Chairpersons' opinions regarding quality control of surgical faculty performance in Japanese academic surgery departments

BACKGROUND

The governance and power structure of the department of surgery depends to a large extent on the chairperson's decisions in Japanese medical schools. This paper reports the current collective opinions of surgery department chairpersons regarding the quality assessment of surgical faculty performance.

METHODS

Surveyed were 78 chairpersons of general surgery departments from 72 Japanese medical schools. Chairpersons were questioned about administrative and organizational decision making: rank order requirements for full-time surgical faculties, coordination of staff for surgical operations, and performance outcome measures.

RESULTS

In all, 68 (87%) chairpersons responded. When selecting surgical faculties, publishing competence (45%) and collaborative personality (44%) were the two foremost concerns of chairpersons. Teaching experience (0%) and board certification (2%) showed the lowest rate for the first priority among the 6 elements listed. The operator was mainly decided by the chairperson (63%) whereas the rest of the operative team members were decided by either the chairperson (28%), a specialty team (38%), or attending surgeons (32%). Thirty-three chairpersons (49%) of 68 respondents used the morbidity and mortality conference as the only available approach for assessing surgical performance on a regular basis, whereas the remaining half did not have routine outcome measures.

CONCLUSIONS

The results of this study indicate that surgery department chairpersons deemed collaborative personality and publishing competence the two major requirements for candidates of surgical faculties. Although the morbidity and mortality conference is currently the only available approach for assessing surgical performance, the majority of chairpersons felt that outcome measures should be based on more objective and structured criteria.

Prospective evaluation of preoperative chemotherapy in resectable squamous cell carcinoma of the thoracic esophagus

A prospective study was performed to clarify the surgical outcome of patients with esophageal carcinoma who would benefit from induction chemotherapy followed by surgery. Of 55 eligible patients, 42 (76.3%) agreed to randomization with either chemotherapy followed by surgery (n = 21) or surgery alone (n = 21). The other 13 refused. The chemotherapy consisted of cisplatin, 5-fluorouracil and leucovorin. All 55 patients underwent esophagectomy with two- or three-field resection, including two (3.6%) hospital mortalities. Of the 21 patients receiving chemotherapy, the response rate was 33.3% after the first course and 60% after the second course. A complete response was not obtained. Responders to the first course showed a prolonged survival, however time to treatment failure did not differ between patients treated with chemotherapy followed by surgery or surgery alone. This chemotherapy offered a worse surgical outcome for patients with pretreatment diagnosis of T3. Multivariate analysis identified a partial response to the first course of chemotherapy to be a favorable prognostic indicator. Preoperative chemotherapy does not give a survival benefit over surgery alone for patients with advanced tumor (T3). Initial response to the first dose of chemotherapy is deemed to be a prognostic factor for patients with less advanced tumor (T1/T2).

Successful rescue of severe recurrent hepatitis C with interferon and ribavirin in a liver transplant patient

BACKGROUND

Rapid graft dysfunction caused by hepatitis C virus (HCV) reinfection, although uncommon, is a disastrous complication in liver transplant patients. Finding an effective therapy for this subgroup of patients with severe recurrent HCV is a priority.

METHOD

We describe a successful rescue of a 46-year-old man with recurrent hepatitis C (HCV genotype 1b) using long-term interferon (IFN) and ribavirin. The patient had a very aggressive type of posttransplantation HCV infection, as judged by biochemical and histologic findings.

RESULTS

Despite high pretreatment values of serum alanine aminotransferase (ALT; peak value of 901 IU/L) and HCV-RNA (2.3 x 10(6) copies/ml), the combination therapy with IFN and ribavirin produced a rapid normalization of the serum ALT values, accompanied by the clearance of serum HCV-RNA. Although HCV-RNA reappeared in the serum at 3 months, the patient had continued ALT normalization and histological improvement with follow-up of over 26 months to date after the initiation of the combination therapy.

