of expertise: total procedure time (p = 0.002), percentage of bronchial segments entered (p = 0.012), percentage of bronchial segments identified (p < 0.001), percentage of repeated bronchial segments entered (p = 0.004), percentage of pathologies identified (p < 0.001), number of times that the bronchoscope tip collided with airway walls (p = 0.013), and number of times oral instruction was needed (p = 0.01).

CONCLUSION

CBBS is a valid training method that increases interest in learning and provides a favorable degree of virtual realism. It can also distinguish various levels of competence at actual bronchoscopy and may have a useful role in the bronchoscopic training curriculum.

Ultrasonography in diagnosing colorectal cancers in patients presenting with abdominal distension

OBJECTIVE

To determine the usefulness of abdominal ultrasonography for diagnosing colorectal cancer in patients presenting with abdominal distension.

DESIGN, SETTING AND PARTICIPANTS

A prospective case series of consecutive adult patients with abdominal distension admitted to the National Taiwan University Hospital between January 2001 and July 2004. All participants were examined by abdominal ultrasonography. Those with suspected colorectal tumours on ultrasonography had follow-up colonoscopy, while all other patients had computed tomography scans.

MAIN OUTCOME MEASURES

Accuracy of abdominal ultrasonography for diagnosing colorectal cancer in patients with abdominal distension; incidence of colorectal cancer.

RESULTS

Of 511 patients eligible for inclusion in our study, 97 (19.0%) were confirmed to have colorectal cancer. For diagnosis of colorectal cancer, ultrasonography had a sensitivity of 92.8% (95% CI, 85.2%-96.8%); a specificity of 98.8% (95% CI, 97.0%-99.6%); a positive predictive value of 94.7% (95% CI, 87.6%-98.0%); a negative predictive value of 98.3% (95% CI 96.4%-99.3%); and an accuracy of 97.7%.

CONCLUSION

Ultrasonography is a sensitive tool for diagnosing colorectal cancer in patients presenting with abdominal distension.

Long-term prognosis and factors affecting biliary atresia from experience over a 25 year period

BACKGROUND

The purpose of this study was to delineate the long-term prognosis and factors we have noted in our 25 years of experience treating patients suffering from biliary atresia (BA) who have undergone Kasai's operation.

METHODS

We studied 141 patients (69 male and 72 female infants) who underwent Kasai's operation at the National Taiwan University Hospital between 1976 and 2000. Factors analyzed included age at time of surgery, postoperative bile flow, frequency of cholangitis, prophylactic long-term oral antibiotics given, and intrahepatic biliary cyst formation.

RESULTS

The 5-year and 10-year survival rates for native liver patients were 34.8% (49/141) and 30.5% (43/141). If surgery was performed before the patient was 60 days old, the results were 44.8% (26/58) and 39.7% (23/58). Good bile flow occurred in 115 patients (81.6%) and 88 (62.4%) became jaundice-free. Cholangitis was encountered in 77 patients (54.6%) within the first two postoperative years. Prophylactic oral antibiotics lowered the rate of recurrent cholangitis (p = 0.011). Multiple intrahepatic biliary cysts occurred in 11.3% (16/141) of patients, who had a higher mortality rate when compared with the other patients (p = 0.037). The factors that had a positive effect include: (1) less than 60 days of age at time of surgery, (2) good bile flow, (3) low frequency of cholangitis, (4) long-term prophylactic antibiotics, and (5) no multiple intrahepatic cyst formation.

CONCLUSION

The long-term survival rate can be improved if Kasai's operation is performed early, there is a detailed dissection producing good bile flow, and long-term prophylactic antibiotics are given to prevent recurrent cholangitis and formation of multiple intrahepatic cysts.

Effects of a high-fiber diet on hepatocyte apoptosis and liver regeneration after partial hepatectomy in rats with fatty liver

BACKGROUND

The morbidity and mortality that accompany fatty liver may occur as a result of increased apoptosis of hepatocytes and decreased liver regeneration. We determined the effects of a high-fiber diet on hepatocyte apoptosis and liver regeneration after partial hepatectomy in rats with fatty liver.

METHODS

Fatty liver was induced in male Wistar rats weighing around 200 g through feeding of a high-fat diet for 4 weeks. The rats were then randomly assigned to 3 groups that received a high-fat diet, a normal diet, or a high-fiber diet for another 4 weeks. Partial hepatectomy (around 70%) was performed, and rats were killed 6, 24, 48, or 72 hours after hepatectomy. We then measured (1) the ratio of remnant liver weight to body weight and assessed the histology of the remnant liver as indicators of fatty liver, (2) caspase-3 activity and in situ cell death detection of DNA fragmentation as indicators of apoptosis, and (3) 5-bromo-2-deoxyuridine (BrdU) activity and (4) ornithine decarboxylase (ODC) contents in remnant livers as markers of regeneration.

RESULTS

We found that (1) a high-fat diet for 4 weeks can markedly induce fatty liver, (2) apoptosis of hepatocytes is greater in fatty liver than in normal liver (98 +/- 19 vs 36 +/- 7) at 6 hours after partial hepatectomy (p < .05), (3) the capacity of liver regeneration decreases significantly (BrdU index: 30 +/- 5 vs 12 +/- 3, and ODC contents: 604 +/- 48 vs 390 +/- 42 mg/dL) in fatty liver 24 hours after partial hepatectomy (p < .05), (4) a normal diet can partially reverse the effects of fatty liver; (5) a high-fiber diet can significantly reverse the effects of fatty liver (p < .05).

CONCLUSIONS

A high-fiber diet can reverse the negative effects of fatty liver on apoptosis and regenerative capacity after partial hepatectomy.

Cecal Volvulus in a Child with CHARGE Syndrome

Cecal volvulus occurring in a child with CHARGE syndrome is presented. This boy was known to have CHARGE syndrome with multiple congenital anomalies, including coloboma, ventricular septal defect, choanal atresia, growth and mental retardation, bilateral cryptorchidism, dysplasia of the right ear, cleft lip, and hydrocephalus. Nissen's fundoplication had been previously performed for severe hiatal hernia and gastroesophageal regurgitation at the age of 1 year. Cecal volvulus occurred with a 540-degree clockwise rotation of terminal ileum to the right transverse colon and a displacement of the rotated loop to the right upper quadrant of the abdomen when he was 10 years old. Right hemicolectomy with divided ileo- and colostomy was performed. A second staged ileocolostomy was performed uneventfully 3 months later. The midline structural defects with nonfixation of the cecum and ascending colon, chronic constipation, and previous abdominal surgery might have been the predisposing factors.

Cecal volvulus in a child with CHARGE syndrome

Cecal volvulus occurring in a child with CHARGE syndrome is presented. This boy was known to have CHARGE syndrome with multiple congenital anomalies, including coloboma, ventricular septal defect, choanal atresia, growth and mental retardation, bilateral cryptorchidism, dysplasia of the right ear, cleft lip, and hydrocephalus. Nissen's fundoplication had been previously performed for severe hiatal hernia and gastroesophageal regurgitation at the age of 1 year. Cecal volvulus occurred with a 540-degree clockwise rotation of terminal ileum to the right transverse colon and a displacement of the rotated loop to the right upper quadrant of the abdomen when he was 10 years old. Right hemicolectomy with divided ileo- and colostomy was performed. A second staged ileocolostomy was performed uneventfully 3 months later. The midline structural defects with nonfixation of the cecum and ascending colon, chronic constipation, and previous abdominal surgery might have been the predisposing factors.

