Acute effects of urinary bladder distention on the coronary circulation in patients with early atherosclerosis

OBJECTIVES

We sought to examine whether distention of the urinary bladder, a physiologic stimulus, could induce impaired coronary circulation in patients with early atherosclerosis.

BACKGROUND

Distention of the urinary bladder reflexively causes an increase in sympathetic activity. The effect of such distention on the coronary circulation in patients with early atherosclerosis remains unknown.

METHODS

To assess the effect of bladder distention on coronary dynamic forces, epicardial and microvascular responses were measured with an intracoronary Doppler flow wire in 40 patients with early atherosclerosis (<50% diameter stenosis). Patients were randomized into two groups according to whether they did not (group 1, n = 20) or did have (group 2, n = 20) pretreatment with an alpha1-adrenergic receptor blocker (oral doxazosin, 2 mg). Coronary flow velocity was monitored by quantitative coronary angiography at baseline, during urinary bladder distention and after intracoronary nitroglycerin injection.

RESULTS

Bladder distention significantly decreased the coronary diameter in the stenotic segments (p<0.001), decreased coronary blood flow (p<0.001) and increased coronary resistance (p<0.001), as compared with baseline values, in group 1 patients. In group 2 patients with bladder distention, the angiographic variables did not show significant changes, as compared with baseline values. No significant differences were noted between the groups in the responses of the angiographic variables after nitroglycerin administration.

CONCLUSIONS

The present study shows, for the first time, that urinary bladder distention caused vasoconstriction of coronary conduit and resistance vessels involved mechanisms related to alpha1 adrenoceptors. Pretreated administration of doxazosin reversed the changes toward baseline. Vasoconstriction during bladder distention can be relieved after nitroglycerin administration, suggesting an unchanged responsiveness of vascular smooth muscle cells to such distention.

Malignant phyllodes tumor of the breast metastasizing to the pancreas: case report

Phyllodes tumor of the breast, or cystosarcoma phyllodes, is an unusual breast tumor. It is usually considered a benign lesion but may have malignant potential. Only a small proportion of malignant phyllodes tumors will metastasize. A phyllodes tumor of the breast metastasizing to the pancreas is rare. This 39-year-old female patient initially presented to us with a 5 x 4 x 2 cm tumor of a right breast. After excision of the tumor, she received another wise excision for a local recurrence of the tumor. Three years had passed when she started having hematemesis and tarry stools intermittently over a period of about one month. Clinical evaluation disclosed a huge mass with an ulcerated and bloody base over the second portion of the duodenum. A pancreatoduodenectomy was then performed. During the postoperative recovery period, a rapidly enlarging tumor of the right breast was noted. She subsequently underwent a total mastectomy of the right breast. Both the duodenal tumor and the breast tumor were found to be malignant phyllodes tumors. The rarity of this kind of patient and presentation is discussed.

Video-assisted endoscopic thyroidectomy

BACKGROUND

Several experimental and clinical reports concerning endoscopic parathyroid surgery have appeared. However, reports concerning minimally invasive surgery for thyroid remains rare. Herein we present a new method, called video-assisted endoscopic thyroidectomy (VAET), for the management of various benign thyroid diseases.

METHODS

In all, 16 consecutive patients who underwent VAET for benign thyroid diseases were retrospectively studied. The study group included nodular hyperplasia in 8 patients, follicular adenoma in 6, and Hurthle's tumor and simple cyst in 1 each. A 2 to 3 cm transverse incision was made on the suprasternal notch. The wound was deepened to expose the underlying trachea from which the plane of the thyroid fascia was accessed directly, and the working space was established with lifting method using conventional instrument. All surgical procedures could be manipulated and monitored under laparoscopy without gas insufflation. The ultrasonically activated scalpel was the principal instrument used for VAET.

RESULTS

All 16 patients underwent VAET successfully without conversion to open thyroidectomy. The surgical procedures included lobectomy in 13 and extirpation in 3. The operation time ranged from 28 minutes to 5 hours (mean 1 hour, 42 minutes). For the 5 most recent cases, lobectomy took an average of 2 hours, whereas extirpation less than 40 minutes. The tumor size ranged from 3.5 cm to 8.0 cm (mean 5.8 cm). There were no surgical complications. All patients but 1 were discharged on postoperative day 2. During follow-up, all patients demonstrated euthyroid function and satisfactory cosmetic results.

