Distant metastasis of gastric cancer is associated with elevated expression of the antimetastatic nm23 gene

To understand the clinical significance of nm23 gene expression in gastric cancer patients, the Nm23-H1 protein level of fresh resected specimens from a total of 37 gastric cancer patients was measured by Western blot analysis. The elevated nm23 expression group (Nm23-H1 protein level in tumor tissue greater than the 75th percentile value of patients) was significantly associated with the histologically differentiated type (P = 0.036). This group had a higher incidence of distant (hematogeneous) metastasis (P = 0.0023) and a lower 2-year disease-free survival rate (P = 0.033) than the non-elevated group. The result was not consistent with the previous assumption that nm23 is an antimetastatic gene for gastric cancer.

Helicobacter pylori in surgical specimens from patients with resectable gastric adenocarcinoma

BACKGROUND

To investigate the prevalence of Helicobacter pylori (H. pylori) in surgical specimens from patients with respectable gastric adenocarcinoma using a histological method, and to study the specific biology of H. pylori-associated gastric cancer.

MATERIALS AND METHODS

The presence of H. pylori in resected specimens from 276 patients treated between October 1994 and October 1996 was evaluated histologically using hematoxylin-eosin stain. Clinicopathologic data, including age, gender, cancer location, invasion depth, histologic type (intestinal or diffuse), stage (early or advanced), and the histology of the noncancerous gastric mucosa, were compared between patients testing positive and those testing negative for H. pylori.

RESULTS

The overall positive rate of H. pylori was 27.5%. H. pylori-positive gastric cancer was frequently associated with atrophic gastritis or intestinal metaplasia in the noncancerous tissue, but was not associated with other variables.

CONCLUSION

The results contradict the prevailing concept that H. pylori rarely colonizes in the metaplastic mucosa. To determine whether patients who have normal mucosa with superficial gastritis have a lower seroprevalence of H. pylori, further serologic study of the IgG antibody against H. pylori is mandatory. Our histologically positive rate is relatively lower than the seropositive one. More tissue samplings and special stains may provide more precise results.

Alcohol-related problems in Taiwan with particular emphasis on alcoholic liver diseases

Socioeconomic development has led to a progressive increase of alcohol consumption in Taiwan, with an accompanying increase in alcohol-related psychiatric problems, traffic accidents, and liver disease. The prevalent rates of alcohol dependence for Han Chinese and Fomosan aborigines were 0.1% and 1%, respectively in 1950. The rate of alcohol dependence increased to 23% for aborigines in 1995. The number of cases of death and serious injuries due to alcohol-related traffic accident has decreased, and the number of fatalities resulting from these accidents has decreased from third to eighth since the inception of a program of random traffic stops with alcohol breath test in 1997. Alcohol liver disease (ALD) was defined as daily alcohol consumption of 60 g, for a duration of longer than 5 years. We classified ALD patients into two groups: (1) those whose average daily consumption of alcohol exceeded 120 g for a duration longer than 15 years (group A); and (2) all other patients (group B). The case records of 33 cases of biopsy-confirmed ALD were obtained for study. The average of daily alcohol consumption in these cases was 160 g. All but one of these patients were male, age ranged from 26 to 69 years, with an average of 43.1. Clinically, ill-defined gastrointestinal symptoms were the most common presentation (61%), and hepatomegaly was the main physical sign (73%). The average mean corpuscular volume values of ALD and non-ALD patients were 102.3 +/- 10.94 and 94.5 +/- 8.1, respectively (p < 0.01). The mean corpuscular volume values of group A and group B were 102.9 +/- 9.7 vs. 96.5 +/- 9.11 (p < 0.05). Result from serum SGOT/SGPT and gamma-glutamyltransferase/alkaline phosphatase for ALD and non-ALD revealed statistically significant differences between these groups. Using the avidin-biotin complex technique, tissue IgA deposition for ALD patients was found to be different from that of non-ALD patients. Ten of 13 ALD patients vs. 2 of 13 non-ALD patients had continuous-form IgA deposition. Histologically, 45.5% of ALD patients had alcoholic cirrhosis, whereas alcoholic hepatitis was present in only 9.1% of patients. Overall, 88% of cases showed various severity of fatty metamorphosis.