Specific oral medications decrease the need for surgery in adhesive partial small-bowel obstruction

BACKGROUND

Nothing by mouth (NPO) is the standard treatment for small-bowel obstruction. Whether oral medications should be prohibited during treatment of adhesive, partial small-bowel obstruction is unclear. The goal of this study was to determine whether a combination of specific oral medications in adhesive, partial small-bowel obstruction will decrease the need for operative intervention.

METHODS

Of 266 consecutive adult patients with partial small-bowel obstruction admitted at a tertiary medical center, 236 were randomized into 2 groups. Group I patients were treated with intravenous hydration, nasogastric tube decompression, and NPO. Group II patients were placed on intravenous hydration, nasogastric tube decompression, and oral fluids incorporating an oral laxative, a digestant, and a defoaming agent. We compared differences between the groups in (1) the number of patients having a successful nonoperative treatment, (2) complications, and (3) recurrence of symptoms.

RESULTS

A total of 116 and 120 patients comprised groups I and II, respectively. The number of patients treated successfully by a nonoperative approach was less in group I than in group II (77% vs 90%, P < .01). The complications and recurrence rate for groups I and II did not differ (4% vs 5% and 5% vs 4%, respectively).

CONCLUSIONS

The NPO status for patients with adhesive, partial small-bowel obstruction may not be necessary. This cocktail of oral medications can decrease the need for operative intervention in patients with presumed adhesive, partial small-bowel obstruction.

Long-term prognosis of patients with biliary atresia: a 25 year summary

OBJECTIVE

The purpose of this study was to delineate the long-term prognosis of biliary atresia (BA) in Taiwan.

STUDY DESIGN

From 1976 to 2000, 185 children were diagnosed with BA, 22 underwent exploratory laparotomy without Kasai operation, and 163 underwent Kasai operation, of which 141 cases had long-term follow-up and formed the basis of this study. The outcome was analyzed.

RESULTS

Among the 141 BA children studied who underwent Kasai operation, 115 (81.6%) had recoloration of stools, and 86 (61.0%) became jaundice-free (bilirubin <34 micromol/L) [corrected]. The resolution of jaundice and the absence of repeated cholangitis contributed to better outcome. Five and 10 year survival rates with native liver were 35% and 31%, respectively. Liver transplantation was performed in 19 patients (all but 2 with a living-related donor), and 15 (79%) survived. Five and 10 year overall survival rates for BA patients were 41.9% and 40.2%, respectively.

CONCLUSIONS

The study delineated the long-term outcome of BA in an Asian country other than Japan. Survival with native liver after a Kasai operation in Taiwan was similar to that in the American and European series. Limited donors for liver transplantation in the years of the study accounted for the poor overall prognosis of BA patients in this series.

The Influence of Biologic Factors on the Surgical Decision in Advanced Neuroblastoma

BACKGROUND

Molecular markers greatly affect the outcome of neuroblastoma. This study evaluated the influence of Trk-A and myelocytomatosis viral-related oncogene, neuroblastoma-derived (MYCN) on the role of surgery in advanced neuroblastoma.

METHODS

Ten stage 3 and 35 stage 4 neuroblastoma patients were included. Tumor resection was classified into gross total resection (GTR) and incomplete resection. Patients were classified into three biological risk groups according to Trk-A expression and myelocytomatosis viral-related oncogene, neuroblastoma-derived (MYCN) status in tumor tissues studied by immunohistochemistry and fluorescence in situ hybridization, respectively: low risk (positive Trk-A and normal MYCN), intermediate risk (negative Trk-A and normal MYCN), and high risk (positive or negative Trk-A and MYCN amplification). The effect of tumor resection on prognosis was studied and stratified according to the risk grouping.

RESULTS

GTR was achieved in 21 patients (46.7%) with a higher complication rate (33% vs. 8% in the incomplete resection group, P = .036). GTR was easier to achieve in low-risk tumors than in intermediate- or high-risk tumors (12 of 13, 4 of 17, and 5 of 15, respectively; P < .001). GTR predicted a favorable prognosis for intermediate-risk patients (P = .037; log-rank test), but not for low- or high-risk patients because of the overall favorable and poor prognosis, respectively.

CONCLUSIONS

GTR carries a potentially higher possibility of complication. Although GTR can be achieved easily in low-risk neuroblastoma patients with a favorable prognosis, surgeons should do their best to achieve GTR for intermediate-risk patients to improve outcome. Nevertheless, sacrificing vital organs to achieve GTR for high-risk patients is not justified.

Clinical Improvement Following Home Parenteral Nutrition in Pediatric Patients with Intestinal Failure

BACKGROUND/PURPOSE

Home parenteral nutrition (HPN) is being increasingly used to treat children with intestinal failure. This study evaluated the long-term growth, outcome and complications in Taiwanese pediatric patients with intestinal failure who were treated with HPN.

METHODS

This retrospective study included 27 consecutive pediatric patients with intestinal failure who received long-term HPN between 1987 and 2002. These patients were categorized into two groups according to whether they had short bowel syndrome or a bowel motility disorder. Growth, prognosis and complications, including cholestasis, hypoglycemia, hyperglycemia and infections were compared between the two groups.

RESULTS

The median age of starting HPN was significantly younger in patients with short bowel syndrome (5 months) than in patients with motility disorders (1.9 years). The median duration of HPN treatment in the overall group was 13.5 months (range, 2.1-113.1 months); weight and height increased 1.7 +/- 2.3 and 1.0 +/- 1.6 in z score, respectively. The most common complications were cholestatic liver disease (52%), hypoglycemia (15%) and hyperglycemia (33%). All patients maintained stable serum glucose levels at follow-up. Cholestatic liver disease developed after 2.3 +/- 2.0 months of total HPN in 13 patients, which subsided after 9.7 +/- 6.9 months in 11 patients, while two patients died. The mean incidence of central venous infection was 3.0 +/- 3.3 per 1000 HPN days. The most common pathogens were Staphylococcus spp. (50%) and Candida spp. (30.6%).

CONCLUSION

HPN treatment can successfully provide a bridge to enteral nutrition in pediatric patients with intestinal failure. The metabolic disturbances and cholestasis are usually transient, but infection control is important throughout the period of HPN treatment.

Nonsurgical management of partial adhesive small-bowel obstruction with oral therapy: a randomized controlled trial

BACKGROUND

Patients with partial adhesive small-bowel obstruction are usually managed conservatively, receiving intravenous hydration and nothing by mouth. Previous studies have suggested that this approach is associated with longer hospital stays and an increased risk of delayed surgery. We conducted a randomized controlled trial to see if combining standard conservative treatment with oral administration of a laxative, a digestant and a defoaming agent would reduce the frequency of subsequent surgical intervention and reduce the length of hospital stay.