CONCLUSION

This observation suggests that IFN in combination with ribavirin may offer an effective therapeutic option for liver transplant patients with severe recurrent hepatitis C.

Semiquantitative morphological analysis of stromal cells in the irradiated and recovering rat thymus

To understand the roles of thymic stromal cells in T-lymphocyte development, we semiquantitatively analysed rat thymi recovering from irradiation (6 Gy), using a transmission electron microscope. The most striking findings were that the percentage of subcapsular epithelial cells significantly increased in the cortex on day 3 after irradiation compared with the control; the percentage of intermediate epithelial cells significantly increased in the cortex on days 3 and 5 after irradiation and in the medulla on days 5 and 7 compared with the control; the interdigitating cells disappeared from the medulla by day 7 after irradiation and reappeared on day 9. The present data thus reveal that during recovery after irradiation (6 Gy), marked changes occur in the relative proportions of different epithelial cell subtypes in the cortex and medulla of the rat thymus. In addition, the percentages of macrophages and interdigitating cells also changed during the recovery. These changes, which may be associated with the abrupt proliferation of thymocytes after irradiation, should shed light on the significance of stromal cells in the T cell development.

Interleukin-1 receptor antagonist mRNA expression and the progression of gastric carcinoma

Interleukin-1 receptor antagonist (IL-1ra), an endogeneous inhibitor of IL-1, plays an immunosuppressive role in vivo by blocking the proinflammatory effects of IL-1. In the present study, we examined whether IL-1ra expression in human gastric carcinoma correlates with tumor progression and/or metastatic potential. The reverse transcription-polymerase chain reaction was used to compare the expression of the secreted form of IL-1ra (sIL-1ra) and the intracellular form of IL-1ra (icIL-1ra) mRNA in tumor and corresponding benign tissue obtained from 38 patients with gastric carcinoma. The incidence of sIL-1ra mRNA expression was significantly higher in tumor (52%) than in corresponding benign tissue (18%) (P = 0.002). On the contrary, icIL-1ra mRNA was detected in all tumors and benign tissues. The expression of sIL-1ra mRNA by malignant tissue correlated positively with both lymph node metastasis (P = 0.008) and liver metastasis (P = 0.015). There was no association between tumor sIL-lra mRNA expression and other clinicopathologic factors. The degree of regional lymph node reaction, such as sinus histiocytosis, in tumors expressing sI-1ra mRNA was significantly weaker than that in tumors without sIL-1ra mRNA expression (5/20 vs. 12/18, P = 0.010). These results demonstrate that the altered expression of sIL-1ra by malignant tissue may be related to the progression of gastric carcinoma via modulating host immune response.

Stimulation of haematogenous liver metastases by ischaemia-reperfusion in rats

OBJECTIVE

To find out whether hepatic ischaemia-reperfusion stimulates hepatic tumour metastases using a cell line of rat ascitic hepatoma (AH130).

DESIGN

Prospective experimental study.

SETTING

University laboratories, Japan.

MATERIALS

118 male Donryu rats.

INTERVENTION

After laparotomy alone (group 1, n = 35) or laparotomy and 20-minutes ischaemia (group 2, n = 34) or laparotomy and 30-minutes ischaemia (group 3, n = 34) of the median and left hepatic lobes, the animals were given either an intraportal injection of 1 x 10(5) or an intravenous injection of 1 x 10(6) viable AH130 cells.

MAIN OUTCOME MEASURES

10 days after inoculation of tumour cells the number of nodules on the surface of the right lobe and of the median plus left lobes were separately counted for each liver.

RESULTS

Irrespective of the route of tumour inoculation in group 1, there was no significant difference in the number of tumours/g liver between the right and the median plus left lobes. However, in groups 2 and 3, the number of tumours/g liver in the median plus left lobes was significantly higher than in the right lobe (p < 0.05). Furthermore, in the median plus left lobes, animals who had had 30 minutes of ischaemia had significantly more tumours than those in the other two groups (p < 0.01).