Mass spectrometric characterization and glycosylation profile of bovine pancreatic bile salt-activated lipase

We developed a procedure for the large scale isolation of bovine bile salt-activated lipase (BAL) for its crystallization [Wang, X., et al. (1997) Structure 5, 1209-1218] and also carried out a study on the molecule's glycosylation profile for a better deduction of the structure of the enzyme. Mass spectrometric analysis of the CNBr-generated peptides indicated that only one (Asn-361) of the two potential N-glycosylation sites (Asn-187 and Asn-361) with NXT motif is glycosylated. The analysis of the isolated CNBr peptide containing Asn-361 showed that it existed in three glycoforms in a ratio of 1.0:2.8:1.0, with oligosaccharide moieties weighing 1900.1, 2045.2, and 2336.4 Da, respectively. The major oligosaccharide chain contained mannose: galactose:N-acetylglucosamine:fucose:sialic acid in a molar ratio of 2:2:4:2:1. It was also determined that the potential O-glycosylated peptide (CB13) is not O-glycosylated and, in addition, it was found that there was microheterogeneity in the C-terminus of the isolated bovine BAL. The results obtained from this mass spectrometric study combined with the X-ray crystallographic studies provide more precise structural information on BAL. The procedure described here for the mass spectrometric analysis of CNBr-generated peptides also has general applicability for analysis of the glycosylation profile of glycoproteins and the C-terminal peptide structure of proteins.

Differing characteristics of hepatitis B and C risk factors among elders in a rural area in Taiwan

BACKGROUND

Both hepatitis B and C are major health concerns in Taiwan. The goal of this study was to determine how risk factors for hepatitis B and C differed in this study population. It was also hoped that the data might help determine how age and place of residence affect hepatitis risk factors.

METHODS

Complete serum and hepatitis marker analysis (HBsAg and AntiHCV) was done for 282 individuals over 65 years old. Of these, 254 were interviewed for risk factor analysis.

RESULTS

Of the 282 subjects, 8.2% were HBsAg+, 27.3% were AntiHCV+, and 3.2% were both HBsAg+ and AntiHCV+. AntiHCV+ subjects were more likely than AntiHCV-subjects to have had frequent medical injections, odds ratio (OR) = 2.94, 95% confidence interval (CI) (1.68, 5.12), and it was the only independent risk factor for determining AntiHCV+, OR = 3.26, 95% CI (1.85, 6.11) (N = 254). The AntiHCV+ group had higher alanine and asparate aminotransferase levels but lower cholesterol and triglyceride levels than AntiHCV- and HBsAg+ groups (p < .0001). Abnormal ALT existed in 40.3% of AntiHCV+ and 10.7% of AntiHCV- cases. ALT was associated with AntiHCV and sex, although abnormal AST was only associated with AntiHCV.

CONCLUSIONS

AntiHCV was closely related with frequent medical injections and was the primary risk factor for abnormal ALT and AST levels in this study population. It appears that frequent medical injections are an important risk factor because of the previously common habit of reusing syringes. This is of major concern to elders in Taiwan because of their much greater likelihood of repeated exposure.

Identification of Anoectochilus formosanus and Anoectochilus koshunensis species with RAPD markers

RAPD (random amplified polymorphic DNA) markers were developed to distinguish Anoectochilus formosanus from Anoectochilus koshunensis and their putative hybrids. Morphological differentiation of these two species beyond the flowering period is difficult. RAPD markers provide a rapid and easy tool for identification of the two Anoectochilus species. In the study, forty arbitrary decamer primers were screened, and nineteen species-specific RAPD markers generated from polymerase chain reactions (PCR) with eight random primers were obtained. Nine were specific to A. formosanus and ten to A. koshunensis. Two primers, OPC-08 and OPL-07, produced two markers, one specific to A. formosanus and the other specific to A. koshunensis, which simultaneously appeared in the hybrids pattern. The RAPD markers can be applied both to identification of A. formosanus and A. koshunensis species and to assessment of the extent fo hybridization in hybrids between them. This information facilitates the breeding program process.

