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

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mucin-producing neoplasms of the pancreas. Intraductal papillary and mucinous cystic neoplasms

OBJECTIVE

The authors compared the clinicopathologic features of the intraductal papillary and mucinous cystic neoplasms of the pancreas and clarified the similarities as well as the differences between these two tumors. In addition, they reviewed 104 cases of the intraductal papillary neoplasm in the English literature to provide a global view of the condition.

SUMMARY BACKGROUND DATA

Controversy about the term and clinicopathologic entity still exist regarding intraductal papillary neoplasm of the pancreas. Currently, with only a few cases of this rare tumor in each report, there continues to be inadequate knowledge available regarding the tumor and methods by which to distinguish it from the mucinous cystic neoplasm.

METHODS

Multiple demographic and clinicopathologic parameters were compared between intraductal papillary and mucinous cystic neoplasms identified from 1985 to 1994 in the Medical Center, Veterans General Hospital--Taipei.

RESULTS

There were four intraductal papillary adenocarcinomas and 10 mucinous cystic neoplasms (8 cystadenocarcinoma and 2 cystadenoma). The sex, age, size, tumor location, and pathologic findings were quite different between these two groups. Clinical presentation of intraductal papillary adenocarcinomas were similar to those of periampullary tumors. The most common presentations of mucinous cystic neoplasm were epigastric pain and abdominal mass. All four intraductal papillary adenocarcinoma showed mucin secretion from a patulous orifice of the ampulla of Vater and filling defects in the dilated main pancreatic duct by endoscopic retrograde cholangiopancreatography (ERCP). Accurate preoperative diagnosis was not easy regarding either group. Serum carbohydrate antigen 19-9 (CA 19-9) was more useful for diagnosis in both groups.

CONCLUSIONS

The intraductal papillary neoplasm is a unique clinical entity but not a variant of mucinous cystic neoplasm in terms of sex, age, size, tumor location, or pathologic picture. The pathognomonic findings of ERCP should lead to diagnosis. Very aggressive surgical procedures should be attempted for these two mucin-producing neoplasms with low-grade malignancy.

Piperacillin/tazobactam in comparison with clindamycin plus gentamicin in the treatment of intra-abdominal infections

BACKGROUND

Concerned about the inactivation of piperacillin by beta-lactamase and the risk of aminoglycoside-induced nephrotoxicity and clindamycin-induced enterocolitis, we conducted the following phase III clinical trial.

METHODS

Between November 1991 and March 1993, 77 surgical patients with intraabdominal infections were enrolled and randomly assigned in a 3:2 ratio to receive either piperacillin/tazobactam or clindamycin plus gentamicin to compare safety, tolerance and efficacy between both two treatment groups.

RESULTS

There were 76 clinically and 50 bacteriologically evaluable patients with 80 isolated pathogens. The demographic data were comparable in both groups. There was no statistically significant difference of clinical response at any time-point of treatment, with 97.8% favorable clinical response rate in piperacillin tazobactam group and 96.6% in clindamycin plus gentamicin group at endpoint. The bacteriological eradication rates were similar, with 97.7% in piperacillin/tazobactam group and 94.4% in clindamycin plus gentamicin group at pathogen level, and 96.7% in piperacillin/tazobactam group and 95.0% in clindamycin plus gentamicin group at patient level. By susceptibility tests, only 3 (4%) isolated pathogens were resistant to piperacillin/tazobactam, which was much superior to the use of piperacillin, clindamycin or gentamicin alone in antimicrobial activity. The piperacillin tazobactam-related adverse experiences included 1 (2.1%) urticaria and 2 (4.3%) diarrhea. However, there were no significant differences in the adverse experiences between these two groups.

CONCLUSIONS

This study has demonstrated that piperacillin/tazobactam is comparable with clindamycin plus gentamicin in efficacy, safety and tolerance in the treatment of surgical patients with intra-abdominal infections. The combination of piperacillin/tazobactam could potentially be the treatment of choice in adjunt to surgical management in intra-abdominal infection.

Is pancreatoduodenectomy justified for periampullary cancers with regional lymph node involvement?