CONCLUSION

Hepatic ischaemia-reperfusion may increase the risk of development of haematogenous liver metastases, by stimulating tumour cell-endothelial cell interactions.

Vascular and stromal changes in irradiated and recovering rat thymus

To analyze the mechanisms responsible for thymocyte proliferation, maturation and migration in the thymus, the rat thymus just after, and recovering from irradiation was studied morphologically. The vascular structures of the rat thymus after a radiation dose of 6 Gy were found to be destroyed on day 3, but had recovered to almost normal by day 7, suggesting that the abrupt recovery of thymus structure after irradiation was due primarily to this change in vascular structure. Furthermore, the epithelial tissues in the thymic cortex appeared to contribute to this abrupt proliferation, and possibly to the abrupt maturation of thymocytes, while medullary epithelial tissues remained sparse and appeared inactive for a relatively long period. These findings are considered important for understanding the interrelationship between thymic epithelial cells and thymocytes with respect to thymocyte proliferation, maturation and migration.

How the lymph node metastases toward cervico-upper mediastinal region affect the outcome of patients with carcinoma of the thoracic esophagus

BACKGROUND

The aim of this study was to establish whether the site of lymph node metastasis influences the survival of patients with carcinoma of the thoracic esophagus.

METHODS

A series of 159 patients with lymph node metastasis who underwent right transthoracic R0 esophagectomy was analyzed retrospectively. Sites of the nodal metastasis were divided into two regions; the neck and/or upper mediastinum above (upward metastasis) and the abdomen and/or lower mediastinum below (downward metastasis) the tracheal carina.

RESULTS

Univariate analysis of prognostic factors revealed the tumor location, distant lymphatic metastasis, number of metastatic nodes and upward metastasis influenced survival, but downward metastasis did not. Multivariate analysis showed that the number of metastatic nodes and upward metastasis were also significant prognostic factors. Thirty-one (33.3%) of the 93 patients with, but only 6 (9.1%) without, upward metastasis had recurrences in the neck and/or upper mediastinum (P = 0.0002). Eighteen (60.0%) of the 30 patients with extranodal invasion in the neck and/or upper mediastinum had recurrence in these regions.

CONCLUSIONS

Nodal metastasis in the neck and/or upper mediastinum was a significant risk factor for prognosis, the same as the number of metastatic nodes.

Does preoperative chemotherapy cause adverse effects on the perioperative course of patients undergoing esophagectomy for carcinoma?

The aim of this study was to clarify whether preoperative chemotherapy caused adverse effects on the perioperative course of patients undergoing esophagectomy. A total of 42 esophageal cancer patients were entered into a randomized trial and were analyzed. Twenty-one patients were assigned to immediate surgery (Surgery Group). The other 21 received two 5-day courses of chemotherapy comprising cisplatin (70 mg/m2) on day 1, and fluorouracil (700 mg/m2) and leucovorin (20 mg/m2) on each of days 1 to 5 (chemotherapy group). Hospital mortality comprised of one patient (2.3%) who had undergone an operation in the beginning of this series at 21 days after chemotherapy. Thereafter, the interval between the chemotherapy and operation was prolonged, with the average being 35 +/- 7 days. Preoperatively, both the lymphocyte counts and serum albumin levels were not increased in the chemotherapy group of patients even though their body weights increased. In the chemotherapy group, the operation time and the blood loss were increased and, on the 1st postoperative day, the development of systemic inflammatory response syndrome was high but the level of C-reactive protein was low. The incidence of positive microbial cultures of sputum and/or wound discharge within 8 postoperative days was higher in the chemotherapy group (42.9%) than in the surgery group (4.8%). The host defense damage caused by chemotherapy may be prolonged and may show adverse effects in patients undergoing esophagectomy in the early postoperative period. Minimally, a 4-week interval between the completion of chemotherapy and operation is recommended for preventing surgical mortality related to the preoperative chemotherapy.