Sepsis during total parenteral nutrition: exploration of risk factors and determination of the effectiveness of peripherally inserted central venous catheters

BACKGROUND

Sepsis is the most frequent serious complication during total parenteral nutrition (TPN), resulting in increased morbidity, mortality and health care costs. Existing reports have not documented the risk factors of sepsis during TPN. The objectives of this study were to determine the rate of sepsis in our practice and to explore the risk factors for sepsis during TPN. We also determined the role and efficacy of using peripherally inserted central venous catheters (PCVC) as insertion catheters to administer TPN.

METHODS

From October, 1994, to May, 1996, we administered TPN to 378 pediatric patients hospitalized at Mackay Memorial Hospital. We followed all cases for the occurrences of any complications while administering TPN. We studied all patients who had fever, a clinical presentation of sepsis and a positive blood culture during their course of TPN.

RESULTS

During the 20-month period 378 patients received TPN for a total of 6562 days. Fifty-six patients presented with clinical sepsis and positive blood cultures. Significant features in the sepsis group included longer duration of TPN, age < 3 months, usage of central venous catheters, gastrointestinal diseases as indication for TPN, low birth weight and short gestational age in prematurity. Seven patients died despite prompt antimicrobial therapy. One hundred eleven patients received TPN via PCVC for a mean duration of 17.1 days, significantly longer than 10.4 days in the peripheral intravenous catheter group but no difference between the sepsis rates.

CONCLUSION

Considering the high incidence of sepsis during TPN, every attempt should be made to minimize the length of TPN therapy and encourage early enteral feeding. We also recommend the use of PCVC in patients requiring prolonged nutritional support.

Anticardiolipin antibody-related Budd-Chiari syndrome: report of a case

We report a case of a 37-year-old female who suffered from upper abdominal pain, progressive abdominal distention, shortness of breath, palpitation and pitting edema of lower legs for more than one month. Abdominal sonography showed small caliber of hepatic veins, mild hepatosplenomegaly and moderate ascites. Computed tomography of abdomen disclosed extensive thrombi in bilateral femoral veins, ovarian veins and inferior vena cava. Ascites was transudate with normal cell count. Laboratory data showed hypoalbuminemia, mild elevation of total bilirubin and iron deficiency anemia. Anti-cardiolipin antibody was positive and antinuclear antibody was negative. The histopathological features, including sinusoidal dilatation with atrophic change of adjacent hepatocytes, slight congestion and hemosiderin-like material within the cytoplasm of Kupffer cells, were compatible with the criteria of Budd-Chiari syndrome. Heparin was intravenously administered immediately to prevent further progression of thrombosis. The ascites was successfully controlled with diuretics (spironolactone and furosemide). After a two-week course of treatment, she was discharged in good condition and on warfarin anti-coagulant medication.

Intra-arterial carbon dioxide-enhanced ultrasonogram of hepatocellular carcinoma treated by transcatheter arterial embolization and percutaneous ethanol injection therapy

The purpose of this study was to investigate the value of carbon dioxide-enhanced ultrasonography (CO2-US) in the evaluation of viable hepatocellular carcinomas (HCC) which were treated by transcatheter arterial embolization (TAE), percutaneous ethanol injection (PEI), or a combination treatment (TAE and PEI). Forty-one patients with 66 HCC were included in the study. They underwent CO2-US and angiography were performed in all tumours after they were treated by TAE, PEI or a combination treatment. Forty-six tumours were positively enhanced by CO2-US and 40 of them were positive by angiography. These 46 tumours were proved to be viable tumours either by biopsy or by follow-up studies. The positive predictive value was 100% for CO2-US and 87.8% in angiography. Twenty tumours were negative by CO2-US and these were also negative by angiography. Carbon dioxide-enhanced ultrasonography is a more reliable method for detecting the viable portion of the treated HCC compared with conventional angiography.

A multidisciplinary approach to major bile duct injury following laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Many series describing the management of major bile duct injuries after laparoscopic cholecystectomy have been reported with satisfactory short-term results. However, the information of their prognosis with sufficient time-period follow-up is sparse.