CONCLUSIONS

VAET emerges as a promising minimally invasive surgical technique replacing conventional thyroidectomy for benign thyroid diseases in selected cases, with the advantage of satisfactory cosmetic results.

Comparison of simultaneous dobutamine echocardiography and thallium-201 stress-reinjection single-photon emission computed tomography in predicting improvement of chronic myocardial dysfunction after revascularization

Previous studies have shown that ultrasonic integrated backscatter is valuable in characterizing stunned myocardium. Recent investigations have demonstrated that resting cardiac cycle-dependent variation of integrated backscatter closely paralleled the contractile reserve in patients with chronic left ventricular ischemic dysfunction. The purpose of this study was to validate whether ultrasonic tissue characterization (UTC) compared with dobutamine stress echocardiography (DSE) and thallium-201 stress-reinjection single-photon emission computed tomography (Tl-SPECT) could predict reversible myocardial dyssynergy in patients with chronic coronary artery disease. Forty-eight patients with stable coronary artery disease underwent UTC, DSE, and Tl-SPECT simultaneously before successful coronary revascularization and were followed up with echocardiograms at rest >3 months later. Among the 58 investigated segments, the weighted amplitude, a composite parameter derived from the integrated backscatter power curve, was larger for those groups with greater functional recovery (p <0.001). For the persistent akinetic segments, the weighted amplitudes were small with large deviations of the nadir ratios that represented the asynchrony between the intramural contractile events and the global systole. Using the cut-off value 2.0 of the weighted amplitude, the sensitivity and specificity for predicting functional improvement after revascularization were both 82.8% (kappa = 0.66) and comparable to the sensitivity and specificity of DSE and Tl-SPECT. UTC, delineating the myocardial physical state and intramural contraction, can be a novel approach in predicting functional improvement of chronic dyssynergy after revascularization.

Role of coronary angiography in myxoma patients: a 14-year experience in one medical center

Cardiac myxoma is the most common form of primary heart tumor and often treated with surgical resection without a preoperative angiographic examination for fear of potential risk of sudden death. During the last 14 years, 24 of 38 patients with myxoma underwent coronary angiography. Coronary artery disease (CAD) and other abnormalities were found in 5. Our findings indicated that CAD is not uncommon among the myxoma patients, and coronary angiography should be performed preoperatively in all cases.

Common bile duct and pancreatic injury after extracorporeal shock wave lithotripsy for renal stone

Common bile duct and pancreatic injury are rare complications following extracorporeal shock wave lithotripsy. We reported a case of peripancreatic abscess with inflammation change of common bile duct and pancreatic head following extracorporeal shock wave lithotripsy for right renal stone. Its anatomical location and subsequent clinical course suggest it was related to trauma caused by the shock wave. It should be considered a relative contraindication to apply extracorporeal shock wave lithotripsy in cases of right renal stone associated with large gall stones.

Prospective and randomized study of gabexate mesilate for the treatment of severe acute pancreatitis with organ dysfunction

BACKGROUND/AIMS

Exaggerated production of various proteases may account for the late presence of organ dysfunction in acute pancreatitis. This study examined the effects of early administration of gabexate mesilate on the condition of patients with severe acute pancreatitis and organ dysfunctions.

METHODOLOGY

Fifty-two patients with acute pancreatitis and organ dysfunction were enrolled. The treatment group included 26 patients receiving intravenous gabexate mesilate infusion at a dose of 100 mg/hr for 7 days. APACHE-II score, clinical and biochemical parameters were monitored intensively.

RESULTS

Coagulopathy ileus, and abdominal pain was significantly improved with gabexate mesilate. Gabexate mesilate reduced the necessity for surgical intervention and peritoneal lavage. The 7-day-mortality and 90-day-mortality rates were also significantly reduced with gabexate mesilate therapy.

CONCLUSIONS

There are strong indications from this study that early intravenous gabexate mesilate infusion results in improved survival in acute pancreatitis with organ dysfunctions.

Gender differences in the patterns of coronary angiography and PTCA use in a university hospital in Taiwan

BACKGROUND AND PURPOSE

Coronary artery angiography (CAG) and percutaneous transluminal coronary angioplasty (PTCA) are important procedures for the diagnosis and treatment of patients with coronary artery disease. However, long-term trends in the frequency of CAG and PTCA use and their relation to gender have not been clearly determined in the Asian population. The purpose of this study was to investigate gender differences in the patterns of CAG and PTCA use in a university hospital in Taiwan during the period of 1983 through 1996.

