Postoperative bowel function and nutritional status following distal pancreatectomy with en-bloc celiac axis resection

BACKGROUND/AIMS

Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) is routinely accompanied by complete resection of the bilateral celiac ganglions and the circumferential plexus of the superior mesenteric artery. The postoperative condition including bowel movement, nutritional status, and tolerance to adjuvant chemotherapy has never been studied.

METHODS

40 patients who underwent DP-CAR were enrolled in this study. Postoperative bowel function was estimated by the requirement of anti-diarrheal agents. Changes of nutritional parameters including body weight and laboratory data for 1 year after surgery were evaluated.

RESULTS

15 (38%) patients needed no anti-diarrheal agent after a median follow-up period of 39 months. The other patients were well controlled for their bowel movement with anti-diarrheal drugs. 13 patients who received adjuvant chemotherapy tolerated it well despite hematologic toxicity in 7 patients who received gemcitabine. Postoperative body weight was significantly decreased and reached a plateau value at postoperative month 3. The values of laboratory data indicating nutritional status were significantly lower at 1 month after surgery and recovered between 3 and 12 months.

CONCLUSION

The patients who underwent DP-CAR scarcely suffered from intractable diarrhea and could achieve a feasible nutritional status after surgery to be able to receive adjuvant chemotherapy.

Kinetics of hydrolysis, oxidation, and adsorption during olive oil degradation by activated sludge

Kinetics of the degradation of olive oil by an acclimated activated sludge were studied. Kinetic constants for the lipid removal from the mixed liquor and for that from the supernatant and for the hydrolysis step were evaluated using Michelis-Menten equations. The maximum specific reactions rates (v(max)) and the saturation constants (K(m)) were v(max) = 1.20 mg lipid mg(-1) MLVSS day(-1) and K(m) = 1290 mg/L for lipid removal from the mixed liquor; v(max) = 1.54 mg lipid mg(-1) MLVSS day(-1) and K(m) = 801 mg/L for that from the supernatant; v(max) = 1.57 mg olive oil mg(-1) MLVSS day(-1) and K(m) = 1750 mg/L for the hydrolysis of olive oil (where MLVSS refers to mixed liquor volatile suspended solids). The adsorption of olive oil by the activated sludge contributed to the lipid removal from the supernatant. The specific rate of this adsorption was also estimated. The hydrolysis, rather than the oxidation of free fatty acids, was the rate limiting step in the degradation of olive oil when the concentration of olive oil was lower than about 800 mg/L.

Absolute cooling rates of freely decaying fullerenes

The cooling rates of C60- have been measured in an electrostatic storage ring between several hundred mus and several tens of ms with one-photon laser excitation. The absolute energy scale is established by the photon energy, and the cooling time interval is derived from the nonexponential decay of the ensemble of hot molecules. The energy decreases due to the combined action of depletion and thermal emission of IR photons with a total energy loss rate that varies inversely proportional to time, 0.9 eV/t. The radiative component decreases from a few hundred eV/s at submillisecond time scales to several tens of eV/s at 20 ms and confirms that the crossover from depletion to predominantly radiative cooling occurs around 5 ms. The method is applicable to any large molecule or cluster which decays spontaneously, irrespective of the specific decay channel.

[Adult Bochdalek hernia with volvulus of the stomach]

We report a rare case of Bochdalek hernia, congenital posterolateral diaphragmatic hernia with volvulus of the stomach, in an adult A 74-year-old man was admitted to our hospital complaining of sudden abdominal pain and vomiting. Roentgenologic examination of the chest showed air above the left diaphragm, and the mediastinum was displaced to the right. Upper gastrointestinal series revealed volvulus of the stomach in which the pylorus was displaced to the left. The surgical repair was done through left thoracotomy with combining laparoscopy and thoracoscopy without surgical complications, 1 year later the patient is asymptomatic.