METHODS

Sixteen consecutive patients with major bile duct injury following laparoscopic cholecystectomy were retrospectively reviewed, including six common bile duct transections, four bile duct perforations, and six hilar strictures but without perforation. With respect to the level of bile duct injuries, there were the following based on Bismuth's classification: type 1 in six patients, type 2 in five patients, type 3 in three patients, type 4 in one patient, and type 5 in one patient. All patients received surgical management, interventional radiology and endoscopic treatment. The time periods of follow-up ranged from 37 to 72 months (mean, 52 months). The final results were rated as being excellent, good, fair, or poor, based on the criteria of symptoms, biochemical data, and radiology.

RESULTS

There was no procedure-related mortality. Ten of the 16 patients had either excellent or good results, two had fair results, and four had poor results. Of the latter four, the patients had been classified as Bismuth type 1, 3, 4, and 5, respectively, and all sustained a failed initial surgical repair.

CONCLUSIONS

Using a multidisciplinary approach, 12 (75%) of the 16 patients attained a promising result through a long-term follow-up, while those with the higher biliary stricture and with an unsuccessful initial surgical repair had a disappointing outcome.

Prognostic study of gastric cancer without serosal invasion: reevaluation of the definition of early gastric cancer

BACKGROUND

Early gastric cancer, a term defined by Japanese researchers in the 1960s, is equivalent to pT1 tumor stage regardless of nodal status. Recently, there were suggestions to exclude node-positive pT1 gastric cancer from this entity and to consider node-negative pT2 gastric cancer as early gastric cancer.

STUDY DESIGN

A survival analysis was conducted of 294 patients who underwent resection for gastric cancers confined within the gastric wall (pT1, n = 164; pT2, n = 130) between 1986 and 1992.

RESULTS

The cumulative 5-year survival rate was 93.5% for pT1 patients and 67.9% for pT2 patients, with an overall survival of 82.5%. There was a significant difference in the 5-year survival rate between node-positive and node-negative pT1 patients (72.8% versus 95.6%; p = 0.0095). The 5-year survival rate of node-negative pT2 patients (80.4%) was significantly worse than that of node-negative pT1 patients (p = 0.011) but was not significantly better than that of node-positive pT1 patients (p = 0.4). If excellent prognosis is a prerequisite for the definition of early gastric cancer, then node-positive pT1 cancer and node-negative pT2 cancer should not be considered early gastric cancer.

CONCLUSIONS

In the 1990s, now that new imaging techniques such as endoscopic ultrasonography has been introduced, the preoperative staging of gastric cancer can be made more accurately than in the 1960s, when the term "early gastric cancer" was defined. Because the prognosis of early gastric cancers, if subcategorized by nodal status, is not homogeneously excellent, a reevaluation of the definition of early gastric cancer may be necessary.

Semen quality in workers with long-term lead exposure: a preliminary study in Taiwan

The objective of this study was to evaluate the semen quality from five workers in a lead battery manufacturing factory. Blood and semen samples were taken to measure lead concentrations. These samples were compared with samples from eight workers not exposed to lead, based on age, marital status and duration of marriage. Results showed lead concentrations in blood and semen were significantly higher in the exposed group. However, comparisons based on sperm count, motility and viscosity showed no significant differences. There was a significant negative relationship for the exposed group between motility and blood-lead and semen-lead concentrations. Comparing sperm count and blood-lead and semen-lead concentrations, there was a non-significant negative relationship. Semen-lead concentrations and semen pH were significant factors that explained the semen count and semen motility results. Prolonged exposure to lead may have harmful effects on the body's reproductive functions.

The crystal structure of bovine bile salt activated lipase: insights into the bile salt activation mechanism

BACKGROUND

The intestinally located pancreatic enzyme, bile salt activated lipase (BAL), possesses unique activities for digesting different kinds of lipids. It also differs from other lipases in a requirement of bile salts for activity. A structure-based explanation for these unique properties has not been reached so far due to the absence of a three-dimensional structure.