Justification of pancreatoduodenectomy for highly malignant periampullary cancers with regional lymph node involvement is questioned. Attempting to clarify the therapeutic dilemma, we compared the prognoses of resectable periampullary cancers with and without lymph node involvement, as well as unresectable cancers with lymph node involvement. The medical records of surgical patients with periampullary adenocarcinoma were reviewed. We compared the survival times of resectable cancers with (resectable TanyN1M0) and without (resectable TanyN0M0) regional lymph node involvement, and the survival times of resectable cancers with lymph node involvement (resectable TanyN1M0) and unresectable cancers with lymph node involvement (unresectable TanyN1M0). There were 138 resectable and 115 unresectable periampullary cancers including 117 cancers of the pancreatic head, 117 cancers of ampulla of Vater, 7 cancers of duodenum, and 12 cancers of distal common bile duct. The prognosis was very poor in cancer of the pancreatic head. Neither resectability nor status of lymph node involvement could influence the survival time of the cancer of pancreatic head. In resectable non-pancreatic periampullary cancers, the prognosis was significantly better in the group without lymph node involvement. However, once the lymph node was involved, the outcomes were the same in the resectable and unresectable groups. Although pancreatoduodenectomy does not seem to be justified for periampullary cancers with regional lymph node involvement, this procedure should be considered for periampullary cancers without nodal involvement.

Complications of continuous ambulatory peritoneal dialysis: one surgeon's experience with 668 patient-month follow-up

BACKGROUND

The technique of continuous ambulatory peritoneal dialysis (CAPD) catheterization is critical to patient success. To clarify how important a surgeon's experience to CAPD is, the experience exclusively from a single surgeon was presented and compared with those from a group of surgeons. The roles of intraoperative fluoroscopy and laparoscopy in CAPD catheterization and the rescue of tube migration in the authors' experience would also be introduced.

METHODS

Fifty-five patients followed for a total of 668 patient-months between July 1990 and July 1993 were included for analysis. All of the catheterization procedures were done by one surgeon.

RESULTS

The overall complication rate was 56%. Twenty-two percent of the patients had peritonitis, with an incidence of 0.56/patient-year, and 25% of the patients had exit-site infection, with an incidence of 0.36/patient-year. Tube migration occurred in two patients (4%). There was no dialysate leakage or incisional hernia. These incidences were much lower than previous reports by groups of surgeons. Laparoscopy successfully rescued a migrated tube. The cumulative 1-year, 2-year and 3-year catheter survival rates were 81%, 75% and 63% respectively. The previous abdominal operation, catheter type and catheterization site were not the prognostic factors of catheter survival.

CONCLUSIONS

Based on this favorable outcomes, an experienced CAPD-surgeon may be one of the factors in minimizing the complications and improving the catheter survival in CAPD. Intraoperative fluoroscopy for every catheterization procedure and laparoscopy for the migrated or dysfunctional tube are highly recommended.

Discrete Fourier preprocessing transforms for the binary phase-only filter

Two useful discrete Fourier preprocessing transforms (DFPTs), say, class 1 and class 2, are applied to the binary phase-only filter. The class-1 DFPT is very close to the discrete Fourier transform (DFT); therefore it preserves the properties similar to those for the DFT. The Class-2 DFPT's are location sensitive and are able to recognize the partial-shape-like input pattern that is the partial set of the pattern in the filter. The Class-2 DFPT's generate a delta-function-like correlation peak whose intensity is larger than that obtained by the DFT. These are different from the DFT-based binary phase-only filter. The elements of the DFPT's are very simple, containing only ±1 and 0; some even contain sparse ±1 values and plenty of zeros. Therefore the DFPT's are suitable for either optical or electrical implementation.