METHODS

We studied the monthly data of all patients who underwent CAG or PTCA in a university hospital in Taipei from 1983 through 1996. A time series analysis was used to estimate gender differences in the patterns of CAG and PTCA use.

RESULTS

The frequency of CAG and PTCA increased significantly during this period. Before 1990, only a small number of patients underwent PTCA. However, this number increased steadily after 1990. Men were more likely to undergo CAG and PTCA than women. A time series analysis with fitted models was used to create an integrated moving average model. For CAG, the value of the estimated intercept for men was 2.5 times greater than that for women. In the PTCA series, the value of the intercept in men was 4.4 times greater than that in women. The patterns of trend change showed greater increases in men than in women, and a greater increase in the PTCA than in the CAG series. By transfer function modeling and intervention analysis, we found that the effect of CAG on the frequency of PTCA in men was 1.8 times greater than its effect in women. The estimated influence of the use of a new catheterization room (added in 1993) was 2.8 times greater in men than in women. The fitted model correlated well with the observed values in the next 12 months for both genders.

CONCLUSIONS

We concluded that women had fewer CAG and PTCA procedures than men, and the influence of CAG on the PTCA series was significantly higher in men than in women.

Hepatic resection for benign tumours of the liver

The most frequent benign tumours of the liver include haemangioma, liver cell adenoma and focal nodular hyperplasia. Patients may undergo hepatic resection because of a preoperative diagnosis of malignancy or uncertainty in diagnosis despite an extensive work-up.

Mutational analysis of the p27(kip1) gene in hepatocellular carcinoma

p27(Kip1) is an inhibitor of cyclin-dependent kinase. It has been reported that reduced p27(Kip1) expression is present in human hepatocellular carcinoma. To determine the role of p27(Kip1) in hepatocarcinogenesis, 46 cases with hepatocellular carcinomas were studied. p27(Kip1) mutation was first screened by single strand conformation polymorphism, and direct DNA sequencing was then performed on those cases with mobility shifts. Two polymorphism sites were found. One is a previously described polymorphism at codon 109 (GTC-->GGC) which was found in two cases. The second polymorphism was identified at codon 55 (GCG-->GCA) in six of the 46 cases. However, the polymorphism at codon 55 was also present in seven of 93 healthy controls (7.5%), indicating that it is not associated with a predisposition for development of hepatocellular carcinoma (Fisher's exact test, 0.05). These results show that p27(Kip1) mutation is not a frequent event in human hepatocellular carcinoma, and suggest that it may be inactivated predominantly by transcriptional and/or posttranscriptional regulation rather than genomic aberrations.

Genetic alternations of p73 are infrequent but may occur in early stage hepatocellular carcinoma

p73, a structural homologue of the tumor suppressor gene, p53, has recently been identified and mapped to chromosome 1p36, where genomic loss of heterozygosity (LOH) often occurs in human hepatocellular carcinoma (HCC). To determine whether p73 is involved in the development of HCC and whether there is an inverse correlation between the mutations of p73 and p53, we examined 22 paired tumors/noncancerous liver tissues for allelic expression, LOH and mutation of p73 and for mutation of p53. p73 was biallelically expressed in noncancerous liver tissues and in 7 out of the 8 informative tumors. One tumor tissue expressed only a single allele. LOH of p73 was found in 2 out of the 11 (18%) informative cases. A tumor-specific five-nucleotide deletion mutation causing a reading frameshift/early truncation of p73 DNA-binding domain was found, in which case no concomitant mutation in the DNA-binding domain of p53 was identified. Nine out of the 22 cases (41%) contained tumor-specific mutations in the DNA-binding domain of p53. Two of the three cases with p73 genetic alternations had a tumor size of less than 2 centimeters. These results suggest that p73 is a biallelically expressed gene in the liver and that allelic loss and mutation of p73 is infrequent and may occur early in HCC. p73 is unlikely to be the putative tumor suppressor gene located at chromosome 1p36 in HCC.

Exercise shifts the platelet aggregation modulatory role from native to mildly oxidized low-density lipoprotein

PURPOSE

The role of low-density lipoprotein (LDL) lipid peroxides in strenuous exercise-induced changes in platelet function was studied in 30 patients (male/female = 22/8) aged 30-62 yr (mean +/- SD = 508).