METHODS

We identified 144 consecutive patients admitted between February 2000 and July 2001 with adhesive partial small-bowel obstruction and randomly assigned 128 who met the inclusion criteria to either the control group (intravenous hydration, nasogastric-tube decompression and nothing by mouth) or the intervention group (intravenous hydration, nasogastric-tube decompression and oral therapy with magnesium oxide, Lactobacillus acidophilus and simethicone). The primary outcome measures were the number of patients whose obstruction was successfully treated without surgery and the length of hospital stay. We also monitored rates of complications and recurring obstructions.

RESULTS

Of the 128 patients, 63 were in the control group and 65 in the intervention group; the mean ages were 54.4 (standard deviation [SD] 15.9) years and 53.9 (SD 16.3) years respectively. Most of the patients were male. More patients in the intervention group than in the control group had successful treatment without surgery (59 [91%] v. 48 [76%], p = 0.03; relative risk 1.19, 95% confidence interval 1.03-1.40). The mean hospital stay was significantly longer among patients in the control group than among those in the intervention group (4.2 [SD 2.7] v. 1.0 [SD 0.7] days, p < 0.001). The complication and recurrence rates did not differ significantly between the 2 groups.

INTERPRETATION

Oral therapy with magnesium oxide, L. acidophilus and simethicone was effective in hastening the resolution of conservatively treated partial adhesive small-bowel obstruction and shortening the hospital stay.

Effects of a medium-chain triacylglycerol/long-chain triacylglycerol fat emulsion containing a reduced ratio of phospholipid to triacylglycerol in pediatric surgical patients

OBJECTIVE

Medium-chain triacylglycerol (MCT) has been shown to provide better nutritional support than long-chain triacylglycerol (LCT). We compared the efficacy of MCT/LCT fat emulsions containing a usual (0.12) or a decreased (0.06) ratio of phospholipid to triacylglycerol (PL:TG) in pediatric patients under surgical stress.

METHODS

Three patient groups (n=10 in each) received equivalent amounts of glucose (12 g.kg(-1).d(-1)) and amino acids (2 g.kg(-1).d(-1)), but group A received a 10% MCT fat emulsion (PL:TG 0.06), group B received a 20% MCT fat emulsion (PL:TG 0.06), and group C received a 10% MCT/LCT fat emulsion (PL:TG 0.12) in amounts of 1.5 g.kg(-1).d(-1) in a randomized study. Total parenteral nutrition was given for 7 d. Blood samples were collected before total parenteral nutrition administration and on days 4 and 7 for determination of various biochemical indexes.

RESULTS

Serum phospholipid concentrations were significantly higher in group C than in group A or B on days 4 and 7 (P<0.05). Serum triacylglycerol and cholesterol concentrations and the very-low-density lipoprotein percentage were also significantly higher in group C than in group A or B on days 4 and 7 (P<0.05). The high-density lipoprotein percentage was significantly higher in group B on days 4 and 7 (P<0.05).

CONCLUSIONS

In pediatric patients under surgical stress, a total parenteral nutrition regimen containing an MCT/LCT fat emulsion with a decreased PL:TG ratio (0.06) is likely to result in partly better lipid and lipoprotein metabolism than an emulsion containing the usual ratio (0.12).

Plasma free amino acid profile in cancer patients

Redistribution or translocation of plasma free amino acids (PFAAs) to support visceral or tumor protein synthesis is an essential feature in cancer patients. An abnormal PFAA profile might be presented via the total reflection of cancer-induced protein metabolism in tumors, skeletal muscle and the liver in cancer patients. Clinical data from 13 studies have demonstrated a cancer-related PFAA profile, especially in digestive organ cancers. The PFAA profile can differ between the early and late stages of cancer. The profile is also affected by the type of cancer. Therefore, it is postulated that a detailed analysis of the PFAA profile may serve as one of the biological markers for cancer patients.

Quantitative gene expression analysis by cDNA microarray during liver regeneration after partial hepatectomy in rats

PURPOSE

It is speculated that genetic regulation plays an important role during liver regeneration. We conducted this study to analyze quantitative gene expression during liver regeneration after partial hepatectomy.

METHODS

Sixty male Wistar rats were randomly assigned into ten groups of six. One group of rats was killed preoperatively and the other nine groups were killed 2, 4, 6, 12, 24, 48, and 72 h, and 5 and 7 days after 70% partial hepatectomy, respectively. The remnant livers were isolated for mRNA extraction. A mass survey of gene expression by cDNA microarray carrying 6144 polymerase chain reaction-amplified cDNA fragments was prepared by an arraying machine. The microarray images were scanned, digitized, and analyzed using a flatbed scanner.

RESULTS

The variations in gene expression were classified into 72 different patterns including a pattern with a single peak, 2, 4, 6, 12, and 72 h, and 5 and 7 days after partial hepatectomy. The other patterns included double peaks, enhancing trend, diminished trend, protruding curve, excavated curve, and various mixed types. Each category of gene expression pattern contained 40-218 different proto-oncogenes.

CONCLUSION

The quantitative gene expression profiles have important implications, warranting further investigation of the genetic mechanisms involved in the process of liver regeneration.

Comparison of childhood hepatic malignancies in a hepatitis B hyper-endemic area

AIM: To examine the differences of clinical behaviors between hepatocellular carcinomas (HCC) and hepatoblastomas (HB) in children.

METHODS: From 1979 to 1997, we collected 73 HCC and 54 HB from two major medical centers in Taiwan. Demog-raphic, laboratory and radiological data, and survival curves were statistically compared.

RESULTS: HCC clinically differed from HB in mean age (10.6 vs 2.5 years; P < 0.001), status of hepatitis B infection (56/56 vs 4/35, P < 0.001) and accompanying liver cirrhosis (26/40 vs 0/30, P < 0.001), portal vein thrombi (22/56 vs 5/38, P = 0.006) and para-aortic lymphadenopathy (10/56 vs 1/38, P = 0.026). Due to a higher recurrence rate (7/12 vs 2/13, P = 0.041), stage I HCC compared poorly in survivals with stage I HB (P = 0.0183). Chemotherapy could only benefit HB as evidenced by 66.7% of resectability conversion and improve survivals for advanced HB, even with unsuccessful conversion. The survival difference between stage I HB and advanced HB with delayed complete resection was of borderline insignificance (P = 0.0507).

CONCLUSION: HCC and HB were preliminarily distinguishable by some clinical clues. Delayed resection after chemotherapy was only possible for HB. However, further studies are needed to strengthen our observation that appropriate reliance upon chemotherapy to subsequently resect advanced HB could achieve the comparable survival to that of stage I HB.

Progressive increase of bowel wall thickness is a reliable indicator for surgery in patients with adhesive small bowel obstruction

PURPOSE

The aim of this study was to determine whether progressive increase of bowel wall thickness during nonoperative treatment is a reliable indicator for surgery in patients with adhesive small bowel obstruction.

METHODS

The study consisted of a prospective case series of 121 patients with adhesive small bowel obstruction who underwent an abdominal ultrasonographic examination. The results of ultrasonographic examinations were classified into two groups according to the presence (Group I) or absence (Group II) of bowel wall thickening. Bowel wall thickening was recognized as a visible small bowel wall > or =3 mm in width as seen by ultrasonographic examination. The findings of subsequent ultrasonographic examinations taken 24 hours later were compared with those taken at admission. Surgery was determined based on the presence of any toxic signs or the failure of nonoperative treatment. The number of patients who had successful nonoperative treatment, the number of patients who underwent surgeries, and the number of complications in each group were calculated to correlate with the ultrasonographic findings.

