[Difficulty in using RP, PL, and EW factors in the Japanese classification of pancreatic carcinoma]

The classification of pancreatic carcinoma by the Japan Pancreas Society reflects the prognosis of each stage better than does the TMN classification. On the other hand, there are too many factors to examine in the Japanese system, some of which are difficult to use and have low accuracy in pre- and/or intraoperative diagnosis (RP and PL), and their analysis requires various specimen handling procedures (EW). We propose that: 1) a simple, easy decision flow chart be established for ew and 2) EW/ew be designated as (-) or (+) and for EW/ew (+) cases other factors (ly, v, pl, and direct tumor invasion) be added (for example, ew (+)-pl).

Long-term postoperative survival of a gastric cancer patient with numerous para-aortic lymph node metastases

A56-year-old man with advanced gastric cancer was referred to our hospital. Preoperative abdominal computed tomography revealed numerous enlarged lymph nodes, including the lymph nodes of the paraaortic region. The patient underwent total gastralectomy, splenectomy, left-adrenalectomy and resection of the body and tail of the pancreas by Appleby's method, along with paraaortic lymph node dissection. Microscopic examination revealed that the tumor was a solid type, poorly differentiated adenocarcinoma, which displayed invasion of the serosal surface. There were apparently many lymph node metastases. We identified 31 cancer-positive paraaortic nodes, while the total number of lymph node metastases was 81. It was not possible to administer sufficient postoperative adjuvant chemotherapy, as the patient experienced postoperative complications, including pancreatic fistula and watery diarrhea. Despite the lack of sufficient chemotherapy, the patient has subsequently remained disease-free for 9 years and 3 months, and continues to visit our hospital as an outpatient. In conclusion, we wish to emphasize the need for a critical application of paraaortic lymph node dissection as one modality of multidisciplinary treatment in patients with advanced gastric cancer in whom paraaortic lymph node metastasis is strongly suspected preoperatively.

Activation of Raf-1 during experimental gastric ulcer healing is Ras-mediated and protein kinase C-independent

Our previous study demonstrated increases in epidermal growth factor receptor (EGF-R) phosphorylation and receptor tyrosine kinase and extracellular signal-regulated kinase (ERK1 and ERK2) activities in the ulcer margin of experimental gastric ulcer during healing. However, the intermediate steps linking activated receptor tyrosine kinase to ERKs during ulcer healing are as yet unknown. Raf-1 is upstream of mitogen-activated protein kinases (MAPK/ERK) and can be activated by Ras-dependent and/or Ras-independent mechanisms. Therefore, we studied Raf-1 activity, its potential activators protein kinase C (PKC) and Ras, and expression and associations of adapter proteins Shc, Grb2, and Sos during experimental gastric ulcer healing. To investigate if Raf-1-ERK activation is attributable to the epithelial component of ulcer margins, we studied the effect of EGF on PKC, Ras, and ERK activities in a rat gastric epithelial cell line (RGM1). Our results demonstrate that gastric ulceration significantly increases Raf-1 kinase activity, Grb2 and Ras protein, and Shc-Grb2 and Grb2-Sos complex levels. In contrast, PKC activity and protein level were significantly decreased in the ulcer margins. In RGM1 cells, EGF significantly increased Ras and ERK2 activities without affecting PKC activity. These findings indicate that Raf-1 activation during gastric ulcer healing is Ras mediated, involves Shc-Grb2-Sos, and is PKC-independent.

Ethanol injury triggers activation of adrenomedullin and its receptor genes in gastric mucosa

Adrenomedullin (AM) is a potent vasodilatory peptide, which is present in the stomach. However, its precise function in the gastric mucosa is unknown. The expression and localization of AM and its receptor in gastric mucosa injured by ethanol also have not been explored, forming the basis for this study. Gastric samples of rats were obtained at 0 and 8 hr and 1, 2, and 4 days after intragastric administration of 100% ethanol. By RT-PCR, AM mRNA expression in gastric mucosa at 8 and 24 hr following ethanol injury was increased by 2-fold and by 2.5-fold (both P<0.01), respectively, and returned to normal at two days. AM receptor mRNA expression was increased by 2.7-fold, 2.3-fold, and 2.4-fold at 8, 24, and 48 hr, respectively (all P<0.01), and returned to normal at four days. By in situ hybridization, AM and AM receptor mRNAs were present in normal gastric mucosa and up-regulated in gastric mucosa following ethanol injury. The immunohistochemical signal for AM was significantly increased in the mucosa bordering erosion sites. We conclude that ethanol injury up-regulates the expression of both AM and AM receptor in gastric mucosa.