Angle-resolving time-of-flight electron spectrometer for near-threshold precision measurements of differential cross sections of electron-impact excitation of atoms and molecules

This article presents a new type of low-energy crossed-beam electron spectrometer for measuring angular differential cross sections of electron-impact excitation of atomic and molecular targets. Designed for investigations at energies close to excitation thresholds, the spectrometer combines a pulsed electron beam with the time-of-flight technique to distinguish between scattering channels. A large-area, position-sensitive detector is used to offset the low average scattering rate resulting from the pulsing duty cycle, without sacrificing angular resolution. A total energy resolution better than 150 meV (full width at half maximum) at scattered energies of 0.5-3 eV is achieved by monochromating the electron beam prior to pulsing it. The results of a precision measurement of the differential cross section for electron-impact excitation of helium, at an energy of 22 eV, are used to assess the sensitivity and resolution of the spectrometer.

[Esophago-bronchial fistula confirmed with bronchoscopy utilized an indocyanine green]

The patient was a 54-year-old female with both headache and vomit presented to the emergency room. Endoscopic examination revealed an advanced esophageal cancer located on the middle thoracic esophagus. Histological analysis revealed squamous cell carcinoma. The clinical stage was diagnosed as T4N2M0 and this case was treated by the chemoradiation. She presented progressive moist cough after chemoradiotherapy. Esophagography demonstrated esophago-bronchial fistula (EBF). EBF was not detected by routine broncoscopy. To confirm fistula, we were performed the bronchoscopy which utilized an indocyanine green. Contrast media colored green were over from the superior segmental bronchus in a bronchoscope. The bronchoscope which utilized an indocyanine green is effective for EBF.

Expression and diversity of Echinococcus multilocularis AgB genes in secondarily infected mice: evaluating the influence of T-cell immune selection on antigenic variation

The T-cell-mediated immune response exhibits a crucial function in the control of the intrahepatic proliferation of Echinococcus multilocularis larvae in mice and humans, both being natural intermediate hosts of the parasite. Antigen B (AgB), a metabolized Echinococcus spp. lipoprotein, contributes to the modulation of the T-cell immune response, and distinct sites of the corresponding AgB1, AgB3 and AgB4 genes were shown to be under positive selection pressure. Since several AgB gene variants are present in a single Echinococcus metacestode, we used secondary E. multilocularis infections in BALB/c and in athymic nude mice (devoid of T-cell responses) to analyze the effect of the cellular immune response on the expression and diversity of EmAgB1-EmAgB4 genes. We demonstrated hereby that EmAgB transcripts were less abundant in nude mice during the early phase of infection (at one month post-infection), and that EmAgB2 is simultaneously down-regulated when compared to the other three genes. A negative relationship exists between the level of transcription and diversity of EmAgB genes. Moreover, no excess of non-synonymous substitutions was found among the distinct EmAgB alleles from a single host. Together, these results pointed to the effect of purifying selection, which seemed to eliminate the detrimental AgB variants generated during the development of the metacestode within the peritoneal cavity of its intermediate host.

Exocrine function following the whipple operation as assessed by stool elastase

What impact does pancreaticoduodenectomy (PD) have on exocrine function? Does the pancreatic anastomosis remain patent? When stool elastase became available for testing in November 2001, we began preoperative assessment and then increasingly employed postoperative measurements. From December 2001 until March 2006, 182 patients underwent PD by the same surgeon. Preoperative stool elastase was measured in 138 (76%) patients and was repeated postoperatively at 3 +/- 1 month, 12 +/- 2 months, and 24 +/- 3 months. At the same time periods, an abdominal CT scan was used to assess patency of the pancreatic anastomosis as implied by pancreatic duct dilation in the remnant (dilation = duct >3 mm or, if duct dilated preoperatively, then duct that failed to decrease in size). All cases were reconstructed with duct-to-mucosa pancreaticojejunostomy. Stool elastase was expressed as normal (>200 microg/gram stool), moderately reduced (100-200 microg/gram), or severely reduced (<100 microg/gram). Preoperative stool elastase values were "normal" in 78% (pancreatic cancer 32% normal vs. all other groups >78%; P < or = 0.001). As compared with preoperative values, the percent of cases with reduced elastase levels at 3 months, 1 year, and 2 years postoperatively was 48%, 73%, and 50%, respectively. The CT scans at the time of the 69 stool elastase measurements after PD showed pancreatic duct dilation in the pancreatic remnant in 9 of 69 (9%) stools but was not more frequent in the group with decreased elastase. Based on cases elastase, one third of patients about to have PD will have exocrine insufficiency, an observation most common among the patients with pancreatic cancer (68%). Stool elastase levels are further depressed in the majority of cases after PD from parenchymal loss because we could not implicate an occluded pancreatic anastomosis. These results suggest that, after PD, exocrine supplementation should be given to all patients with pancreatic cancer, especially those with impending adjuvant therapy. To further improve the long-term results after PD, each surgeon should assess the effect of their own type of pancreaticoenteric technique on exocrine function.