Pseudomyxoma peritonei: does a true mucolytic agent exist? In vitro and in vivo studies

Reproducibility of the so-called "mucolytic effect" of the 2%-10% dextrose-water solution is questioned. To test the mucolytic effect of 5% and 10% dextrose-water solutions and to determine what could be a true mucolytic agent, in vitro and in vivo studies were undertaken in two proven pseudomyxoma peritonei cases. In vitro study: Immediately after the mucin jelly was taken out of the peritoneal cavity, the jelly was immersed in various 40 cc solutions including: 1) 5% dextrose-water; 2) 10% dextrose-water; 3) normal saline; 4) lactated Ringer; 5) distilled water. The mucolytic effects of these solutions were observed once every hour after vigorous mixing. In vivo study: After completion of the operation, the peritoneal cavity was repeatedly irrigated with massive warm 5% dextrose-water and normal saline solutions in an attempt to dissolve the residual mucin cake and jelly. Neither 5% and 10% dextrose-water solution nor control solutions of normal saline, lactated Ringer, and distilled water could dissolve the mucin jelly in test tubes at 0, 1, 2, and 3 hours. The "claimed" mucolytic agent, 5% dextrose-water solution could not facilitate the removal of both mucin jelly and cake in the peritoneal cavity. The 5% dextrose-water solution was not superior to the normal saline solution in terms of mucolytic effect. In the present study, a true mucolytic agent does not exist. Currently, multiple laparotomy for aggressive cytoreduction remains the treatment of choice for pseudomyxoma peritonei.

Anastomotic leakage following pancreaticoduodenectomy

BACKGROUND

Since Whipple's successful resection of the head of the pancreas and duodenum in 1935, pancreaticoduodenectomy has become a standard operation for periampullary malignancies. Although the operative mortality has decreased dramatically in the recent years, it continues to be associated with high morbidity; with anastomotic leakage remaining a major problem.

METHODS

One hundred and seventy-six pancreaticoduodenectomies performed for periampullary lesions during the past 27 years were reviewed. These included 171 Whipple operations, 4 total pancreatectomies and 1 pylorus-preserving pancreaticoduodenectomy. Among them, 40 cases were complicated with anastomotic leakage following pancreaticoduodenectomy. Their management strategy and outcome were reevaluated. Furthermore, the factors suggested to affect pancreaticojejunostomy leakage were also analyzed.

RESULTS

The overall operative mortality was 15.3%, which decreased to 6.7% in recent two years. However, a high complication rate of 50% remained. Among the complications of the whole series (46.6%), anastomotic leakage accounted for 22.7% (40/176). Leakage occurred in 28 pancreaticojejunostomies (16.3%), 9 hepaticojejunostomies (5.1%) and 6 gastrojejunostomies (3.4%). Twelve patients required reoperation for ongoing sepsis or bleeding. This experience disclosed that in most cases hepaticojejunostomy leakage (8/9) could be successfully managed without operation. While three of the six gastrojejunostomy leaks survived after conservative treatment, two of the remaining three patients operated died of sepsis. Among cases with pancreaticojejunostomy leakage, 12 survived after conservative treatment, whereas 6 died of sepsis. Among 10 operated patients, only 3 patients survived. Earlier reexploration for uncontrolled leakage, probably within the first eight postoperative days, seemed to be the only chance for life saving. As far as the risk factors of pancreaticojejunostomy leakage are concerned, there seemed to exert no significant influence in terms of intraoperative blood loss, type and sequence of anastomosis as well as pancreatic stenting. The only clue that may affect the surgical outcome is technical; more experienced (> or = 10 Whipple operations) surgeons tended to render less morbidity and mortality.

CONCLUSIONS

The retrospective analysis of our experience in pancreaticoduodenectomy discloses a trend toward decreased mortality rates in the recent years but operative complications remain high. Among the possible complications, anastomotic leakage is still a troublesome concern. Although conservative treatment can benefit most patients, earlier reexploration for uncontrolled sepsis should be considered. If a good result is anticipated, this complicated procedure should only be performed by an experienced surgeon.

Intraductal mucin-hypersecreting papillary adenocarcinoma of the pancreas: a case report

A 68-year-old male was admitted with jaundice and abdominal fullness. Abdominal ultrasonography and computed tomography (CT) scan showed a diffusely dilated main pancreatic duct (MPD) with microcystic lesions over the pancreatic head and dilatation of the biliary tract. Duodenoscopy revealed mucin secretion at the orifice of the papilla of Vater. Findings of endoscopic retrograde cholangiopancreatography (ERCP) were compatible with a mucinous tumor of pancreas invading the common bile duct. The patient was treated with a modified Whipple's operation. Pathological diagnosis was papillomatosis with papillary adenocarcinoma of the pancreas.