RESULTS

The crystal structures of bovine BAL and its complex with taurocholate have been determined at 2.8 A resolution. The overall structure of BAL belongs to the alpha/beta hydrolase fold family. Two bile salt binding sites were found in each BAL molecule within the BAL-taurocholate complex structure. One of these sites is located close to a hairpin loop near the active site. Upon the binding of taurocholate, this loop becomes less mobile and assumes a different conformation. The other bile salt binding site is located remote from the active site. In both structures, BAL forms similar dimers with the active sites facing each other.

CONCLUSIONS

Bile salts activate BAL by binding to a relatively short ten-residue loop near the active site, and stabilize the loop in an open conformation. Presumably, this conformational change leads to the formation of the substrate-binding site, as suggested from kinetic data. The BAL dimer observed in the crystal structure may also play a functional role under physiological conditions.

Role of hepatic resection in surgery for bilateral intrahepatic stones

BACKGROUND

Hepatic resection is the treatment of choice for unilateral intrahepatic stones. The availability of the flexible choledochoscope has greatly changed the management of intrahepatic stones. Little has been reported regarding hepatic resection for bilateral intrahepatic stones.

METHODS

Fifty-nine (15.1 per cent) of 392 patients with bilateral intrahepatic stones underwent hepatic resection. The indications and results were reported. Surgical outcome and long-term follow-up were analysed, and results were compared with those in patients not undergoing hepatectomy.

RESULTS

Fifty-nine patients underwent hepatic resection because of destruction of the left liver by repeated infection (n = 40), multiple cholangitic liver abscesses (n = 18) or associated intrahepatic cholangiocarcinoma (n = 1). The hospital mortality rate was 1.7 per cent. The majority of complications were wound infection (9 per cent), haematobilia (5 per cent) and biliary fistula (3 per cent). The incidence of residual stones after surgery was 60 per cent. One year after postoperative choledochoscopic stone extraction, the rate of complete stone clearance was 84 per cent. In patients who did not have hepatectomy the respective rates were 90.1 and 52.9 per cent. The recurrence rate for stones in the hepatectomy and no-hepatectomy groups was 12 and 33.0 per cent respectively.

CONCLUSIONS

Compared with patients not undergoing hepatectomy, those having hepatic resection had similar operative risks, fewer residual stones and a low incidence of recurrent stones (P < 0.05).

Retrograde lymphatic spread: a likely route for metastatic ovarian cancers of gastrointestinal origin

In order to outline the pathways of gastrointestinal malignancies metastasizing to the ovaries, we reviewed 103 cases of metastatic ovarian tumors, and also performed para-aortic lymph node sampling on 11 patients at operation for metastatic ovarian tumors. Of the 103 patients, 74% (26/35) with gastric cancer and 67% (45/67) with colorectal cancer had lymph node metastasis at or before the diagnosis of ovarian tumor. Intraperitoneal metastases presented in 49 and 42% of patients with gastric and with colorectal cancers, respectively. Twenty-three percent of gastric cancer patients and 25% of colorectal cancer patients presented with both lymph node and intraperitoneal metastases. The ovary was the first or among the early metastatic organs diagnosed in 51 of the 53 patients with metachronous ovarian metastases. Only 4 patients with colorectal cancer and none with gastric cancer showed parenchymal organ metastases. These 4 patients also showed intraperitoneal lesions, and 3 of these 4 patients had node metastasis. Among the 11 patients who underwent prospective para-aortic lymph node sampling during operation for the ovarian tumors, only 1 had enlarged para-aortic nodes depicted by computed tomography, 2 had grossly enlarged (>/=1.5 cm) para-aortic lymph nodes noted at surgery, and 6 of the 7 patients with gastric cancer and all 3 with colorectal cancer had metastatic nodes histologically. Among the 58 nodes taken from these patients, 67% showed metastatic foci. We concluded that lymph node metastasis is frequently seen in patients with metastatic ovarian tumors of gastrointestinal origin, and hypothesized that retrograde lymphatic spread is a likely route for the metastases.