14-3-3- and II/3-10-gene expression as molecular markers to address viability and growth activity of Echinococcus multilocularis metacestodes

The present study aimed to search for and characterize parasite molecules, whose expression levels correlate with the viability and growth activity of Echinococcus multilocularis metacestodes. We focused on the expression profiles of 2 parasite-derived genes, 14-3-3 and II/3-10, as putative molecular markers for viability and growth activity of the larval parasite. In experiments in vivo, gene expression levels of 14-3-3 and II/3-10 were relatively quantified by real-time reverse transcription-PCR using a housekeeping gene, beta-actin, as a reference reaction. All three reactions were compared with growth activity of the parasite developing in permissive nu/nu and in non-permissive wild type BALB/c mice. At 2 months p.i., the transcription level of 14-3-3 was significantly higher in parasites actively proliferating in nu/nu mice compared to parasites moderately growing in wild type mice. Immunoblotting experiments confirmed at the protein level that 14-3-3 was over-expressed in parasites derived from nu/nu mice at 2 months p.i. In vitro treatment of E. multilocularis with an anti-echinococcal drug nitazoxanide resulted in a significant decrease of both 14-3-3 and II/3-10 transcription levels found after 8 days of treatment, which correlated with the kinetics of a housekeeping gene, beta-actin. The conclusion is that 14-3-3, combined with II/3-10, exhibits good potential as a molecular marker to assess viability and growth activity of the parasite.

[Metastatic sternal tumor from thyroid papillary carcinoma; report of a case]

A 68-year-old male was referred to our department for treatment of a metastatic sternal tumor in the manubrium sterni. Primary lesion was papillary carcinoma of the left lobe of the thyroid gland. Total thyroidectomy, cervical lymph node dissection, resection of manubrium sterni with concomitant resection of bilateral clavicles, 1st ribs and 2nd ribs, and chest wall reconstruction using Marlex Mesh were performed on January 29, 2001. Considering relatively good prognosis and good response to multimodality therapy, surgical resection of sternal metastatic lesion from differentiated thyroid cancer seems to be a choice of therapy as a part of multimodality approach, including surgery, radioiodine and external radiation therapy, to thyroid cancer with systemic spread.

Differential mechanisms of constitutive Akt/PKB activation and its influence on gene expression in pancreatic cancer cells

Activated Akt/protein kinase B transmits oncogenic signals leading to inhibition of apoptosis, cellular proliferation, and tolerance to hypoxia. Presently, mutational inactivation of PTEN and activation of Ras are considered to be the major causes of Akt activation. Here we report differential mechanisms of constitutive Akt activation in 4 human pancreatic cancer cell lines (KMP-3, KMP-4, PCI-66, and PCI-68). These 4 cell lines displayed phosphorylation and functional activation of Akt both in the presence and absence of serum, while three control cell lines (PCI-79, KMP-8, and PSN-1) did so only in the presence of serum in culture. All the 7 cell lines harbored K-Ras activated by mutations at codon 12 resulting in MAP kinase kinase (MEK1/2) phosphorylation, and all except one (KMP-8) had p53 mutations, indicating that these mutations are not sufficient for constitutive Akt activation. KMP-3 and KMP-4 had lost PTEN function owing to loss of expression or a mutation, but PCI-66 and PCI-68 retained wild-type PTEN. Phosphorylation of Akt was inhibited by the phosphatidylinositol-3-kinase (PI3K) inhibitor LY294002 and the tyrosine kinase inhibitor genistein in KMP-3 and KMP-4 cells, indicating that upstream signals are required for Akt activation in these two cell lines. In contrast, neither LY294002 nor genistein inhibited Akt activation in PCI-66 and PCI-68 cells, indicating the involvement of another unknown mechanism of Akt activation independent of PI3K-mediated signaling to Akt. Irrespective of the differential mechanisms, the 4 cell lines showed similar mRNA expression patterns of 49 genes assessed by cDNA array as compared to the 3 cell lines without Akt activation, suggesting that the mechanisms have the same consequences on the downstream signaling of the constitutive Akt activation.