RESULTS

There are 49 and 72 patients in Groups I and II, respectively. The number of patients who had successful nonoperative treatment and number of patients who underwent surgeries in Group I are 40 (81.6 percent) and 9 (18.4 percent) and in Group II the numbers are 68 (94.4 percent) and four (5.6 percent), respectively (P = 0.036). All 12 (100 percent) patients with progressive increase of bowel wall thickness underwent surgery. Progressive increase of bowel wall thickness as an indicator for surgery has a sensitivity of 92.3 percent (95 percent confidence interval, 62.1-99.6 percent) and a specificity of 100 percent (95 percent confidence interval, 95.7-100 percent).

CONCLUSIONS

Patients with initial bowel wall thickening have a higher incidence of surgery, and progressive increase of bowel wall thickness that appears 24 hours later is a reliable indicator for surgery in patients with adhesive small bowel obstruction.

Calreticulin expression in neuroblastoma--a novel independent prognostic factor

BACKGROUND

Calreticulin (CRT), an endoplasmic reticulum protein, has been reported to be essential for the differentiation of neuroblastoma (NB) cells, suggesting that CRT may affect the tumor behavior of neuroblastoma. The aim of this study was to evaluate the association of clinicopathologic factors and patient survival with the expression of CRT in patients with NB.

PATIENTS AND METHODS

Sixty-eight NBs were investigated by immunohistochemical staining against CRT, and were divided into positive and negative immunostaining groups. Correlations between calreticulin expression, various clinicopathologic and biologic factors, and patient survival were studied. In seven tumor samples, CRT mRNAs and proteins were evaluated with real-time PCR and western blot, respectively, and correlated with immunohistochemical findings.

RESULTS

Among 68 NBs, 32 (47.1%) showed positive CRT expression. Positive CRT immunostaining strongly correlated with differentiated histologies, as well as known favorable prognostic factors such as detected from mass screening, younger age (< or =1 year) at diagnosis and early clinical stages, but inversely correlated with MYCN amplification. Kaplan-Meier analysis revealed that NB patients with CRT expression did have better survival. Multivariate analysis demonstrated CRT expression to be an independent prognostic factor. Moreover, CRT expression also predicted better survival in patients with advanced-stage NBs, and its absence predicted poorer survival in patients whose tumor had no MYCN amplification. The amount of CRT mRNAs and proteins in NB tumor samples tested correlated well with the immunohistochemical expressions.

CONCLUSIONS

CRT expression correlates with the differentiation of NB and predicts favorable survival, thereby suggesting CRT to be a useful indicator for planning treatment of NB.

Fecal elastase 1, serum amylase and lipase levels in children with cholestasis

BACKGROUND/AIM

The pancreatic functions of children with cholestatic liver diseases were unclear. Due to anatomic vicinity and common ontogenic origin, hepatobiliary disorders of infancy may also affect pancreatic function. The aim of the study was to evaluate the exocrine pancreatic function and common pancreatic function tests in children with cholestatic disorders.

METHODS

In 40 children with cholestasis, fecal elastase 1 (FE1) concentrations were measured. Serum amylase and lipase values were tested. The diagnoses included 32 patients with extrahepatic cholestasis (biliary atresia (BA) and choledochal cyst), and 8 patients with intrahepatic cholestasis (progressive familial intrahepatic cholestasis and Alagille syndrome). None had renal insufficiency or clinical symptoms/signs of acute pancreatitis.

RESULTS

All the patients had normal FE1 (>200 microg/g). Nineteen percent (7/37) had elevated serum amylase levels (>100 U/l). Thirty-two percent (12/37) had elevated serum lipase levels above the normal (>120 U/l). Seventy-three percent (8/11) of BA patients with bilirubin >2 mg/dl had elevated serum lipase levels compared to 18% (3/17) with bilirubin < or = 2 mg/dl (p = 0.0036). None had detectable pancreatic abnormality on ultrasonography and magnetic resonance images.

CONCLUSIONS

None of the cholestatic children in this study had exocrine pancreatic insufficiency as detected by FE1. Hyperamylasemia and/or hyperlipasemia were frequently found. In children with BA, those with impaired biliary excretion tended to have elevated serum pancreatic enzymes as compared with those who had no jaundice. A decreased hepatic metabolism may be the cause.

Ultrasound may decrease the emergency surgery rate of incarcerated inguinal hernia

OBJECTIVE

Manual reduction is the standard procedure for incarcerated inguinal hernia reduction. The role of ultrasound in incarcerated inguinal hernia reduction has not been defined. The aim of this study was to determine whether ultrasound can improve the ability to reduce incarcerated inguinal hernia safely when manual reduction fails and thereby decrease the emergency surgery rate.

MATERIAL AND METHODS

Between January 1994 and December 2003, 112 adult patients with incarcerated inguinal hernias were admitted to a university medical center and classified into two groups. Group I consisted of 61 patients who received emergency surgical reduction after the failure of two attempts at manual reduction. In Group II, comprising 51 patients, ultrasound-guided reduction was performed when two attempts at manual reduction failed. Emergency surgical reduction was scheduled if both ultrasound-guided reduction and two attempts at manual reduction failed. The difference in emergency surgery rates between groups I and II was compared.

RESULTS

In group I, manual reduction was successful in 55 cases (90.2%) and 6 patients underwent emergency surgery. In group II, manual reduction was successful in 45 cases, ultrasound-guided reduction in 4 cases, 1 reduction was avoided after ultrasonic examination, and 1 patient underwent emergency surgery. The emergency surgery rates in groups I and II were 9.8% and 2.0%, respectively.

CONCLUSIONS

Ultrasound can improve the ability to reduce incarcerated inguinal hernia safely when manual reduction fails and may decrease the rate of emergency surgery.

GRP78 expression correlates with histologic differentiation and favorable prognosis in neuroblastic tumors

Glucose-regulated protein 78 (GRP78), an endoplasmic reticulum protein, is essential for the differentiation of neuroblastoma cells and is selectively induced when the cells are undergoing apoptosis. These findings suggest that GRP78 may affect the tumor behavior of neuroblastoma. Our study evaluates the association of clinicopathologic factors and patient survival with the expression of GRP78 in patients with neuroblastoma. GRP78 expression in 68 neuroblastic tumors was investigated semiquantitatively by immunohistochemistry. GRP78 mRNA and protein levels in 7 tumor tissues were also quantified by real-time PCR and Western blot respectively and correlated well with the immunohistochemical results. Forty (58.8%) of the 68 neuroblastic tumors showed positive GRP78 expression. The percentage of positive GRP78 immunostaining increased as the tumor histology became differentiated (p = 0.001). Furthermore, positive GRP78 expression strongly correlated with early clinical stages (P = 0.002) but inversely correlated with MYCN amplification (p = 0.001). Kaplan-Meier analysis showed that patients with positive GRP78 expression did have better survival than those with negative expression (5-year survival rate, 72.9% and 23.4% respectively, p < 0.001). Multivariate analysis further showed that GRP78 expression was an independent prognostic factor. Moreover, GRP78 expression predicted better survival in patients with either undifferentiated or differentiated histologies. GRP78 expression still had significant prognostic value when the analysis was restricted to tumors of advanced stages or without MYCN amplification. Thus, GRP78 can serve as a novel independent favorable prognostic factor for patients with neuroblastoma.