METHODS

All subjects were subjected to a treadmill exercise test, using the standard Bruce protocol. Blood samples were collected pre-, peak, and 10 min postexercise to assess hematological and biochemical parameters and platelet aggregation. Ex vivo whole blood platelet aggregation during treadmill exercise was assessed in 10 subjects by adding mildly oxidized LDL.

RESULTS

Preexercise, a correlation existed between plasma thromboxane (TX) levels and plasma LDL cholesterol or beta-thromboglobulin (beta-TG) levels (r = 0.48, P < 0.05: r = 0.47, P < 0.05, respectively), whereas, at peak exercise, TX and beta-TG levels increased, but no correlation was seen. At peak exercise, platelets showed hyperaggregability in terms of maximal amplitude and reaction slope (P < 0.001 and P < 0.01, respectively). In contrast to the increase in plasma lipid peroxide levels seen during peak exercise (P < 0.05), LDL lipid peroxides decreased during exercise, this decrease reaching a statistical significance at 10 min postexercise (P < 0.05). In addition, the ex vivo addition of mildly oxidized LDL (10 mg protein x L(-1)) to peak exercise blood resulted in a significant attenuation of platelet aggregation and a decrease in TX release. At 10 min postexercise, a correlation was seen between LDL lipid peroxides and TX levels (r = 0.78, P < 0.001) or beta-TG levels (r = 0.68, P < 0.005).

CONCLUSION

These results suggest that LDL lipid peroxides play a role in modulating and attenuating platelet aggregation during strenuous exercise.

p16INK4 gene mutation and allelic loss of chromosome 9p21-22 in Taiwanese hepatocellular carcinoma

BACKGROUND

The p16INK4 (MTS1/CDNK2A) gene, located on chromosome 9p21, is an inhibitor of cyclin-dependent kinase 4. Various data have shown that it is frequently inactivated in several types of cell lines and primary human cancers.

MATERIALS AND METHODS

Thirty cases with hepatocellular carcinoma were studied for possible p16INK4 gene mutation in Taiwan. Homozygous deletion was determined using polymerase chain reaction (PCR). The p16INK4 gene mutation was first screened by single strand conformation polymorphism, then direct DNA sequencing was performed on the cases with mobility shifts. Deletion mapping of chromosome 9p21-22 was also carried out with two polymorphic microsatellite markers (D9S925 and D9S168) using PCR.

RESULTS

One of the 30 cases had homozygous deletion at exon 3 of the p16INK4 gene. Another tumor had altered electrophoresed mobility in exon 2 with G to T transversion in the first nucleotide of codon 61 by direct sequencing causing a stop codon (GAG-->TAG). At the D9S925 and D9S168 loci, six out of 24 (25%) and three out of 19 (16%) informative cases showed loss of heterozygosity, respectively.

CONCLUSION

Point mutation and homozygous deletion of the p16INK4 gene are present in a subset of hepatocellular carcinomas in Taiwan. The patterns of the p16INK4 gene alteration are, however, different from those from other regions. In addition, allelic loss on chromosome 9p21-22 is not an uncommon event in hepatocellular carcinomas. Therefore, the significance of chromosome 9p loss deserves to be extensively investigated.

Biliary cutaneous stent insertion via T-tube tract by choledochoscopy

BACKGROUND

Postoperative biliary ductal dilation and stent insertion are mandatory for managing complicated residual hepatolithiasis with intrahepatic strictures. Usually this procedure is performed under fluoroscopic guidance. Choledochoscopic examination is a routine procedure for residual hepatolithiasis. This is the first report of choledochoscopic biliary cutaneous stent insertion.

METHODS

Fifty-three patients underwent biliary cutaneous stent insertion under postoperative choledochoscopic guidance. Of the 53 patients, 35 had strictured intrahepatic ducts, 6 a stenotic hilum, 9 a tortuous fistula tract and 3 a choledochoduodenocutaneous fistula.

RESULTS

A total of 120 procedures have been performed in the 53 patients. Two thirds necessitated a repeated procedure. No major complication was found except 2 patients experienced mild abdominal pain after the procedure. Neither fluoroscopy nor contrast medium was used.

CONCLUSIONS

Choledochoscopic guidance is effective for postoperative biliary cutaneous stent insertion. It has the advantage of being technically easy and is relatively safe.