A case of lung cancer with hypercalcemia which was incidentally complicated with primary hyperparathyroidism due to parathyroid adenoma

In lung cancer patients, hypercalcemia is a fairly common metabolic problem associated with malignancy. However, the occurrence of hypercalcemia in lung cancer patients means an ominous prognostic sign. As hypercalcemia often causes early death, quick diagnosis and treatment for hypercalcemia are required. A 69-year-old woman was admitted to our hospital with anorexia caused by hypercalcemia. On admission, serum level of PTH was elevated and PTHrP was normal. From the results of CT findings and transbronchial lung biopsy, the cause of the hypercalcemia was determined as lung cancer incidentally complicated with primary hyperparathyroidism. First, serum calcium level was returned to normal through hydration with saline and bisphosphonates. Next, left hemithyroidectomy for primary hyperparathyroidism was performed. Histologically, the tumor was diagnosed as parathyroid adenoma. Fifteen days later, left lower lobectomy for primary lung cancer was performed under a video-assisted thoracoscopic approach. Histologically, the tumor was diagnosed as a moderately differentiated adenocarcinoma. Four years and three months after the operation, the patient is alive and well with no sign of recurrence. When a lung cancer patient is complicated with hypercalcemia, we need to consider that primary hyperparathyroidism is a possible cause of the hypercalcemia.

A case of primary leiomyosarcoma of the chest wall successfully resected under the video-assisted thoracoscopic approach

We report a case of a 62-year-old woman with primary leiomyosarcoma of the chest wall which was successfully resected under the video-assisted thoracoscopic approach. The disease was found during the treatment for a malignant melanoma of the left heel. On the preoperative CT images, the lesion was suspected to be a metastasis of the malignant melanoma. The thoracoscopic surgery revealed that the tumor originated from the parietal pleura, and it was resected with a 5-mm margin of normal pleura. Histopathologically, the tumor was diagnosed as low-grade leiomyosarcoma. Since no residual tumor cells were proven in the resected margins histologically, further resection was not performed. At present, she is alive and well with no sign of recurrence of leiomyosarcoma two years and one month after operation. Thoracoscopic surgery is worth trying for accurate diagnosis of and effective treatment for a chest lesion without apparent invasion of the chest wall on the preoperative CT images.

Decreased absorption and retention rates of magnesium in the rats fed on spinach-supplemented diets: possible explanations

We studied the bioavailability of magnesium (Mg) in spinach after boiling with distilled water, using Mg-deficient growing male rats. The rats were fed a semipurified diet (Mg:0.063 per cent (w/w)) for 3 days. then a Mg-deficient diet (Mg:0.001 per cent (w/w)) for 5 days. They were then divided randomly into 7 groups of 6 rats each, and fed the semipurified diet (Mg: 0.063, 0.045 or 0.027 per cent (w/w)), or the spinach-supplemented diet (10 per cent (w/w) dried and powdered spinach after boiling with distilled water for 3 min at 100 degrees C). The Mg content of the diets supplemented with spinach grown on chemical nutrients, and on manure from pigs, cattle and fowl, was 0.069, 0.051, 0.043 and 0.036 per cent (w/w), respectively. Water intake and volumes of urine and faeces were significantly greater in the rats fed the spinach-supplemented diets than in those fed the semipurified diets. Apparent absorption of Mg, and urinary and faecal excretions of Mg were directly related to Mg intake: no significant difference was observed amongst the groups. Both the ratios of Mg absorption and retention were significantly lower in the rats fed diets supplemented with spinach than in those fed semipurified diets. The plasma Mg level was directly related to Mg intake in the rats fed the semipurified diets and the spinach-supplemented diets. However, the plasma Mg level in the rats fed spinach grown organically on manure from fowl tended to be higher than in the other groups. From these results, it was concluded that bound Mg in spinach was effectively utilized by Mg-deficient rats, however, the absorption and retention rates of Mg in rats fed diets supplemented with spinach were decreased. Possible explanations were discussed.