Reduced adrenomedullin expression in gastric mucosa of portal hypertensive rats after ethanol-induced injury

OBJECTIVE

To determine the expression and localization of adrenomedullin (AM) and its receptor (AM-R) in portal hypertensive (PHT) gastric mucosa after intragastric ethanol administration.

SUMMARY BACKGROUND DATA

The repair of gastric mucosal injury requires reestablishment of the microvascular network. The authors previously demonstrated impaired angiogenesis of PHT gastric mucosa after ethanol-induced injury. Because AM, a potent vasodilatory peptide, is also a novel growth and angiogenic factor, the authors hypothesized that AM is involved in the impaired repair of PHT gastric mucosa and its microvasculature after damage.

METHODS

Either PHT or sham-operated rats received intragastrically 100% ethanol, and the stomachs were excised at 1, 6, and 24 hours later. Expression and localization of AM and AM-R mRNA were examined by competitive reverse transcription-polymerase chain reaction and in situ hybridization. AM protein expression was examined by Western blot analysis.

RESULTS

One hour after ethanol administration, AM mRNA expression in PHT gastric mucosa was significantly decreased by 81%, especially in the superficial mucosa, compared with the gastric mucosa in sham-operated rats. The significant decrease lasted for 24 hours. AM protein expression was significantly decreased by 43% compared with the sham-operated gastric mucosa. Although AM-R mRNA expression in both groups was significantly increased 1 hour after ethanol administration and lasted for 24 hours compared with baseline, there were no differences between the two groups.

CONCLUSIONS

The expression of AM in PHT gastric mucosa after ethanol-induced injury is significantly decreased compared with controls. This finding could explain one mechanism for the impaired angiogenesis after injury of PHT gastric mucosa.

A selective cyclo-oxygenase-2 inhibitor, NS-398, may improve portal hypertension without inducing gastric mucosal injury

BACKGROUND AND AIMS

Prostacyclin has been shown to play a role in hyperdynamic circulation in portal hypertension. Recently, a new subtype of cyclo-oxygenase (COX), COX-2, which acts as an inducible synthase in response to various stimuli. The aim of this study was to investigate whether COX-2 contributes to portal hypertension and whether a COX-2 blockade induces the same sort of gastric mucosal injury as a COX-1 blockade.

METHODS

Portal hypertension (PHT) in rats was induced by a two-step ligation of the portal vein. The mean arterial pressure (MAP), portal pressure (PP), visceral blood flow volume (BFV), serum levels of 6-keto-prostaglandin F1alpha (PGF1alpha), thromboxane B2 (TXB2) and gastric mucosal injury induced by pure ethanol were all measured in PHT rats receiving different inhibitors (indomethacin, a highly selective COX-1 inhibitor; NS-398, a highly selective COX-2 inhibitor). Control rats treated by a sham operation were also studied.

RESULTS

The NS-398 administration significantly decreased PP to the same extent as indomethacin at doses of 5 and 10 mg/kg in PHT rats after a 60 min administration, while neither inhibitor affected the control rats. Both inhibitors significantly increased PP after a 30 min administration in the PHT and control rats at a dose of 5 mg/kg while both inhibitors significantly decreased PP after 60 min administration only in the PHT rats. Portal vein ligation treatment induced a significant increase in PP and BFV of the portal vein, gastric mucosa, oesophageal mucosa and the serum levels of 6-keto-PGF1alpha and TXB2, while portal vein ligation treatment induced a significant decrease in BFV of the liver. Both blockades increased MAP and decreased PP and BFV in the splanchnic area and decreased the serum level of 6-keto-PGF1alpha and TXB2 in the PHT rats, while neither blockade modified any parameters in the control rats, except that indomethacin administration significantly decreased the BFV of the gastric mucosa. Indomethacin administration significantly increased the ulcer index (UI). The NS-398 had no effect on UI in either the PHT or control rats. Only indomethacin significantly increased the number of rats demonstrating gastric mucosal long lesions (> 2 cm) in the PHT rats.