Carcinogenesis in the biliary system associated with APDJ

Anomalous pancreaticobiliary ductal junction (APDJ) is a rare congenital anomaly which is considered to be an etiological factor in the development of carcinoma of the biliary tract. It is generally accepted that pancreatic juice reflux into the biliary tract due to APDJ is one of the etiologies of biliary tract cancers. Refluxing pancreatic juice results in changes of bile and induces chronic inflammation and increased cellular proliferation, leading to epithelial hyperplasia, metaplasia, and carcinoma of the biliary tract. K-ras mutations are more prevalent in the carcinomas of biliary tract associated with APDJ compared with those without APDJ. There is no difference in the overexpression of p53 between biliary tract carcinomas associated with APDJ and those unassociated with APDJ. Further studies are needed to evaluate the role of cytokines and growth factors in carcinogenesis of the biliary system associated with APDJ.

A comparison of carbon dioxide monitoring and oxygenation between facemask and divided nasal cannula

The divided nasal cannula is a device recently released in Australia that couples oxygen delivery and end-tidal carbon dioxide (PETCO2) monitoring. This study compares the accuracy of PETCO2 measurements by the divided nasal cannula and those measured by a modified facemask (as currently used in this institution), with arterial partial pressure of carbon dioxide (PaCO2). In this crossover study, 30 patients who had arterial lines as part of their routine monitoring were given oxygen via nasal cannula and facemask preoperatively. The PETCO2 was measured with each device and a simultaneous PaCO2 and PaO2 measured after equilibration. The results demonstrate a significant difference between the PETCO2 as measured by each technique. The divided nasal cannula more accurately reflects PaCO2 (mean arterial to end expired gradient of 5 mmHg) and provides a more representative trace when compared to a traditional facemask system. Both methods provided adequate oxygenation.

Effects of timing of diatrizoate (water-soluble contrast medium) administration on pancreatic microcirculatory derangement in cerulein pancreatitis in rats

OBJECTIVE

We investigated whether the timing of administration of contrast medium after onset of acute pancreatitis is critical in determining the magnitude of microcirculatory derangement.

METHODS

An acute pancreatitis model in male Sprague-Dawley rats (225-275 g) was established by continuous infusion of cerulein (15 mg/kg per hour). The mean arterial pressure was monitored continuously by means of a femoral artery catheter. Diatrizoate (Hypaque-76), a water-soluble contrast medium, was delivered through a femoral vein catheter at doses corresponding to those given to humans, either 1, 2, or 3 hours after pancreatitis induction. In vivo microscopy and laser-Doppler flowmetry were used to investigate microcirculatory derangement. The water contents of the pancreas and lung, the malondialdehyde levels of the pancreas, and the trypsinogen activation peptide levels in the serum were measured at the end of the experiment (8 hours after infusion of cerulein).

RESULTS

Early administration of contrast medium (1 hour after pancreatitis induction) resulted in significantly greater changes in microcirculation and mean arterial pressure than did late administration (2 or 3 hours after pancreatitis induction). Rats given contrast medium 1 hour after induction also had highest pancreas and lung water contents, the highest pancreas malondialdehyde levels, and the highest serum trypsinogen activation peptide levels.

CONCLUSION

These results show that a water soluble contrast medium that is often used for computed tomographic imaging of the pancreas can adversely affect the pancreatic microcirculatory parameters, such as tissue perfusion and leukocyte sticking, and hemodynamics in a cerulein-induced model of acute pancreatitis. Early administration seems to cause more severe derangement of the pancreatic microcirculation.

Malignancy in choledochal cysts

BACKGROUND/AIMS

Malignancy in choledochal cysts is a rare condition. This study presents our experience with this condition, with emphasis on the clinical presentation, management and outcome.

METHODOLOGY

Subjects included 80 adults with choledochal cysts treated from January 1979 to December 1995. Of these patients, 8 were found to have malignancy in the cyst and formed the basis of this study.

RESULTS

Four patients had synchronous and 4 had metachronous carcinoma lesions arising in the choledochal cyst. The clinical presentation was: biliary tract infection in 5 patients, gastric outlet obstruction in 2 and right upper quadrant pain and body weight loss in 1. Operations for bile duct malignancy included total excision in 2 patients, choledochotomy with T-tube drainage in 2 patients, gastrojejunostomy in 2 patients, percutaneous transhepatic biliary drainage and gastrojejunostomy in 1 patient and metastatic lymph node biopsy only in 1. One patient died due to septic shock within 30 days of the operation (operative mortality). Postoperative survival time ranged from 4-13 months with a mean of 6.2 months.