mdr1 mRNA expression by RT-PCR in patients with primary breast cancer submitted to neoadjuvant therapy

mdr1 expression by reverse transcription and polymerase chain reaction (RT-PCR) has been compared to P-glycoprotein (Pgp) expression by immunohistochemistry (IHC) and correlated with clinical response to neoadjuvant therapy. RNA has been recovered from glass slide smears of fine-needle aspiration from 57 untreated primary breast cancers prior to neoadjuvant chemotherapy (33 cases), hormone therapy (23 cases), or both (1 case). Furthermore, mdr1 mRNA has been analyzed in 6 cases after 2 months of treatment. The neoadjuvant therapy consisted of 4 cycles of adriamycin and cyclophosphamide or tamoxifen. Of 57 tumor specimens, an interpretable result was obtained in 52 cases, indicating the feasibility of the analysis by RT-PCR with very small tumor specimens. The presence of mdr1 mRNA has been documented in 44/52 (84%) tumor samples with a spectrum of expression levels. The expression of mdr1 mRNA was compared with P-glycoprotein (Pgp) expression by IHC using JSB-1, 4E3, and C494 monoclonal antibodies in 48 of the 52 interpretable tumor samples. 12/48 (25%) expressed Pgp by IHC. All tumors expressing Pgp by IHC were also positive by RT-PCR. The results confirm the higher prevalence of mdr1 mRNA compared to the protein expression. However, mdr1 mRNA expression was found to correlate significantly with resistance to neoadjuvant hormone therapy only while Pgp expression detected by JSB-1 immunostaining only correlated with chemoresistance. The lack of convincing correlation with chemoresistance suggests that mRNA and Pgp may not be directly or solely responsible for clinical response to drugs. Further studies should focus on the post-translational modulation of P-glycoprotein and other mechanisms of drug resistance.

Characterization of a lily tapetal transcript that shares sequence similarity with a class of intracellular pathogenesis-related (IPR) proteins

This study addresses isolating and characterizing a cDNA clone corresponding to a tapetum-specific transcript, designated as PR-10a from Lilium longiflorum. Anther ontogeny is histologically divided into three consecutive phases. The first encompasses early proliferative stages and differentiation of the locules. The second concerns microspore development from the onset of meiosis through microspore maturation. The final phase involves pollen maturation, originating with microspore mitosis through pollen formation. The lily PR-10a transcript is anther-specific and temporally expressed only at the phase of microspore development during which the tapetal cells become polarized, highly secretory, and exhibit loss of cell walls. The maximal level of PR-10a transcript coincides strictly with the peak of tapetal secretory function. Comparing mRNA and cDNA insert sizes reveals that PR-10a is close to full-length. Sequence analysis demonstrates similarity between the predicted lily PR-10a and asparagus AoPR1 protein, potato pSTH2 and pSTH21 proteins, parsley PcPR1 and PcPR3 proteins, bean PvPR1 and PvPR2 proteins, lupin L1R18B protein, pea 149 protein and a family of major allergens including Cor a 1 of hazel, Car b 1 of hornbeam, Aln g 1 of alder, Bet v 1 of birch and Api g 1 of celery. To the authors' knowledge, this is the first reported organ/tissue-specific IPR protein.

Massive extra-enteric gastrointestinal hemorrhage secondary to splanchnic artery aneurysms

BACKGROUND/AIMS

Gastrointestinal hemorrhages of obscure origin are often difficult to diagnose and manage. Of these, splanchnic artery aneurysms have emerged as an important disorder because of the increasing prevalence and formidable mortality rate associated with their rupture. We herein evaluated extra-enteric gastrointestinal bleeding related to these ruptured aneurysms.

METHODOLOGY

The medical records of 17 patients with splanchnic artery aneurysms known to be exclusively manifested as gastrointestinal bleeding were reviewed. The pathogenesis, clinical picture, diagnostic tests, management, complications, and outcomes were compiled and analyzed.

RESULTS

Of the seventeen patients, 12 patients had true aneurysms; 5 patients had false aneurysms. Pancreatitis, trauma, iatrogenic hepatobiliary injury, and atherosclerosis were the four major etiologies. The sensitivity rates measured by endoscopy, ultrasonography, computed tomography and visceral angiography were 20%, 50%, 67%, and 100%, respectively. An exact diagnosis was attained in 94% of the patients at the time of management. Transcatheter embolization was employed in 7 patients, complicated with hepatic and splenic infarcts, and pyogenic liver abscesses in 2 instances. Two patients had recurrent bleeding aneurysms post embolotherapy. Ten patients underwent surgical intervention which resulted in 2 cases of hepatic failure. One out of 5 patients with a true aneurysm died, while 4 out of 12 patients with false aneurysms eventually died. Overall, the mortality rate was 29%.