CONCLUSION

In the PHT rats, prostaglandin seemed to contribute to portal hypertension. Both COX blockades reduced PP and BFV of the portal vein and gastric mucosa. NS-398, a selective COX-2 inhibitor, may, therefore, improve portal hypertension without inducing gastric mucosal injury.

Laparoscopic splenectomy for splenic artery aneurysm

Two cases undergoing a laparoscopic splenectomy for the treatment of a splenic artery aneurysm are herein reported. This lesion is relatively rare. Surgical treatment is indicated for such cases since approximately 10% of these aneurysms tend to rupture which thus results in fatal hemorrhaging. Both cases demonstrated aneurysms measuring more than 2 cm in diameter based on the ultrasonography, computed tomography and celiac angiography findings and, as a result, a laparoscopic splenectomy was thus prophylactically performed. This procedure is the preferred technique for high risk patients, such as those with chronic renal failure, as observed in case 1, since patients can be spared the disadvantages of undergoing a laparotomy.

Activation of VEGF and Ras genes in gastric mucosa during angiogenic response to ethanol injury

Our previous studies demonstrated that ethanol injury triggers the angiogenic response in gastric mucosa bordering necrosis. The present study was aimed to determine whether vascular endothelial growth factor (VEGF) (a potent angiogenic peptide selectively acting on endothelial cells) and Ras (a mediator of cell proliferation and a putative regulator of VEGF expression) are involved in gastric angiogenesis after ethanol injury. We studied the angiogenic response and expression of VEGF and Ras in gastric mucosa after ethanol injury. Ethanol damage triggered 1) angiogenesis in the gastric mucosa bordering necrosis, 2) significant increases in VEGF mRNA and protein expression, and 3) significant increases in the expression of Ki-ras mRNA and Ras proteins. Neutralizing anti-VEGF antibody significantly reduced (by greater than threefold) the angiogenic response to ethanol-induced injury. Moreover, mevastatin, an inhibitor of Ras activation, completely blocked the induction of VEGF expression in cultured primary endothelial cells. Because, in other tissues, VEGF is one of the most potent angiogenic factors and VEGF expression is dependent on Ras, our data indicate that Ras and VEGF are involved in gastric mucosal angiogenesis after ethanol injury.

Characterization of mast cell-committed progenitors present in human umbilical cord blood

Human mast cells are derived from CD34(+) hematopoietic cells present in cord blood, bone marrow, and peripheral blood. However, little is known about the properties of the CD34(+) cells. We demonstrated here that mast cell progenitors that have distinct phenotypes from other hematopoietic cell types are present in cord blood by culturing single, sorted CD34(+) cells in 96-well plates or unsorted cells in methylcellulose. The CD34(+) mast cell-committed progenitors often expressed CD38 and often lacked HLA-DR, whereas CD34(+) erythroid progenitors often expressed both CD38 and HLA-DR and CD34(+) granulocyte-macrophage progenitors often had CD33 and sometimes expressed CD38. We then cultured single cord blood-derived CD34(+)CD38(+) cells under conditions optimal for mast cells and three types of myeloid cells, ie, basophils, eosinophils, and macrophages. Of 1,200 CD34(+)CD38(+) cells, we were able to detect 13 pure mast cell colonies and 52 pure colonies consisting of either one of these three myeloid cell types. We found 17 colonies consisting of two of the three myeloid cell types, whereas only one colony consisted of mast cells and another cell type. These results indicate that human mast cells develop from progenitors that have unique phenotypes and that committed mast cell progenitors develop from multipotent hematopoietic cells through a pathway distinct from myeloid lineages including basophils, which have many similarities to mast cells.