CONCLUSIONS

The frequency of malignancy in the choledochal cysts was 10% in the present series. Malignancy in the choledochal cyst should be highly suspected in patients with cholangitis symptoms, body weight loss and anemia. Prognosis in this disease entity is poor.

Selective inhibition of inducible nitric oxide in ischemia-reperfusion of rat small intestine

PURPOSE

We investigated the role of constitutive and inducible nitric oxide (NO) synthases in intestinal ischemia-reperfusion (I/R) injury by observing the alterations in hemodynamics and intestinal microcirculation in response to I/R in rats, with or without inhibitors of NO synthases.

METHODS

Adult male Sprague-Dawley rats (n = 9/group) received a standard I/R procedure alone: I/R plus intravenous administration of aminoguanidine (an inhibitor of inducible NO synthase); I/R plus L-NAME (NG-nitro-L-arginine methyl ester, an inhibitor of constitutive and inducible NO synthase); IR + L-Arg (L-arginine, an NO precursor); or a sham operation plus the vehicle. The I/R procedure was performed by clamping the perfusion vessels of a segment of the terminal ileum, and medication was administered intravenously before and after intestinal ischemia. The intestinal perfusion and leukocyte-endothelial interactions were evaluated with in vivo microscopy and laser Doppler flowmetry. Surface expression of CD11b (an adhesion molecule) of circulating granulocytes was measured with flow cytometry.

RESULTS

Intestinal I/R produced circulatory alterations, intestinal microcirculatory derangement, energy depletion, and lipid peroxidation. Aminoguanidine significantly attenuated the reperfusion-related depression of mean arterial pressure (MAP), the decrease in intestinal perfusion index, the decrease in tissue ATP preservation, the increase in tissue malondialdehyde (MDA) level, and the expression of CD11b of circulating granulocytes. Administration of L-NAME had only minor and transient effects on reperfusion-related changes of MAP, intestinal flux, numbers of adherent leukocytes, and CD11b expression, but had some protective effects on tissue MDA and adenosine triphosphate levels and flow velocity. L-Arg further decreased the MAP but did not affect reperfusion-related variables.

CONCLUSIONS

Our results show that the selective inhibition of inducible NO synthase by aminoguanidine attenuates the hemodynamic and microcirculatory derangement that results from intestinal I/R.

Combined heart transplantation and resection of dissecting aneurysm of ascending aorta and aortic arch: a case report

A 21-year-old male patient had suffered from palpitation and exertional dyspnea since October, 1997. He was admitted to our hospital, and a series of examinations were performed. Chest computed tomography (CT) revealed marked dilatation of the ascending aorta (about 7.5 cm at the proximal portion) and aortic annulus, an intimal flap in the ascending aorta and aortic arch was also noted. Cardiac catheterization revealed the pulmonary capillary wedge pressure was 33 mmHg, pulmonary artery pressure was 47/38 mmHg with a mean of 35.4. The cardiac index was 1.01 l/min/m2. Poor left ventricular contractility was shown by a left ventricular ejection fraction (LVEF) of 13.8% and a right ventricular ejection fraction (RVEF) of 5.13% by a radionuclide angiogram (RNA) study. Under the diagnosis of dilated cardiomyopathy and dissecting aortic aneurysm of the ascending aorta and aortic arch, he was put on a waiting list for heart transplantation. On November 11, 1997 he received heart transplantation. Resection of the dissecting aneurysm of the ascending aorta and the aortic arch and replacement with a 26 mm Vascutek graft were performed first under deep hypothermia and retrograde cerebral perfusion. Then while he was rewarming up, heart implantation was performed. He was discharged 30 days after surgery and has been doing well since then. As far as we know, no literature regarding combined heart transplantation and resection of a dissecting aneurysm of the ascending aorta and aortic arch has been reported.