CONCLUSION

Even though the exact diagnosis can be made in most of the patients by modern imaging studies, the mortality rate was still formidable, especially in patients with false aneurysms, in whom the underlying causal diseases substantially influenced the major outcome.

An analysis of unnatural deaths between 1990 and 1994 in A-Lein, Taiwan

This is an analysis of all unnatural deaths (ICD-9, E47-E55) that occurred between 1990 and 1994 in A-Lein, Taiwan. Unnatural deaths for this period totalled 134, or 89.66 per 100,000 per year. The crude accidental mortality rate (E47-E53) and road traffic accident (RTA) mortality rate (E54 is many times larger than in other industrialized countries: 2.1-5.1 times and 2.4-7.7 times, respectively. These figures are even higher for males. The reported suicide rate in A-Lein is approximately equal to that in the UK, but less than other industrialized countries. The actual suicide mortality rate in A-Lein as computed in this survey was 1.8 times higher than reported, which was 2.4 times that of Taiwan as a whole and 2.1 times Great Britain; 30.9 per cent of male and 75 per cent of female unnatural deaths excluding RTAs were suicides (ICD-9 E48-E55). RTA deaths were 3.2 times higher among males than among females (P < 0.05) and 26.8 per cent were associated with alcohol consumption. Only 21.4 per cent of killed motorcyclists wore helmets and only 8.3 per cent of killed car drivers used seat belts. Unnatural deaths excluding RTAs were mostly among people of low socio-economic status aged 50-60 years with less than a college education. Of these, 75 per cent occurred at home or at work. The most common cause of non-traffic unnatural death excluding RTAs was suicide, and the second most common was drowning. In conclusion, it was found that high unnatural death rates in A-Lein are related to low socio-economic level, sex (males), drinking, inadequate safety protection while working and driving, and inadequate law enforcement.

Biliary complications during and after laparoscopic cholecystectomy

BACKGROUND/AIMS

Bile duct injury and bile leak are the most serious complications of laparoscopic cholecystectomy. The purpose of this study to present our experience in the management of biliary complications during and after laparoscopic cholecystectomy.

MATERIAL AND METHODS

There were eight biliary complications (0.72%) in 1115 consecutive laparoscopic cholecystectomies during the period from January 1991 to December 1995.

RESULTS

The biliary complications included: bile duct injuries in 3 patients, bile leak in 4 patients and malapplication of the endoclips on the common bile duct in patient. Three biliary complications were corrected by immediate conversion to laparotomy with good outcomes. Two patients with immediate postoperative bile leakage required laparotomy for religation of the cystic duct and one patient with delayed bile leakage was successfully corrected with conservative treatment. One common hepatic duct and right hepatic duct developed necrosis due to electrocoagulation and required a laparotomy with T-tube stent and had repeated attacks of cholangitis during the 21 month follow-up period. Another patient with common hepatic duct stricture due to endoclip injury needed re-laparotomy with T-tube stent and remained stationary over the 9 month follow-up period.

CONCLUSION

Bile leak and bile duct injuries after laparoscopic cholecystectomy present a difficult surgical problem, surgical or endoscopic interventions are needed to correct the biliary problem after the diagnosis was established by the radiological image study.

Pancreaticojejunal anastomotic leak after pancreaticoduodenectomy--multivariate analysis of perioperative risk factors