Comparison of resectable and unresectable periampullary carcinomas

Two hundred and fifty-eight patients with pathologically proved periampullary carcinomas who underwent surgical treatment between the years 1965 and 1992 were evaluated. Comparison was carried out between the resectable and unresectable groups. Carcinoma of the pancreatic head occurred in less than one-half (47 percent) of the patients, and only 23 percent were resectable. In contrast, carcinoma of the ampulla of Vater had a similar rate of occurrence, but a much higher resectable rate (86 percent). Thus, carcinoma of the pancreatic head was the minor group (19 percent) in the resectable patients we studied. The main clinical presentations and durations of symptoms before diagnosis did not differ in the resectable and unresectable groups, so it was impossible to predict the resectability by symptoms. Incidences of diabetes mellitus and diarrhea increased twofold in the unresectable group. Preoperative biopsy was difficult to perform for those with carcinoma of the pancreatic head. Comparing pancreatoduodenectomy and palliative operation, pancreatoduodenectomy resulted in a higher complication rate (43 versus 13 percent), a higher surgical mortality rate (17 versus 9 percent) and a longer hospitalization period (31 versus 20 days), but there was no statistical difference in the median survival time between the resectable and unresectable carcinomas of the pancreatic head (seven and one-half versus five months). Most of the patients (81 percent in the resectable group and 70 percent in the unresectable group) we studied died of cachexia with tumor recurrence. Although the advantage of pancreatoduodenectomy for resectable carcinoma of the pancreatic head was questioned, we still recommend this procedure for all periampullary carcinomas to avoid depriving the occasional patients with pancreatic carcinomas of long term survival and forfeiting the chance of cure for some misdiagnosed patients with other more favorable periampullary carcinomas.

Comparison of aged and young adult patients with cholelithiasis: a prospective controlled study

BACKGROUND

Surgical operations for gallstones are associated with increased perioperative mortality in the elderly. The presence of pre-existing cardiovascular disease and acute cholangitis might be the cause as found in the literature.

METHODS

From August 1989 to December 1990, twenty-nine patients (Age > or = 70 years) with cholelithiasis undergoing biliary surgery in Veterans General Hospital-Taipei were collected as experimental group. Twenty-nine patients from 62 patients (Age < or = 50 years) with cholelithiasis were selected as control group. The basic data, symptomatology, blood biochemistry, peri-operative complications, mortality and gallstone compositions were analyzed and compared between both groups.

RESULTS

There was a higher male to female ratio (4.8:1) in the aged group. Aged patients had higher incidence of common bile duct stone (11/29 versus 3/29, P < 0.025), while young adult patients had higher incidence of intrahepatic stone (1/29 versus 10/29, P < 0.05). The perioperative morbidity and mortality was higher in the aged group (37.9% and 3.4%) as compared with the young age group (3.4% and 0%, P < 0.005).

CONCLUSIONS

Aged cholelithiatic patients were associated with male preponderance, more common bile duct stones, higher perioperative morbidity and mortality, as compared with the young adult cholelithiatic patients.

DNA ploidy as a major prognostic factor in resectable ampulla of Vater cancers

The archival paraffin-embedded specimens from 63 ampulla of Vater cancers after pancreaticoduodenectomy between 1965 and 1991 were analyzed by flow cytometry. Of the 63 cancers, 31 (49.2%) were diploid DNA cancers and 32 (50.8%) were aneuploid. Patients with diploid DNA cancer had a median survival time of 159.0 months, and patients with aneuploid DNA cancer had 24.0 months. This difference is statistically significant (P = 0.0257). The aneuploid group did have a poorer prognosis than the diploid group. The multivariate analysis demonstrated that DNA ploidy was an independent and very important prognostic factor, even stronger than the stage and lymph node status. There was a tendency toward higher values of S-phase fraction, proliferative index, and total aneuploid DNA fraction in the shorter survival groups, but they were of no statistical significance. These data suggest that DNA ploidy appears to be the most important and the only pre-operative predictor of prognosis in resectable ampulla of Vater cancers since endoscopic biopsy is feasible.