Impact of concomitant hepatolithiasis on patients with peripheral cholangiocarcinoma

The association of hepatolithiasis (HL) and peripheral cholangiocarcinoma (PCC) has been well recognized. However, information concerning the impact of hepatolithiasis on patients with peripheral cholangiocarcinoma is sparse and therefore difficult to assess. A total of 162 consecutive patients with histologically proven peripheral cholangiocarcinoma were treated surgically at Chang-Gung Memorial Hospital between 1977 and 1994. Among them, 106 patients (65.4%) had associated hepatolithiasis (PCC + HL group), and the remaining 56 patients (34.6%) did not (the PCC - HL group). The differences in demographics, symptomatology, laboratory data, tumor staging, histological pattern, resectability rates, and long-term survival of these two groups were compared. The male to female ratio was 0.7 in the PCC + HL group and 1.3 in the PCC - HL group (P < 0.05). Two thirds of the PCC + HL group presented with acute cholangitis, whereas two thirds of the PCC - HL group presented with hepatomegaly (P < 0.01). Those patients in the PCC + HL group were in earlier stages than those of the PCC - HL group at the time of the initial diagnosis (P < 0.05). The resectability rate for the PCC + HL group was 31.1% and for the PCC - HL group, 26.8% (P > 0.05). Surgical mortality rates were 3.8% in the PCC + HL group and 3.6% in the PCC - HL group (P > 0.05). The morbidity rate was much higher in the PCC + HL group than in the PCC - HL group (P < 0.01). The 1-, 3-, and 5-year survival rates were 35.5%, 20.5%, and 16.5% in the PCC + HL group and 27.2%, 8.8%, and 7.8% in the PCC - HL group (P > 0.05). In conclusion, the presence of hepatolithiasis hindered an exact diagnosis of underlying cholangiocarcinoma preoperatively, precipitated biliary sepsis which affected resectability, and increased postoperative morbidity. Hepatolithiasis per se, however, did not influence the long-term survival.

Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings

OBJECTIVE

We studied the efficacy of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of malignant perihilar biliary obstructions, with reference to endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

A total of 40 patients with malignant perihilar biliary obstructions, who underwent both MRCP (Magnetom Vision; Siemens, Erlangen, Germany; projection technique and multislice plus maximum intensity projection) and ERCP examinations, were studied. The study group included hilar cholangiocarcinoma (Klatskin tumor) in 26 patients, icteric hepatocellular carcinoma in four patients, gallbladder carcinoma in five patients, and metastasis from other than hepatobiliary origin in five patients. Axial and coronal magnetic resonance (MR) images were added simultaneously to the MRCP. The mean serum bilirubin level on admission was 11.5 mg/ml (range, 2.8-28.5 mg/ml). The presence and extent of malignant biliary obstruction were determined with both MRCP and ERCP following the known criteria: an abrupt and irregular character of a distal narrow segment, a proportionally dilated biliary tree proximally, and an irregularly shaped intraluminal filling defect. The efficacy of the MRCP examination in detecting the presence of biliary obstruction, its anatomical extent, and the underlying cause, respectively, was compared to that of ERCP.

RESULTS

MRCP examination was successfully performed on all patients, whereas ERCP examination was unsuccessful in two patients. Both MRCP and ERCP were very effective in detecting the presence of biliary obstructions (40 of 40 vs. 38 of 38, p = 1.0). MRCP was superior in its investigation of anatomical extent (34 of 40 vs. 24 of 38, p = 0.015) and the cause of the jaundice (31 of 40 vs. 22 of 38, p = 0.023) compared to ERCP. Specifically, the performance of MRCP is promising for the interpretation of cholangiocarcinoma (22 of 26) and gallbladder carcinoma (five of five), but is relatively ineffective for the interpretation of icteric HCC (two of four) and metastasis (two of five).

CONCLUSION

MRCP represented an ideal noninvasive diagnostic tool for the evaluation of malignant perihilar biliary obstructions with reference to ERCP.

Effect of n-3 fatty acids on the composition and binding properties of lipoproteins in hypertriglyceridemic patients

BACKGROUND

Treatment of hyperlipidemic patients with fish oil results in an increase in plasma LDL cholesterol despite a marked decrease in the LDL precursor, VLDL.

OBJECTIVE

We studied the relation between VLDL composition and LDL concentrations.

DESIGN

Fourteen hypertriglyceridemic patients were treated with encapsulated fish oil (containing 1.45 g eicosapentaenoic acid and 1. 55 g docosahexaenoic acid/d) for 4 wk. Venous blood samples were collected before and after treatment. Eleven normolipidemic subjects served as a control group.