The records of 131 consecutive patients with periampullary carcinoma who underwent pancreaticoduodenectomy within a 12-year period were reviewed to determine the perioperative risk factors of pancreaticojejunal (PJ) anastomotic leak. Twenty-one PJ leaks were identified, for a frequency of 16% (21 of 131); 19% (4 of 21) of these patients eventually died of PJ leak-related complications. A total of 23 items of perioperative data, presumed as risk factors predisposing to PJ leak, were examined. By univariate analysis, advanced age, prolonged duration of untreated jaundice, deep jaundice, decreased creatinine clearance, increased intraoperative blood loss, and shock during operation were statistically significant. However, by multivariate analysis, only duration of jaundice, creatinine clearance, and intraoperative blood loss turned out to be independent risk factors. Noteworthily, jaundiced patients with impaired creatinine clearance not only had a higher incidence of PJ leak, but were also more liable to experience sepsis and intraabdominal bleeding, which uniformly elicited a grave clinical course. Routine preoperative biliary drainage failed to enhance the security of PJ. Completion pancreatectomy continued to carry a poor prognosis, and should be avoided when possible and replaced by early, aggressive radiologic intervention.

Enteric intussusception due to metastatic intestinal tumors

Enteroenteric intussusception caused by metastatic tumors is a very rare condition. Because of its rarity and rather mild abdominal physical presentation, preoperative diagnosis is not easily made. Two cases of enteric intussusception due to metastatic intestinal tumors, with the main symptom of melena, are reported. Intussusception was caused by metastatic liposarcoma in one patient and metastatic melanoma in the other. Both patients had long histories of malignant disease, for 15 and 8 years, respectively. They had undergone repeated surgical treatment for metastatic lesions. The diagnosis of enteric intussusception was initially made by computed tomographic scans and small bowel series and was confirmed by laparotomy and pathologic findings. We suggest that tumor metastasis to the small intestine with intussusception should be considered in patients with recurrent tumors and tarry stools.

Serum alanine aminotransferase level in relation to hepatitis B and C virus infections among blood donors

To assess the serum alanine aminotransferase (ALT) activity in relation to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among blood donors, antibodies to HCV (anti-HCV) and hepatitis B surface antigen (HBsAg) were detected in 400 blood donors with normal ALT level (< or = 750 mumol/s per liter), and 76 blood donors with raised ALT level. The prevalence of anti-HCV (10.5%) and HBsAg (28.9%) in the latter was higher than that (2.0% and 17.5%, respectively) in the former (p < 0.001 and p < 0.03, respectively). There was a trend that indicated that the risk of anti-HCV positivity increased with increasing age (p < 0.001). Thirty of 76 (39.5%) donors with raised ALT level were positive for anti-HCV or HBsAg. Compared with HBsAg-positive donors, donors with anti-HCV had higher serum ALT levels (p < 0.01) and greater mean age (p < 0.01). Multivariate analysis indicated that both anti-HCV (odds ratio: 6.2; 95% confidence interval: 2.2-17.8) and HBsAg (odds ratio: 2.2; 95% confidence interval: 1.3-3.9) were significantly associated with raised serum ALT activity. The estimated population-attributable risk was 8.6% for anti-HCV, and 13.8% for HBsAg. In conclusion, although HBV and HCV infections are independent risk factors of raised ALT activity among blood donors, they play a minor role in the etiology of raised ALT activity.

Clinical experience of esophageal ulcers and esophagitis in AIDS patients

In Taiwan, numbers of patients with the acquired immunodeficiency syndrome (AIDS) have been increasing in recent years. We present esophageal disease of different causes in 5(16%) heterosexual men among 31 AIDS patients over a 5-year period. Major symptoms included mild dysphagia in 4 (80%) patients and odynophagia in 3 (60%) patients. The duration of symptoms varied from 3 days to 6 months. The symptoms occurred before the diagnosis of AIDS in 3 patients. At esophagogastroduodenoscopy (endoscopy), all 5 patients had esophagitis and/or esophageal ulcers proved by histopathologic evaluation. Four had Candida esophagitis, 3 had cytomegalovirus esophagitis/ulcers and 2 had idiopathic esophageal ulcerations (IEU). Three patients had different esophagitis/ulcers at the same time or during follow-up. The median CD4 lymphocyte count at the time of diagnosis of esophageal disease was 12.2 cells/mm3 (range, 3 to 35 cells/mm3). The endoscopic pictures of the different causes of esophagitis/ ulcers lack uniformity in number, size and appearance. These observations make a conclusion that all AIDS patients with an esophageal disease should undergo endoscopy with biopsy to obtain a definitive diagnosis.