Resveratrol-induced cellular apoptosis and cell cycle arrest in neuroblastoma cells and antitumor effects on neuroblastoma in mice

BACKGROUND

The prognosis of neuroblastoma patients remains unsatisfactory. Therefore, developing an effective treatment strategy is important. Resveratrol, a natural polyphenol, possesses chemopreventive and antitumor effects. We investigated the effects of resveratrol on the proliferation, apoptosis, and cell cycle alteration of neuroblastoma cells and determined its effects on neuroblastoma tumors in mice.

METHODS

Cytotoxic effects, cellular apoptosis, and alterations in the cell cycle were determined in neuro-2a neuroblastoma cells exposed for varying lengths of time to a series of resveratrol concentrations. Expression of associated cell cycle regulatory proteins, cyclin E and p21, was detected by Western blot analysis, and the antitumor effects of resveratrol were investigated by treating subcutaneous neuroblastoma tumors with intraperitoneal injections of 40 mg/kg resveratrol daily for 28 days.

RESULTS

Resveratrol exerted cytotoxic effects on neuroblastoma cells. After resveratrol treatment, the apoptosis rate of the neuroblastoma cells significantly increased, a significant accumulation of cells occurred at the S phase of the cell cycle, p21 was downregulated, and cyclin E was upregulated. In addition, resveratrol treatment suppressed the growth rate of subcutaneous neuroblastomas, resulting in 70% long-term survival.

CONCLUSION

Resveratrol caused significant cytotoxicity and increased apoptosis and S-phase accumulation of neuroblastoma cells. S-phase accumulation was related to the down-regulation of p21 and up-regulation of cyclin E. In addition, resveratrol exerted antitumor effects on neuroblastomas in mice. Thus, resveratrol shows promise for the treatment of neuroblastoma.

Comparison of critical conservative treatment versus emergency operation in children with ruptured appendicitis with tumor formation

BACKGROUND AND PURPOSE

Management of ruptured appendicitis with tumor formation in children includes emergency appendectomy or initial conservative treatment, the choice of which remains controversial. This study compared the clinical courses of children with ruptured appendicitis with tumor formation (RATF) who received emergency appendectomy or initial conservative management.

METHODS

A retrospective study was conducted of 59 pediatric patients with RATF treated from January 1996 to September 2002. Twenty seven patients received emergency appendectomy and 32 patients received initial conservative treatment. Patients who received initial conservative treatment were further divided into those who recovered from the initial conservative treatment (n = 23) and those 9 patients who failed initial conservative treatment and received appendectomy at the same admission. Clinical factors including age, gender, body weight, duration of symptoms, duration of ileus after initial treatment, duration of fever and the usage of antibiotics, hospital stays, and major and minor complications were compared between groups.

RESULTS

The emergency appendectomy group and initial conservative treatment group had similar distributions of age, gender, body weight, and duration of symptoms. Patients who received emergency appendectomy had a shorter duration of fever (2.7 +/- 1.9 vs 8.0 +/- 7.0 days; p = 0.003) but were fed later (4.4 +/- 3.9 vs 1.8 +/- 2.9 days; p = 0.005) compared with those who received conservative treatment initially. Patients who received emergency appendectomy also had a higher complication rate (33.3% vs 17.4%; p = 0.038). Patients who recovered from initial conservative treatment were fed earlier after operation (0.7 +/- 0.6 vs 4.2 +/- 4.1 days; p = 0.002), had a lower complication rate (33.3% vs 4.3%; p = 0.02) and a shorter hospital stay (16.6 +/- 10.9 vs 29.3 +/- 33.6 days; p = 0.03) than those who failed initial conservative treatment. Histopathological study of the appendix in the 17 patients who received interval appendectomy showed fecal materials (58.8%) and fecoliths (29.4%) in lumen, microscopically suppurative inflammation (31.3%), and focal mild inflammation (31.3%).

CONCLUSIONS

In this study, conservative treatment of RATF in children was associated with a lower complication rate. Pathological analysis of the appendix suggests that interval appendectomy should be advocated in patients with successful initial conservative treatment.

Gastrocolocutaneous fistula in a child with congenital short bowel syndrome: a rare complication of percutaneous endoscopic gastrostomy

Gastrocolocutaneous fistula is a rare major complication of percutaneous endoscopic gastrostomy (PEG). We report a case of this complication in a 2-year-old boy with congenital short bowel syndrome with dilated bowel loops who underwent PEG insertion. Fever developed and stool-like substance was discharged from the gastrostomy tube 1 year later. Further upper gastrointestinal study and panendoscopy revealed a gastrocolonic and colocutaneous fistula. He underwent laparotomy to close the fistula. The recovery was uneventful and he was discharged 10 days after surgery. This case suggests that a previous history of abdominal surgery or dilated bowel loops should be a relative contraindication to PEG procedure. Open surgical gastrostomy is recommended for such patients.

Corrosive esophagitis in children

We evaluated the outcome and optimal management of corrosive esophagitis in 24 children (male:female=8:16, mean age 5.0+/-5.4 years old, ranged from 15 months to 18 years of age) from January 1984 to July 2001. In 20 patients this was the result of accidental ingestion, 4 were suicide attempts and 15 patients (63%) were below 3 years of age. The ingested substances included alkali (n=17, 71%), acid (n=6, 25%), and neutral detergent (n=1, 4%). The "dumpling alkaline oil", a traditional food additive used in Taiwan, was the most common culprit in this study. A total of 9 patients ingested the dumpling alkaline oils, which comprised 38% of the total 24 patients and 53% of the 17 alkaline ingestion accidents. Of the patients 21 (88%) suffered from esophageal injury, and 15 among these 21 patients developed esophageal strictures. Esophageal strictures occurred in all patients with second or third-degree burns. Of these 15 patients with esophageal strictures, 9 (60%) received endoscope-associated dilatation and 6 (40%) underwent an operation (esophagectomy and intestinal interposition). The 9 patients who did not develop esophageal strictures had good body weight gain without feeding difficulty (functionally normal recovery). On the other hand, among the 15 patients with esophageal strictures, 9 patients had functionally subnormal recovery and 6 patients had poor recovery with either frequent feeding difficulty or growth retardation. In conclusion, accidental ingestion of alkaline oil is the most common cause of corrosive esophagitis in Taiwan. The degree of burns correlated with stricture formation.

Primary volvulus of the ileum in a preterm infant

Primary volvulus of the small intestine is rare in neonates. We report a case of primary volvulus of the ileum in a preterm newborn. Vomiting and abdominal distension began 10 hours after birth, followed by hypovolemia, hyponatremia, and acidosis. Plain abdominal radiograph revealed a pattern of diffuse ileus and very dilated loops at the right upper quadrant of the abdomen. Three days later, another plain film showed increased fluid accumulation and decreased air in these dilated loops. Emergency laparotomy revealed primary volvulus of the distal ileum with gangrenous change. Resection of the necrotic ileum with an end-to-end ileoileostomy was performed and the patient recovered fully. In a newborn with ileus and rapidly deteriorating hemodynamics, early surgical intervention is essential to achieve good prognosis.