Gastrointestinal mucosal regeneration: role of growth factors

Growth factors and their receptors play important roles in cell proliferation, migration, tissue injury repair and ulcer healing. In gastric mucosa, transforming growth factor alpha (TGF-alpha) and epidermal growth factor (EGF) by activating their common receptor, control cell proliferation. TGF-alpha predominantly plays this role under normal conditions and after acute injury, while EGF exerts its actions mainly during healing of chronic ulcers. During regeneration of injured gastric mucosa, these growth factors serve predominantly to restore the epithelial component. Other growth factors, basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) serve to promote restoration of the connective tissue and microvessels (angiogenesis) in injured mucosa. During healing of chronic ulcers, a new epithelial lineage secreting EGF and other growth peptides develops and the majority of cells lining the ulcer margin overexpress the EGF receptor. Activation of the EGF receptor induces dramatic increases in MAP (Erk -1 and -2) kinase activity and phosphorylation levels. Inhibition of this signaling pathway dramatically delays ulcer healing. Granulation connective tissue, which grows under the stimulation of bFGF and VEGF is the major source for regeneration of connective tissue lamina propria and microvessels within the ulcer scar. Other growth factors such as insulin - like growth factor, keratinocyte growth factor, hepatocyte growth factor and trefoil peptides have been implicated in gastrointestinal (gastric ulcers, colitis) regeneration following injury. This paper is intended to provide an overview of the role of growth factors in gastrointestinal mucosal regeneration.

Laparoscopic splenectomy: the latest modern technique

BACKGROUND/AIMS

Recent advances in technical instruments have resulted in increased safety and simplicity in laparoscopic surgery. The purpose of this article is to introduce our latest operative techniques for laparoscopic splenectomy.

METHODOLOGY

The patient is placed in the right semidecubitus position and the gastrosplenic ligament including the short gastric vessels was performed by using an ultrasonically activated scalpel. The splenic artery and vein were resected at the splenic hilum with an autosuture device. The electromechanical morcellator was used to remove the spleen.

RESULTS

The laparoscopic splenectomy was successfully performed in all 74 patients from 1992-1997. There was no deaths related to the operation. Conversion to open surgery with a small incision of 5 cm was required in one patient with advanced liver cirrhosis and portal hypertension and 45 patients with portal hypertension.

CONCLUSIONS

A laparoscopic splenectomy is considered to be a safe and feasable modality for the treatment for hematologic disorders of both the spleen and other benign tumors.

Systemic effects of ethanolamine oleate in analbuminemic rats

BACKGROUND/AIMS

The present study was an attempt to clarify whether only serum albumin inactivates ethanolamine oleate (EO) in vivo and whether EO has an adverse effect on the lung, kidney, and liver in the presence of analbuminemia.

METHODOLOGY

Fifty-five female Nagase Analbuminemia Rats (NAR) and 55 female Sprague-Dawley Rats (SDR) were injected with 5% EO in the left femoral vein. Changes in respiratory, renal, and hepatic function and the extent of hemolysis following the injection of the EO were examined.

RESULTS

In both groups, a transient but significant increase was seen in serum hemoglobin at up to 1 hour after injection of EO. No significant changes in PaO2, PaCO2, blood urea nitrogen, or serum creatinine following injection of EO were seen in either group. The total bilirubin significantly increased within 30 min in the SDR group, but this increase was prolonged for 5 days in the NAR group. Glutamic pyruvic transaminase (GPT) increased for 12 hours in the NAR group, while no change was seen in the SDR group.

CONCLUSIONS

These observations suggest that EO may have hepatotoxic effects, that serum albumin may afford protection, and that other humoral substances which inactivate EO, including serum globulin, may be present.

Translocation of MAP (Erk-1 and -2) kinases to cell nuclei and activation of c-fos gene during healing of experimental gastric ulcers

We examined localization of extracellular signal regulated kinases (Erk) 1 and 2, and c-fos mRNA expression in normal and ulcerated gastric mucosa in rats at 1, 3 and 7 days after gastric ulcer induction. In normal gastric mucosa immunofluorescence signal for Erk-1 and Erk-2 was detectable in surface epithelial, neck and some glandular cells. In gastric mucosa of the ulcer margin, almost all epithelial cells displayed strong Erk-1 and Erk-2 immunoreactivity in the basolateral membranes and the cytoplasm. In addition 19+/-3% of cells showed nuclear localization of the Erk-1 and -2 signal. The c-fos mRNA expression was increased by 790+/-14% and 220+/-10%, respectively in gastric ulcer at 3 and 7 days after ulcer induction. Since in in vitro models nuclear translocation of Erk-1 and -2 triggers cell proliferation, our finding indicates relevance of this mechanism to gastric ulcer healing.

Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism

BACKGROUND

The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices.

STUDY DESIGN

Laparoscopic gastric devascularization and splenectomy (Hassab's operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n=4) and recurrent rebleeding gastric varices (n=6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints.

RESULTS

The duration of the operation ranged from 200 to 400 minutes (mean+/-standard deviation; 287.5+/-66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5+/-507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0+/-126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 x 10(4)/microL (average, 4.5+/-2.7 x 10(4) microL) and the postoperative count was from 5.9 to 36.0 x 10(4)/microL (average, 21.7+/-11.5 x 10(4) microL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8+/-4.1 months (average, 8 to 20 months).

CONCLUSIONS

The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.

Expression of adrenomedullin in portal hypertensive gastric mucosa of rats

We examined the expression and localization of adrenomedullin (AM) mRNA, AM receptor (AM-R) mRNA and AM protein in normal and portal hypertensive (PHT) rat gastric mucosa. Methods included competitive reverse transcription-polymerase chain reaction (RT/PCR), in situ hybridization and Western blot analysis. Both AM mRNA and AM-R mRNA were strongly expressed not only in normal rat gastric mucosa but also PHT rat gastric mucosa. While total AM and AM-R mRNA abundance was similar in both normal and PHT stomachs, in the superficial mucosa-where major defense mechanisms are located-their expression was significantly reduced in PHT rats by 33% (AM mRNA) and 25% (AM-R mRNA) (both p .0.05). AM protein was also expressed similarly in both normal and PHT gastric mucosa. We conclude that AM and its receptor play a role in regulation of gastric mucosal microcirculation and thus gastric mucosal defense.

Decreased endothelial nitric oxide synthase in gastric mucosa of rats with chronic renal failure

According to recent reports, chronic renal failure (CRF) increases the susceptibility of gastric mucosa to injury. Since nitric oxide plays a major role in gastric mucosal defense and injury, we investigated, in rats with CRF produced by five-sixths nephrectomy and in control rats, the expression of nitric oxide synthase(NOS) in the stomach and measured mucosal and submucosal gastric blood flow. In CRF rats, gastric mucosal blood flow was significantly reduced compared with control rats, whereas submucosal and serosal blood flow was significantly increased. CRF significantly decreased endothelial NOS (eNOS) mRNA abundance by 53% (P < 0.01) and reduced expression of eNOS protein by 42% (P < 0.01) compared with the controls. Enzyme activity of eNOS was significantly reduced in gastric mucosa of CRF rats (P < 0.05). These data are consistent with reduced gastric mucosal blood flow in CRF rats and can explain altered susceptibility of gastric mucosa to injury in CRF rats.

Tumor necrosis factor alpha regulates nitric oxide synthase expression in portal hypertensive gastric mucosa of rats

Anti-tumor necrosis factor alpha (TNF-alpha) treatment decreases nitric oxide (NO) synthesis and ameliorates the hyperdynamic circulation in portal hypertensive rats. We have recently demonstrated that nitric oxide synthase isoform 3 (NOS3) is overexpressed in portal hypertensive gastric mucosa and that resultant NO overproduction probably is responsible for the increased susceptibility of the mucosa to damage. In the present study, we examined whether TNF-alpha is overexpressed in portal hypertensive gastric mucosa and whether anti-TNF-alpha treatment affects gastric NOS3 messenger RNA (mRNA) and protein expression. We examined plasma concentrations of TNF-alpha and its protein expression in gastric specimens from portal hypertensive and sham-operated rats using Western blotting and immunohistochemistry. We also measured gastric mucosal blood flow, gastric expression of NOS3 mRNA and protein, and NOS3 enzyme activity in rats with and without TNF-alpha-neutralizing antibody treatment. The TNF-alpha protein levels in portal hypertensive stomachs were significantly increased by 57% compared with levels in sham-operated controls. TNF-alpha antibody treatment normalized gastric mucosal blood flow in portal hypertensive stomachs and significantly reversed overexpression of gastric NOS3 mRNA, protein, and its enzyme activity in portal hypertensive rats by 48%, 45%, and 33%, respectively. These results suggest that TNF-alpha may regulate NOS3 expression in the portal hypertensive stomach and that anti-TNF-alpha treatment may ameliorate the pathophysiological abnormalities of portal hypertensive gastric mucosa.