Surgical therapy for tremor in multiple sclerosis: an evaluation of outcome measures

OBJECTIVE

To assess the reliability, validity, and sensitivity of outcome measures that might be used in a clinical trial of surgery for the treatment of severe tremor associated with MS (MS tremor).

METHODS

Nine patients with MS tremor were evaluated before and 3 and 12 months after thalamic surgery (six thalamotomy, three deep brain stimulation). A clinical tremor rating scale (CTRS), a novel quantitative movement analysis technique (QMA), and a variety of measures of disability, neurologic impairment, and quality of life was utilized.

RESULTS

Both the CTRS and QMA were reliable measures of tremor and both were sensitive to the improvement in tremor following surgery. However, QMA correlated with disability measures and corresponded better to patient and examiner assessment of surgical results. The disability scales used were insensitive to functional improvements that may follow surgery. The box and blocks test clearly separated three patients who had excellent results from three who had poor results. Baseline QMA values predicted improvement on the box and blocks test.

CONCLUSIONS

1) QMA is a reliable, objective and valid measure of MS tremor that could be used in a clinical trial. 2) The box and blocks test can detect the improvement in prehensile function that follows surgery, but standard disability scales are poorly responsive to this change. 3) Preoperative QMA values may predict which patients are most amenable to functional improvement after surgery.

[Thymidine phosphorylase expression in hepatic metastasis from colorectal carcinoma]

Thymidine phosphorylase (dThdPase) is identical to platelet-derived endothelial cell growth factor (PD-ECGF), and has angiogenic activity. It has been reported that a higher level of dThdPase activity is associated with an unfavorable patient prognosis. The activity of dThdPase was investigated in 15 patients who underwent hepatectomy for hepatic metastasis from colorectal carcinoma, and an assessment was made as to whether its expression was correlated with the prognosis. The dThdPase activity was significantly higher in the patients with extrahepatic metastasis after hepatectomy (n = 5) than in those without extrahepatic metastasis (n = 10) (168.2 +/- 50.8 vs 95.1 +/- 35.2 Unit/mg prot., p < 0.05). This dThdPase activity could be a significant prognostic indicator, and was useful in predicting the extrahepatic recurrence after hepatectomy for hepatic metastasis from colorectal carcinoma.

Increased Fas antigen in uremia accelerates adhesion of mononuclear cells to endothelial and sinovial cells via stimulated hyaluronan production

We examined influences of increased soluble Fas (sFas) and hyaluronan in uremia on apoptosis and peripheral blood mononuclear cell (MNC) adhesiveness. Synovocytes, human umbilical cord endothelial cells (HUVEC), human coronary artery smooth muscle cells (CASMC), and MNC were prepared in this study. In cultures of synovocytes, HUVEC, and CASMC, sFas or high molecular hyaluronan was added to media at medium change. After 1 day, Fas-positive cells were calculated by fluorescence-activated cell sorting. Uremic level of sFas enhanced Fas-positive cells in all cell lines (P < 0.01) not in CASMC. On the contrary, hyaluronan inhibited Fas expression in all cell lines (P < 0.05). In culture with uremic serum, Fas were induced in all cell lines. At this time, the hyaluronan levels of the supernatant were measured and hyaluronan production was estimated. In contrast to the results using sFas supplement, hyaluronan production was increased in culture with sFas and uremic sera. MNC adhesiveness was increased in synovocytes and HUVEC lines by adding hyaluronan or sFas. Higher adherent cell numbers were recognized when both sFas and hyaluronan were added to the media. A most remarkable increase in cell numbers was observed in uremic MNC suspension as compared with that of MNC from healthy subjects. In conclusion, these results indicate that increased sFas in uremia stimulates apoptosis and hyaluronan production. Both sFas and hyaluronan are responsible for accelerated MNC adhesiveness in uremia.