Retroperitoneal cystic lymphangioma in adults

Retroperitoneal lymphangioma is an unusual disease, more customarily reported in infants, only occasionally in adults. This paper reports four cases of histologically-confirmed retroperitoneal cystic lymphangiomas detected in adulthood. All four patients presented with palpable abdominal mass. The diagnostic imaging methods used included abdominal ultrasonogram and CT scan. Correct preoperative diagnosis was made in only one case, but four tumors were totally excised. Biochemical analysis of the lymphangioma content from three of the patients proved protein and fat rich. The CT attenuation numbers of both serous and chylous lymphangioma were similar and near that of water and so were not helpful in differential diagnosis with other cystic lesions with watery density content.

Extracorporeal shock-wave lithotripsy of gallbladder stones

Recently, extracorporeal shock-wave lithotripsy has been introduced as a nonoperative treatment for gallstone disease. To evaluate its applicability in Taiwan, where cholesterol stones are not very frequent, 18 patients out of 194 (9.3%) were selected according to the Munich inclusion criteria to receive this treatment. Chenodeoxycholic acid and ursodeoxycholic acid were administered as adjunctive litholytic therapy. Twenty-eight sessions of lithotripsy were performed, resulting in a 83% satisfactory fragmentation rate (< or = 5 mm). No serious complications were encountered; however, two patients later underwent laparoscopic cholecystectomy. The stones disappeared in four patients after treatment, but recurred in one after discontinuation of oral bile acids. The long-term result was discouraging compared to European reports. A 13% stone-free rate was noticed at one year and 25% was anticipated during the 13-18 month follow-up. It is our conclusion that low eligibility, low cost-effectiveness and poor treatment results will restrict the wide-spread use of this nonoperative therapy in Taiwan.

[The incidence and cause of death following surgery for benign biliary tract disease]

A total of 4056 consecutive patients operated for benign biliary tract disease between January 1983 and June 1990 were reviewed retrospectively. There were 71 in-hospital deaths, representing 1.75% of morality rate. Cholecystectomy was performed in 2275 patients; common bile duct exploration was carried out in 1494, with operative mortality rates of 0.4% and 3.1% respectively. Sepsis was the leading cause of mortality. The second common cause of death was hepatic failure, and respiratory failure the third. Cardiovascular problems accounted for 11.3% of death, which was much lower than reports from western series. Other causes of mortality included hypovolemic shock, anaphylactic shock, epilepsy and hypoglycemia. Of the total 4056 patients, 28.5% underwent emergency surgery. The mortality rate for emergency surgery was 3.6 times higher than for those who underwent elective operations (p less than 0.005) Significantly higher mortality rates were also seen for those aged over 70 years and of male gender. Because the mortality rate of patients who underwent emergency operation due to acute inflammatory or obstructive complications were much higher than that of elective operation group, we suggested early surgical intervention for the symptomatic patients before complications occurred.

Factors affecting morbidity and mortality in biliary tract surgery

Thirty-six clinical and laboratory parameters in 770 consecutive patients undergoing biliary tract surgery over a 3 year period were analyzed in an effort to define the patients at greatest risk. Twelve parameters had a significant correlation with hospital mortality, while multivariate analysis revealed that septic shock, malignant obstruction, serum albumin less than 3.0 gm%, history of hypertension, and plasma urea nitrogen greater than 20 mg% had an independent significance in predicting postoperative mortality. The presence of more than 2 of these risk factors identified a group of patients with an 18% mortality rate. It is for this group of patients that adequate pre-operative preparation such as fluid resuscitation, prophylactic antibiotics, and nutritional support are essential. The controversial preoperative biliary drainage might be only indicated in this group of patients.