Chemosensitivity of human pancreatic cancer cell lines serially transplanted in nude mouse

BACKGROUND

Pancreatic cancer frequently recurs or metastasizes even after apparently curative surgical resection. Because of a low, five-year survival rate after radical surgery, multi-modal adjuvant treatment must be used to prevent recurrence of systemic spread.

MATERIALS AND METHODS

The effectiveness of the experimental cancer chemotherapy of mitomycin C (MMC), cisplatin (DDP), doxorubicin (DXR) and 5-fluorouracil (5-FU) was evaluated in three human pancreatic cancer xenografts serially transplanted in nude mice.

RESULTS

When the effects of these agents were evaluated by 3-(4,5-dimethylthiazol-2yl)-2,5-diphenyl-2H tetrazolium bromide (MTT) assay, only MMC and DDP were effective on PAN-3-JCK, a poorly differentiated adenocarcinoma. When PAN-12-JCK, a moderately differentiated adenocarcinoma, was used an in vitro assessment of combined chemotherapy of MMC and DDP, a synergistic combination effect was observed. Three xenografts were transplanted subcutaneously into nude mice and the maximum tolerated doses of these agents were administered intraperitoneally or intravenously (DXR). MMC showed positive antitumor activity on PAN-3-JCK and PAN-12-JCK, and 5-FU was effective on PAN-12-JCK.

CONCLUSIONS

These results reflect the low sensitivity of clinical pancreatic cancer to conventionally available antitumor agents, and suggest the possible synergistic combination antitumor activity of MMC and DDP.

Cold stimulation test and histamine release in primary acquired cold urticaria

The patient was a 10-year-old boy who complained of urticaria upon exposure to cold air and after swimming in the pool. He also had seasonal asthma and wheezing after strenuous activities. To determine whether he had primary acquired cold urticaria, we performed a cold stimulation test twice. We likewise wanted to know whether a difference in response with regard to histamine release existed between blood samples taken from the challenged and the unchallenged sites. We obtained blood samples for histamine release initially at the site opposite the challenged forearm, and then on the same side on two separate occasions. We noted the appearance of constitutional signs and symptoms and correlated the time of their appearance with the result of histamine levels. The patient complained of pruritus and wheals appeared at the 5 minute in both tests. Results of plasma histamine release in the two measurements showed the highest releasability at 15 min. Our findings revealed that histamine is released systemically in response to cold stimulation regardless of the site where the blood sample was obtained.

Perforated diverticulum of the transverse colon

We report a case of perforated diverticulitis of the transverse colon. The preoperative diagnosis of perforated appendicitis was made on the basis of findings of both ultrasonography and CT. At surgery, an inflammatory mass resembling carcinoma was found in the transverse colon, and segmental resection was then performed. Diverticulitis of the transverse colon is rare, and there have been few reports in the English-language medical literature. This report describes a true diverticulum of the transverse colon that presented as acute diverticulitis.

Mitomycin C and cisplatin increase survival in a human pancreatic cancer metastatic model

Pancreatic cancer is one of the most intractable of all human cancers. We have previously developed a patient-like model of human pancreatic cancer by surgical orthotopic implantation (SOI). After SOI of the human tumor xenograft PAN-12-JCK into the tail of the nude mouse pancreas, mitomycin C (MMC) and cisplatin (DDP) were administered intraperitoneally at a dose of 4 and 6 mg/kg, respectively, on day-7. The mice were observed for 95 days. There was a statistically significant increase in disease-free and overall survival rates in the MMC- and MMC + DDP-treated groups. Local tumor growth was eliminated only in the group treated with MMC + DDP. Hepatic metastasis and peritoneal disseminations were completely inhibited by MMC but not DDP. This study demonstrates the usefulness of the SOI model of pancreatic cancer to study the differential efficacy of agents affecting primary tumor growth metastasis and survival, thus presenting an opportunity for the discovery of new agents for this highly resistant cancer.