Effects of octreotide on epidermal growth factor receptor, tissue plasminogen activator, and plasminogen activator inhibitor during intraperitoneal adhesion formation

BACKGROUND

Intraperitoneal adhesions remain a problem after abdominal surgery. Octreotide has been proved to be able to reduce the number, strength, and extent of fibrous bands at and away from the anastomotic site in an animal model of rats with intestinal resection and reanastomosis. The aim of the present study was to investigate whether epidermal growth factor receptor (EGF-R), tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI) are involved in this process.

METHODS

Laparotomy with intestinal resection and reanastomosis was performed on 60 male Wistar rats. All rats were randomly assigned to five groups: receiving no medication (control; C), normal saline (NS), octreotide solution peritoneal irrigation (Oc), octreotide intramuscular injection (IM), and Oc plus octreotide intramuscular injection (Oc + IM). The concentrations of serum EGF-R, plasma tPA, PAI-1, and PAI-2, and the strength of wound healing were measured.

RESULTS

The serum EGF-R concentration showed no significant change from the preoperative level in the C and NS groups 7 and 14 days after the abdominal surgery. However, it decreased significantly on postoperative days 7 and 14 in groups Oc, IM, and Oc + IM ( P < 0.05). The plasma tPA concentrations were significantly higher than the preoperative level in all groups of rats on postoperative day 7. The levels were higher in groups Oc, IM, and Oc + IM than in group C or group NS at that time ( P < 0.05). On postoperative day 14, the plasma tPA concentrations had returned to the preoperative level in group C and group NS. However, the concentrations in groups Oc, IM, and Oc + IM still remained at a significantly higher level than the concentrations in group C and group NS. The plasma PAI-1 and PAI-2 concentrations showed no significant difference from the preoperative level in group C and group NS on days 7 and 14 after the abdominal surgery. However, the concentrations in groups Oc, IM, and Oc + IM on postoperative days 7 and 14 were markedly lower than those in groups C and NS ( P < 0.05). The wound strength was significantly greater on day 14 than on day 7 in all groups.

CONCLUSIONS

In the rats with octreotide irrigation, the EGF-R level was decreased, the plasma tPA concentration was higher, and the plasma PAI-1 and PAI-2 concentrations were lower when compared with values in group C and group NS rats on days 7 and 14 after surgery. The data suggest that EGF-R, tPA, PAI-1, and PAI-2 are all involved in the mechanism of octreotide's action in reducing adhesion formation.

A trend of improved survival of childhood hepatoblastoma treated with cisplatin and doxorubicin in Taiwanese children

Hepatoblastoma is the second most common childhood malignant hepatic tumor in Taiwan. Its prognosis used to be poor. We reviewed our cases in this decade to see if there has been any improvement of survival in our patients with hepatoblastoma. From 1988 to 2000, 19 patients with hepatoblastoma in this institution were included in the study. These patients' clinical manifestations, laboratory and image studies, histological findings, treatment modalities and prognostic significance were analyzed. The mean age at diagnosis was 13.5 months, ranging from 0 to 4 years old (male:female =11:8). Abdominal distension was the most common symptom, and hepatomegaly was the most common physical finding. Laboratory abnormalities included elevated alpha-fetoprotein, thrombocytosis and abnormal liver function profiles. Treatment modalities included primary surgery with postoperative chemotherapy in three, chemotherapy only in four and preoperative chemotherapy plus surgery with or without postoperative chemotherapy in nine patients. The overall 2-year survival rate is 38.6%. The significant prognostic factors include patients' compliance, resectability and chemotherapy protocol. The introduction of a new chemotherapy protocol designed by the International Society of Pediatric Oncology Study (SIOPEL) in 1994 improved the 2-year survival rate from 12.5 to 58.4% ( P=0.01). In conclusion, the improved chemotherapy protocol enhances the survival rate of hepatoblastoma in Taiwanese children.

Prophylactic oral antibiotics in prevention of recurrent cholangitis after the Kasai portoenterostomy

PURPOSE

The aim of this study was to evaluate the efficacy of trimethoprim-sulfamethoxazole (TMP/SMZ) and neomycin as the prophylactic agents against the recurrence of cholangitis in children with biliary atresia (BA) after a Kasai portoenterostomy.

METHODS

Nineteen BA patients aged 0 to 2 years, who had one episode of cholangitis after a Kasai portoenterostomy, were recruited in this study. Patients were assigned randomly into 2 groups: one (9 cases) with TMP/SMZ (TMP 4 mg/kg/d and SMZ 20 mg/kg/d, divided in 2 doses) and the other (10 cases) with neomycin (25 mg/kg/d, qid, 4 days a week). Another 18 BA patients aged 0 to 2 years, with cholangitis but not put on long-term prophylaxis, served as the historical control group.

RESULTS

The mean prophylactic periods were 14.6 months and 14.7 months in the TMP/SMZ and neomycin groups. Patients who received prophylaxis with either TMP/SMZ or neomycin had lower recurrence rates of cholangitis than those in the control group (P =.042 and.011). There was no difference in the recurrence rates of cholangitis between the TMP/SMZ and neomycin groups (P =.641). The survival rates were higher in the TMP/SMZ and neomycin groups than in the control group (P =.09 and.018).

CONCLUSIONS

Use of TMP/SMZ or neomycin is effective as a prophylactic agent against the recurrence of cholangitis after the Kasai portoenterostomy, but there is no difference in efficacy between these 2 regimens.

Comparison of medial-to-lateral versus traditional lateral-to-medial laparoscopic dissection sequences for resection of rectosigmoid cancers: randomized controlled clinical trial

This study aimed to compare medial-to-lateral versus lateral-to-medial laparoscopic dissection sequences for resecting rectosigmoid cancers. We hypothesized that the medial-to-lateral approach was a more efficient procedure and with potentially better oncologic results. Between January 1997 and June 1999, a total of 67 patients of rectosigmoid cancer treated by one surgeon using the laparoscopic approach were recruited for this prospective, randomized, double-blind clinical trial. Using the blocked randomization method, 36 patients were allocated to a medial-to-lateral (M) group and the other 31 to a lateral-to-medial (L) group; the groups were well matched in age, gender, symptoms, body mass index, American Society of Anesthesiology (ASA) class, tumor location, tumor distance above the anal verge, tumor gross morphology, TNM stage of the tumor, and accuracy of preoperative TNM staging (p > 0.05). All patients were followed up until June 2001. We found that the M group had a significantly shorter operating time and lower overall costs than the L group (p < 0.05). There was no significant difference between these two groups in terms of intraoperative complications, conversion rate, postoperative ileus, hospitalization, postoperative pain, postoperative complications, wound length, or disability (p > 0.05). The postoperative proinflammatory response, evaluated by the C-reactive protein level and the erythrocyte sedimentation rate, was significantly lower in the M group (p < 0.05). There was no significant difference between these two groups regarding postoperative immunosuppression, as evaluated by the alterations of total lymphocyte counts and the CD4(+)/CD8(+) ratio (p > 0.05). The extent of dissection of these two dissection approaches was similar, as the harvested lymph nodes were equivalent (p > 0.05). During the whole follow-up period (median 32 months, range 24-54 months), the tumor recurrence rate was similar for these two groups of patients (5.6% in the M group vs. 6.5% in the L group; p > 0.05). These findings indicated that the medial-to-lateral approach was quicker, less expensive and possibly less invasive; moreover, it gave oncologic results similar to those achieved with the traditional lateral-to-medial dissection sequence. We thus concluded that the medial-to-lateral dissection sequence may currently be the most appropriate procedure for laparoscopic resection of rectosigmoid cancers.