Relative prevalence of gallstone diseases in Taiwan. A nationwide cooperative study

For many years, it has been said that Taiwan has the highest relative prevalence of hepatolithiasis among the Asian countries. To confirm this, and to reevaluate the chronological changes regarding gallstone disease in Taiwan, a retrospective nationwide cooperative study was conducted in this country. A total of 17,182 patients from 28 medical centers are included in this survey. A gradual increase during the past 20 years in gallstone prevalence with a concomitant decrease of choledocholithiasis and hepatolithiasis are well demonstrated. Both nutritional and environmental factors are involved in these changes. With respect to hepatolithiasis, Taiwan continues to have the highest prevalence among Asian countries, and 20% may be the average figure for the whole country.

Age-dependent 6kb deletion in human liver mitochondrial DNA

Using PCR technique, restriction mapping and DNA sequencing, we analyzed liver mitochondrial DNA (mtDNA) of 2 stillborn babies and 62 Chinese subjects with non-liver disease from 27 to 86 years old. The results showed an age-dependent 6,063 bp deletion in the liver mtDNA of older subjects. We found a TAACAGAC sequence flanking the 5'-end breakpoint at 7,842 nucleotide position and an imperfect repeat sequence CAACATAC flanking the 3'-end breakpoint at 13,905 nucleotide position. The incidence of the deleted mtDNA was found to increase with age. The deleted mtDNA was not detected in the liver of the stillbirth or blood cells of all the subjects. This is the first account that an age-related 6,063 bp deletion occurs in the liver mtDNA of old humans. The occurrence of this and previously reported 4,977 bp deletions is consistent with our recent finding that liver mitochondrial respiratory functions decline with age and support the hypothesis that continuous accumulation of mtDNA mutations is an important contributor to ageing process in the human.

DNA polymorphisms and deletion analysis of the Duchenne-Becker muscular dystrophy gene in the Chinese

In our investigation of Duchenne muscular dystrophy (DMD)-Becker muscular dystrophy (BMD) gene in the Chinese, the analysis of relevant restriction fragment length polymorphisms (RFLPs) was first made in 30 normal female volunteers to determine their allele and genotype frequencies, and then in 29 DMD-BMD families for informativeness of different combinations of RFLPs in making carrier detection and prenatal diagnosis. We further screened the mutant gene, first with four 5' end intronic, genomic probes (pERT87-1, pERT87-8, pERT87-15, and XJ1.1) which did not show any deletions, and then with all dystrophin cDNA probes which disclosed 13 partial gene deletions out of 29 patients studied (45%). The deletions were nonrandomly distributed, clustering primarily near the central region of the gene. Fifty percent of the deletions involved single exon-containing HindIII restriction fragments, and again most were located near the center of the gene, emphasizing the importance of this area. Some exceptions were found against the previous suggestion that intactness of translational open reading frame resulted in a BMD phenotype. Neither the location of the breakpoints nor the length of the deletions was useful in predicting a certain phenotype. One of our patients had an intriguing pattern of partial gene deletion that lost part of the gene at the 3' end. Carrier determination was attempted by use of dosage analyses or identification of junction fragments which greatly improved accuracy and reliability.

[Breast cystosarcoma phyllodes. A clinicopathologic study of twenty-seven cases]

Twenty-seven cases of cystosarcoma phyllodes (CSP) diagnosed at the Veterans General Hospital, Taipei, were reviewed. Of the twenty-seven cases, seventy per cent were benign, thirty per cent were malignant. One of the malignant cases was transformed from benign one. Of the benign CSPs, one had multifocal lesions and eight were associated with other breast lumps, including fibroadenoma and fibrocystic disease. The mean age of patients with benign CSP was 33 years old, and with malignant CSP, 52 years old. The most frequent location was in upper outer quadrant. We found no positive correlation between tumor size, clinical symptoms, tumor epithelial carcinoembryonic antigen, hypervascularity, mixed mesenchymal components, and benign or malignant CSP. Estrogen and/or progesterone receptors were positive in five benign CSPs detected, but malignant CSP was negative. Variable degrees of epithelial hyperplasia, squamous metaplasia, and apocrine metaplasia, were found in both benign and malignant CSPs. Part of the epithelial component in CSP may be derived from normal breast lobule and duct being trapped into the tumor during tumor infiltration. The mesenchymal differentiation in malignant CSPs include fibrosarcoma, malignant fibrous histiocytoma, liposarcoma, and collision of chondrosarcoma and malignant fibrous histiocytoma. One of the malignant CSPs was found within an old, calcified fibroadenoma. When benign CSP was excised under impression of fibroadenoma, the recurrent rate was 50%. In view of this, we recommend a wide excision for a benign CSP. No axillary lymph node metastasis was detected in malignant CSP, so radical mastectomy was not indicated.