[Surgical treatment for the upper and middle bile duct cancer]

A total of 45 patients with bile duct cancer, 13 patients predominantly with Bs bile duct cancer, 14 with Bm cancer, and 18 with Bim cancer, were chosen from 104 patients with bile duct cancer, not including gallbladder cancer or cancer of the papilla of Vater, who underwent surgical resection in our department between Sep 1974 and Nov 1996, and were evaluated with respect to surgical procedure, pathological findings, and outcome. The patients with Bs cancer were compared with 39 patients with cancer of the main hepatic duct junction who underwent hepatectomy, and the patients with Bim cancer were compared with another 20 patients with Bi bile duct cancer. The effect of combined resection of the vessels and hepatopancreatoduodectomy (HPD) on patients with advanced cancer was assessed. To attain a hw (-) margin, hepatectomy should be performed in patients with Bs bile duct cancer, unless localized. Bm and Bim bile duct cancer patients with negative margins had a relatively favorable outcome irrespective of surgical procedure. Resection of the vessels and HPD were useful in improving the resectability rate, but not in attaining longer survival.

Repeated injection sclerotherapy is preferable to combined therapy with variceal ligation to avoid recurrence of esophageal varices:--a prospective randomized trial

BACKGROUND/AIMS

The aim of this prospective randomized study is to investigate the safety, efficacy, complications and recurrence of varices after repeated endoscopic injection sclerotherapy (EIS), and combined therapy of endoscopic variceal ligation (EVL) and repeated EIS, for the treatment of esophageal varices.

MATERIAL AND METHODS

Sixty-one consecutively treated cirrhotic patients were examined. Thirty patients were placed randomly in the EIS group and the other 31 in the EVL+EIS group. For the EIS group, EIS was repeated at weekly intervals using 5% ethanol- amine oleate (EO) until all the varices had been eradicated. In the EVL+EIS group, EVL was done at the initial session, then EIS was repeated at weekly intervals from one week after EVL.

RESULTS

There was no significant difference between the EIS and EVL+EIS groups with regard to the rate of eradication (80.0% vs 74.2%), the total number of treatment (4.1 +/- 0.8 sessions of EIS vs EVL and 3.0 +/- 0.5 sessions of EIS) and hospitalization time (4.9 +/- 1.6 vs 4.4 +/- 1.0 weeks). The total volume of EO used for the EVL+EIS group was significantly less than that for the EIS group (26.3 +/- 8.3 vs 47.1 +/- 11.6 ml, p < 0.01) and the incidence of minor complications at the initial treatment in the EVL+EIS group was significantly (p < 0.01) lower than that in the EIS group. Follow-up endoscopy showed that the rate of attaining circumferential ulceration and the following fibrotic scarring in the EVL+EIS group was significantly lower than that in the EIS group (21.7% vs 91.7%, p < 0.01) and that the incidence of variceal recurrence was significantly higher in the EVL+EIS group than in the EIS group (39.1% vs 8.3%, p < 0.05) over a median follow-up of 12.3 months.

CONCLUSION

The combined therapy of EVL and repeated EIS seems favorable from the viewpoint of fewer complications, but repeated EIS is preferable to combined therapy to avoid recurrence of the esophageal varices.

Eradication of large gastric varices by sclerotherapy combined with percutaneous transhepatic obliteration

BACKGROUND/AIMS

The long-term results of a combination therapy of sclerotherapy with percutaneous transhepatic obliteration (PTO) was reviewed in 37 patients with large gastric varices. The study suggests that sclerotherapy combined with PTO can safely and effectively eradicate large gastric varices as an alternative approach to surgery. Complete eradication has also been shown to prevent the recurrence of gastric varices.

MATERIAL AND METHODS

The long-term results of a combination therapy of sclerotherapy with PTO was reviewed in 37 patients with large gastric varices.

RESULTS

Complete eradication of the gastric varices was obtained in 26 patients (70.3%). There was no recurrence of the varices in whom complete eradication had been obtained, but in 11 patients with incomplete eradication gastric varices recurred during the mean follow-up period of 37.5 months. Bleeding occurred in 4 after the treatment and one patient died of massive bleeding from the recurrent gastric varices. There were no major complications with the procedure except for one who had a peripheral pulmonary arterial embolization as a result of a steel coil used for the PTO.

CONCLUSION

This study suggests that sclerotherapy combined with PTO can effectively and safely eradicate large gastric varices and is an alternative approach to surgery for treating patients with gastric varices. It is also shown that complete eradication leads to a prevention of recurrence of gastric varices.