High-frequency microsatellite instability predicts better chemosensitivity to high-dose 5-fluorouracil plus leucovorin chemotherapy for stage IV sporadic colorectal cancer after palliative bowel resection

The influence of MSI on treatment outcome of colorectal cancers remains unclear and deserves further investigation. We recruited 244 patients with stage IV sporadic colorectal cancers for our study, based on appropriate eligibility criteria. Patients were nonrandomly allocated to 2 treatment groups of either with or without high-dose 5-FU plus leucovorin chemotherapy (HDFL, 5-FU 2,600 mg/m(2) leucovorin 300 mg/m(2) maximum 500 mg). Each treatment group was further divided into 2 subgroups according to high-frequency MSI (MSI-H) status. MSI-H was defined as the appearance of MSI in at least 2 of the 5 examined chromosomal loci (BAT-25, BAT-26, D5S346, D2S123, D17S250). We compared clinicopathologic parameters, p53 overexpression and overall survival between the groups. In addition, 4 subgroups were identified as follows: MSI-H(+)HDFL(+), n = 35; MSI-H(-)HDFL(+), n = 134; MSI-H(+)HDFL(-), n = 17; MSI-H(-)HDFL(-), n = 58. There was no significant difference of background clinicopathologic data between the HDFL(+) and HDFL(-) treatment groups (p > 0.05). Survival analyses indicated that the patients of subgroup MSI-H(+)HDFL(+) survived significantly longer than those of subgroup MSI-H(-)HDFL(+), with median survival times of 24 (95% CI 20.2-27.9) and 13 (95% CI 11.6-14.4) months, respectively (p = 0.0001, log-rank test). In contrast, in patients without chemotherapy, the prognosis was poor irrespective of MSI status, with median survival times of 7.0 (95% CI 4.6-9.4) and 7.0 (95% CI 6.1-7.9) months in the MSI-H(+)HDFL(-) and MSI-H(-)HDFL(-) subgroups, respectively (p = 0.8205, log-rank test). MSI-H cancers responded significantly better to HDFL (p = 0.001), with a mean response rate of 65.71% (95% CI 49.98-81.44%) in subgroup MSI-H(+)HDFL(+) compared to 35.07% (95% CI 26.99-43.15%) in subgroup MSI-H(-)HDFL(+). There appeared to be no preferential metastatic site where response to HDFL can be predicted based on the MSI status of the primary tumor. Toxicity to HDFL was similarly minimal between MSI-H(+) and MSI-H(-) patients (p > 0.05). Multivariate analysis of all patients further indicated that MSI-H and chemotherapy were independent favorable prognostic parameters (p < 0.05). Thus, the better prognosis of stage IV sporadic colorectal cancers with MSI-H may be associated with better chemosensitivity, rather than lower aggressiveness in biologic behavior.

Effects of irradiated tumor vaccine and continuous localized infusion of granulocyte-macrophage colony-stimulating factor on neuroblastomas in mice

BACKGROUND/PURPOSE

Immunomodulatory treatment has been proposed as a feasible strategy for neuroblastoma treatment. In this study, the antitumor effects of a continuous localized subcutaneous infusion of granulocyte-macrophage colony-stimulating factor (GM-CSF) into the injection site of irradiated tumor vaccine used as a source of tumor antigens on mouse neuroblastoma were investigated.

METHODS

A/J mice were inoculated subcutaneously with wild type neuro-2a neuroblastoma cells and then treated with 5 doses of irradiated tumor vaccine or continuous localized infusion of GM-CSF (1 ng/d or 10 ng/d) via an osmotic minipump. Survival rates and survival times were compared among the groups. Tumor growth rates and animal survival times were followed and compared among different groups. Histologic and immunohistochemical analyses were performed to observe the immune response induced by various treatment strategies.

RESULTS

Tumor growth rates were reduced significantly and survival times prolonged significantly by the treatment using tumor vaccine and continuous infusion of 10 ng/d of GM-CSF when compared with the control group (P <.05). One mouse treated with tumor vaccine and a 10 ng/d infusion of GM-CSF showed tumor regression and long-term survival, and no tumor growth was noted after rechallenge with wild-type neuro-2a cells. In contrast, using tumor vaccine only, or tumor vaccine combined with a 1 ng/d infusion of GM-CSF was less effective than tumor vaccine combined with a 10 ng/d infusion of GM-CSF (P <.05). Infusion of GM-CSF alone had no antitumor effects. Immunohistologic analyses showed significant CD4+ and CD8+ T cell infiltration of the tumor in the mice treated with tumor vaccine and a 10 ng/d infusion of GM-CSF.

CONCLUSIONS

The results suggest that an irradiated tumor vaccine combined with continuous localized infusion of GM-CSF may induce a tumor-specific antitumor immune response that can suppress tumor growth and prolong survival. Such a treatment strategy deserves consideration as a possible adjuvant treatment for neuroblastoma.

Multiple intrahepatic biliary cysts in children with biliary atresia

PURPOSE

The aim of this study was to investigate the incidence, clinical course, and outcome of multiple intrahepatic biliary cysts in patients with biliary atresia.

METHODS

From 1992 to 2000, 154 patients with biliary atresia were examined for intrahepatic cysts. They were followed and examined routinely using abdominal ultrasonography.

RESULTS

Twenty-three patients had single intrahepatic cysts, and 16 patients had multiple cysts. The incidence of intrahepatic cysts in these patients were 25.3% (39 of 154) for all kinds of cysts and 10.4% (16 of 154) for multiple intrahepatic cysts. Of the 16 patients with multiple cysts, 13 (81.3%) had jaundice, and 15 (93.8%) had a history of cholangitis before cysts were detected. Image studies showed multiple discrete ovoid or round intrahepatic biliary cysts with various sizes along the biliary trees. The cysts decreased in size or number in 7 patients after antibiotic treatment and disappeared in only one patient. The mortality rate was higher in patients with multiple cysts than in those with single cysts (P =.037).

CONCLUSIONS

Multiple intrahepatic biliary cysts are a common complication in patients with biliary atresia and suggests a poor prognosis. Prolonged parenteral antibiotics treatment should be administered when signs of biliary infection appear.

Laparoscopic Ladd's procedure for intestinal malrotation: report of three cases

Ladd's procedure for laparoscopic repair of malrotation has many advantages over conventional surgical techniques, such as earlier feeding and discharge. However, this procedure is still not commonly used in Taiwan. This report describes the results of treatment of intestinal malrotation in three patients using laparoscopic Ladd's procedure. The patients, aged 8 days, 17 days, and 3 years, underwent laparoscopic Ladd's procedure between July 1999 and September 2000. All three patients had symptoms of intermittent vomiting and were shown to have intestinal malrotation by upper gastrointestinal series study. The procedure was performed using three trocars of 5 mm diameter placed at the infraumbilical ring and the right and left lower quadrants. All procedures were completed laparoscopically. The operative times were 4.8, 3.6, and 3.5 hours, respectively. Feeding was started on postoperative Day 2 to 5, and the hospital stay was 6 to 11 days. Our results suggest that laparoscopic Ladd's procedure can be performed safely in pediatric patients. In addition, patients are expected to benefit from the smaller incision, earlier feeding, shorter hospital stay, and fewer complications compared with traditional Ladd's procedure.