Angiographic arterio-venous shunt and venous thrombosis in the prognosis of hepatoma

Angiograms and clinical data for 249 patients with hepatoma were evaluated, with particular attention paid to the arteriovenous (A-V) shunt and venous thrombosis (including occlusion). There were 43 cases (17.3%) with A-V shunt and 140 cases (56.2%) with venous thrombosis. A statistically significant difference in survival was noted among the unresectable patients with and without these vascular changes. Furthermore, in the resectable patients, presence of venous thrombosis also showed a poor prognosis. A-V shunt did not influence the survival in the unresectable patients with venous thrombosis, and 93.0% of A-V shunt was associated with venous thrombosis. This seemed to imply that these two vascular changes might be the same entity. In the presence of either A-V shunt or venous thrombosis, the survival rate in the surgical group was still better than that of medical groups treated by either transarterial embolization (TAE) or conservative methods. Most of the A-V shunt (81.4%) and venous thrombosis (56.4%) occurred in the diffuse type of hepatoma, and the prognosis for unresectable patients was the worst in this type, with a mean survival time of 3 months. Since A-V shunt and venous thrombosis are factors in poor prognosis and occur frequently, careful preoperative evaluation of these vascular changes is mandatory. However, in patients with localized tumor, coexisting with such vascular involvement, surgical resection is still recommended.

Partial liver resection in the treatment of intra-hepatic duct calculi

From Jan. 1980 to Dec. 1987, 53 patients with symptomatic intrahepatic stones were treated with hepatic resection. The indications for hepatic resections in our patients include: 1) stones located in an anatomic area, 2) extensive liver tissue damage or fibrosis, and 3) strictures of the intrahepatic bile ducts in the involved portion. The stones are located mainly on the left side. Lateral segmentectomy was performed in 31 patients. There was no operative mortality, and fourty-six patients were followed up for an average of 25 months. Results show that 67.4% were symptom free, 23.9% had occasional mild symptoms of cholangitis and 8.7% had severe cholangitis requiring further surgical intervention. The low morbidity and mortality of the operation and the good results reveal that hepatic resection is a safe and rewarding procedure in the treatment of some primary intrahepatic stones.

Serum amylase, isoamylase, and lipase in the acute abdomen. Their diagnostic value for acute pancreatitis

We evaluated the diagnostic value of serum amylase, isoamylase, and lipase for the diagnosis of acute pancreatitis from sera of patients with acute abdominal pain. Comparison was first made in condition A between 32 patients with image-proven pancreatitis and 414 patients with nonpancreatic acute abdomen (the control group), then in condition B, between 62 pancreatitis patients with or without image proof and the control group. We found (a) that patients with image-proven pancreatitis suffer a more severe clinical course than those without; (b) that the sensitivity, positive predictive value, and accuracy in condition B are higher than in condition A at any cutoff level; (c) that none of the enzyme assays is specific at the upper reference limit, but their diagnostic yields are much improved by raising cutoff levels to about three or four times the upper limit; and (d) that at these selected cutoff levels, amylase had a diagnostic value similar to p-isoamylase or lipase in both conditions (sensitivity 84% and 92% for amylase in conditions A and B, respectively; specificity 98% and 98%; positive predictive value 75% and 90%; negative predictive value 99% and 99%; accuracy 91% and 97%). In conclusion, at an appropriately selected cutoff level, amylase can be effectively used as the first-line test and isoamylase or lipase as adjunct tests for acute abdominal conditions.