RESULTS

Fish oil effectively lowered plasma lipid and apolipoprotein (apo) E concentrations in the hypertriglyceridemic patients, whereas apo B concentrations increased. The lipid and apolipoprotein content of VLDL decreased, whereas LDL cholesterol and LDL apo B increased. Fractionation of VLDL by heparin-affinity chromatography showed that before treatment hypertriglyceridemic patients had more VLDL in the 0.05-mol NaCl/L subfraction and less in the 0.20-mol/L subfraction than did control subjects (P < 0.05), whereas the subfraction distribution pattern was normalized after fish-oil treatment. Nevertheless, plasma concentrations of the 0.05-mol NaCl/L subfraction were decreased and those of the 0.20-mol/L subfraction were increased in hypertriglyceridemic patients after fish-oil treatment (P < 0.05). Fish-oil treatment both enhanced VLDL binding and lowered LDL binding to fibroblasts.

CONCLUSION

Treatment of hypertriglyceridemic patients with fish oil caused differential effects on VLDL subfractions and decreased LDL binding to fibroblast receptors, which may have contributed to the paradoxical increase in LDL-cholesterol concentrations.

Peripheral cholangiocarcinoma (cholangiocellular carcinoma): clinical features, diagnosis and treatment

Peripheral cholangiocarcinoma is a relatively rare cancer. However, it is known to have an unfavourable prognosis compared with that of hepatocellular carcinoma. Little is known about its aetiology, clinical or pathological features. Recently, with the development of imaging modalities, early staged cholangiocarcinoma has been diagnosed with relative ease. Surgery is the optimal therapy. Total hepatectomy does not provide survival benefit. Conventional surgery remains the only effective treatment, even for patients with advanced-stage tumours. Factors influencing survival after hepatectomy were tumour-free margin, lymphnodes metastasis and histopathology of tumour. Palliative intrahepatic tubing or percutaneous transhepatic biliary drainage and brachytherapy can alleviate jaundice and cholangitis, thereby prolonging survival in some cases.

Aminoguanidine attenuates hemodynamic and microcirculatory derangement in rat intestinal ischemia and reperfusion

BACKGROUND

Nitric oxide (NO) participates in the regulation of hemodynamic and microcirculatory changes in intestinal ischemia and reperfusion (I/R). However, the nature of the involvement of an inducible NO release has been controversial. This study evaluates the impact of an inducible NO synthase inhibitor, aminoguanidine, used as a treatment in a rat intestinal I/R model.

METHODS

We investigated the hemodynamics by measuring the mean arterial pressure (MAP), and the microcirculatory responses of the intestine and liver to systemically administered aminoguanidine by use of laser-Doppler flowmetry (LDF), in vivo microscopy, and flow cytometry.

RESULTS

During the 30-min ischemia of the selected 20-cm ileal segment, no MAP change was noted. At reperfusion, a marked decrease of MAP was noted and the lowest levels were noted 3 hours after reperfusion (67 +/- 4% vs. 99 +/- 5% in sham-operated control animals). A marked decrease in liver perfusion as measured by LDF was noted 1 hour after reperfusion and remained low at 5 hours (72 +/- 4% vs. 97 +/- 3% in sham-operated control animals). A marked decrease in intestine perfusion was noted by using LDF 1 hour after reperfusion and remained low at 5 hours (43 +/- 3% vs. 92 +/- 4% in sham-operated control animals). The flow velocity of the postcapillary venules of the intestine was markedly decreased (1.01 +/- 0.62 vs. 2.67 +/- 0.34 mm/s in sham-operated control animals) at 5 hours after reperfusion. The flow velocity of the postsinusoidal venules of the liver was also markedly decreased (1.01 +/- 0.62% vs. 2.67 +/- 0.34% in sham-operated control animals). Leukocyte-endothelial interaction (adhesion) was increased in the postcapillary venules of the intestine (54 +/- 12 vs. 6 +/- 4/microm2 in sham-operated control animals) and in the postsinusoidal venules of the liver (32 +/- 8 vs. 2 +/- 2/microm2 in sham-operated control animals). Concomitantly, the granulocyte count was increased (9.1 +/- 0.6 vs. 2.1 +/- 0.3% of total circulating leukocytes in sham-operated control animals), with an increase of CD 11b expression. Aminoguanidine administration (1 mg/kg) 0.5 hour before ischemia and 1 hour after reperfusion significantly increased MAP, increased intestine and liver perfusion, decreased adhesion, and decreased circulating granulocytes and CD 11b expression.

CONCLUSION

Inhibition of an inducible NO release by aminoguanidine in intestinal I/R can attenuate hemodynamic and microcirculatory derangement.