Prediction of the outcome of pull-through surgery for Hirschsprung's disease using acetylcholinesterase activity

BACKGROUND AND PURPOSE

Advances in surgical procedures for the treatment of Hirschsprung's disease have afforded the majority of patients a satisfactory outcome after definitive corrective surgery. However, some patients continue to have signs of persistent bowel dysfunction despite adequate resection of the aganglionic bowel segment. The definite etiology of persistent bowel dysfunction in these patients remains controversial.

MATERIALS AND METHODS

The acetylcholinesterase activity in the proximal resection margin of pull-through surgical specimens collected from September 1992 to June 1998 was evaluated and correlated with clinical outcome.

RESULTS

A total of 24 patients were studied, 15 males and 9 females. The follow-up period ranged from 1 year 7 months to 7 years 6 months. The Soave procedure was performed in 17 cases and the Duhamel in 7. Twenty cases had a good or fair clinical outcome and four (16.7%) had a poor outcome. There was no mortality. Among the 20 patients with a good or fair outcome, the acetylcholinesterase activity in the proximal section margins was not increased in 12, mildly increased in seven, and moderately increased in one. The four cases with poor outcome all had moderately increased acetylcholinesterase activity in at least one specimen. The association between moderately increased acetylcholinesterase activity and poor surgical outcome was significant (p = 0.0005). In contrast, there was no association between the surgical method (Soave or Duhamel) used and clinical outcome (p = 0.55).

CONCLUSION

Acetylcholinesterase activity in the proximal resection margins of pull-through surgical specimens is a useful indicator for predicting the postoperative outcome in Hirschsprung's disease.

Magnetic resonance cholangiopancreatography diagnosed pancreatitis associated choledochal cyst: report of one case

This report describes a 6-year-old girl with a choledochal cyst associated with recurrent pancreatitis. A cystic dilatation of the common bile duct was detected by abdominal ultrasound and magnetic resonance cholangiopancreatography (MRCP). She displayed only one of the classic triads: abdominal pain plus pancreatitis. Cyst excision and Roux-en-Y hepaticojejunostomy was indicated in this case. MRCP can be considered as a unique non-invasive tool and the first choice in evaluation of choledochal cyst in pediatric group.

Bacterial cholangitis in patients with biliary atresia: impact on short-term outcome

Bacterial cholangitis (BC) is a common complication in patients with biliary atresia (BA) and is characterized by fever, acholic stools and positive blood cultures. The diagnosis is often empirical because the yield of blood cultures is low. It is difficult to differentiate BC from other febrile episodes. In order to characterize the clinical and laboratory features of BC in patients with BA, identify risk factors, and correlate cholangitis with outcome, 37 patients with BA from 1993 to 1998 who underwent a Kasai operation in our hospital were studied. The follow-up period ranged from 6 to 59 months. A total of 107 febrile episodes were documented in these patients. The diagnostic criteria for cholangitis were fever, increased jaundice, or acholic stools. The clinical features, laboratory data, results of bacterial cultures, and outcomes were analyzed retrospectively. A total of 107 febrile episodes, including 78 bouts of cholangitis and 29 non-cholangitis infections, were found in 34 patients. Patients with BC had higher postoperative bilirubin levels (P = 0.02) and less frequent use of prophylactic antibiotics (P = 0.05) than those with non-cholangitis infections. Abnormal white blood cell counts (> 12,000 or <4,000 mm3) tended to be present in patients with BC (P = 0.08). There were no statistical differences in the risk factors and laboratory data between culture-positive (n = 16) and -negative (n = 62) cholangitis cases. The occurrence of cholangitis significantly reduced survival in both patients with good (P = 0.03) and inadequate bile flow (P = 0.03). All 9 patients who had never had cholangitis survived during the follow-up period. Repeated attacks of BC further decreased survival probability. The responsive organisms were mainly enteric bacteria, including Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumanni, and Salmonella typhi. The sensitivity tests justified empirical therapy with ceftriaxone. The effectiveness of prophylactic trimethoprim-sulfamethoxazole or neomycin warrants further studies. BC was a highly prevalent postoperative complication in patients with BA, especially those with inadequate bile drainage. It significantly affected early mortality. Aggressive and complete treatment with empirical ceftriaxone was appropriate.

Complete genome sequence of an M1 strain of Streptococcus pyogenes

The 1,852,442-bp sequence of an M1 strain of Streptococcus pyogenes, a Gram-positive pathogen, has been determined and contains 1,752 predicted protein-encoding genes. Approximately one-third of these genes have no identifiable function, with the remainder falling into previously characterized categories of known microbial function. Consistent with the observation that S. pyogenes is responsible for a wider variety of human disease than any other bacterial species, more than 40 putative virulence-associated genes have been identified. Additional genes have been identified that encode proteins likely associated with microbial "molecular mimicry" of host characteristics and involved in rheumatic fever or acute glomerulonephritis. The complete or partial sequence of four different bacteriophage genomes is also present, with each containing genes for one or more previously undiscovered superantigen-like proteins. These prophage-associated genes encode at least six potential virulence factors, emphasizing the importance of bacteriophages in horizontal gene transfer and a possible mechanism for generating new strains with increased pathogenic potential.

Prognostic indicators of survival in infants with congenital diaphragmatic hernia

PURPOSE

This study sought to identify the factors predictive of the short-term outcome in infants with congenital diaphragmatic hernia (CDH).

METHODS

We retrospectively reviewed medical records from September 1985 to December 1998 for all infants born with CDH and managed at National Taiwan University Hospital (NTUH). Coexisting pathology and measures of respiratory function were analyzed to determine the prognostic factors.

RESULTS

A total of 32 infants with CDH were managed at NTUH over the past 13 years. The investigated factors associated with poor prognosis in CDH included congenital heart disease, chromosomal abnormality, pneumothorax, and preoperative parameters including arterial partial carbon dioxide pressure greater than 40 mmHg, arterial partial oxygen pressure less than 100 mmHg, alveolo-arterial partial oxygen pressure greater than 610 mmHg, and oxygen index (OI) greater than 0.4. Multiple logistic regression analyses indicated that only an OI greater than 0.4 and pneumothorax were significant indicators of poor prognosis. When the incidence of pneumothorax was compared between patients who received ventilation using a conventional mechanical ventilator or high-frequency oscillatory ventilator (HFOV), a trend toward a lower incidence of pneumothorax in those using HFOV for initial stabilization was found (p = 0.08).

CONCLUSIONS

An OI greater than 0.4 before surgery and pneumothorax are poor prognostic indicators in infants with CDH. A high OI is reflective of the severity of pulmonary dysfunction in infants. Pneumothorax further compromises the dysfunction of a hypoplastic lung in infants with CDH. The results of this study show the importance of avoiding iatrogenic pneumothorax during management of infants with CDH.