Mediastinal esophageal cyst causing unilateral hyperlucent lung

Unilateral emphysema secondary to bronchial obstruction by a foregut-derived mediastinal cyst is rare. Here we describe an infant with a unilateral hyperlucent lung due to compression on the left main bronchus by an esophageal cyst, visualized by chest computed tomography and magnetic resonance imaging. A chest roentgenogram and a perfusion scan presented the normalized left lung after resection of the cyst.

Thymidine phosphorylase in human esophageal squamous cell carcinoma

BACKGROUND

Experimental evidence has shown that thymidine phosphorylase (dThdPase) is identical to platelet-derived endothelial cell growth factor (PD-ECGF) and has angiogenic activity. The enzymatic activity of dThdPase was needed for the angiogenesis by the enzyme. These observations were catalysts for the current study.

METHODS

The authors examined retrospectively the expression of the angiogenic factor dThdPase in 163 primary esophageal squamous cell carcinomas and its association with angiogenesis and clinicopathologic findings. To determine whether dThdPase expression was a prognostic factor after adjustment for the established prognostic factors and microvessel count, the authors conducted a survival analysis using the Cox proportional hazards model.

RESULTS

dThdPase was expressed significantly more frequently (P < 0.001) in esophageal carcinomas (83 of 163, 50.9%) than in adjacent nonneoplastic esophageal tissue samples (20 of 163, 12.3%). Microvessel counts were significantly higher (P < 0.001) in dThdPase positive carcinomas (18.3+/-6.2) than in dThdPase negative carcinomas (8.2+/-7.5). Significant correlations were observed between dThdPase expression and numerous clinicopathologic findings, including pT, pN, pM categories; lymphatic invasion; venous invasion; and residual tumors. Prognostic variables studied using a Cox hazard regression model confirmed that dThdPase expression was an independent prognostic factor in esophageal squamous cell carcinoma, although pN category was the best predictor of patient survival.

CONCLUSIONS

This study indicated that in esophageal squamous cell carcinoma, dThdPase expression is associated with angiogenesis and is an unfavorable prognostic factor. These findings implied that the inhibition of dThdPase would improve the prognoses of some patients with dThdPase positive esophageal tumors.

Assessment of cervical lymph node metastasis in esophageal carcinoma using ultrasonography

OBJECTIVE

To evaluate the efficacy of ultrasonography for the diagnosis of cervical lymph node metastasis in esophageal carcinoma.

SUMMARY BACKGROUND DATA

Ultrasound (US) examination is useful for diagnosing lymph node metastasis. However, few reports have examined its role in the decision to perform cervical lymph node dissection in esophageal carcinoma.

METHODS

Ultrasound examination was performed to evaluate cervical lymph node metastasis in 519 patients with esophageal carcinoma. The patients were divided into 5 groups according to treatment received: group 1, 153 patients who underwent curative resection of primary tumor by right thoracotomy and complete bilateral cervical lymphadenectomy; group 2, 112 patients who underwent curative resection of primary tumor by right thoracotomy but without cervical lymphadenectomy; group 3, 78 patients who underwent esophagectomy by left thoracotomy or blunt dissection with or without removal of cervical lymph nodes; group 4, 76 patients with palliative resection without cervical lymphadenectomy; and group 5, 100 patients without any surgical treatment. US diagnosis was compared with histologic findings or cervical lymph node recurrence.

RESULTS

Lymph node metastasis was detected in 30.8% of patients (160/519). The sensitivity, specificity, and accuracy of US diagnosis in group 1 were 74.5%, 94.1%, and 87.6%, respectively. Cervical lymph node recurrence was seen in 7 patients (4.6%) in group 1, in 4 patients (3.6%) in group 2, and 3 patients (3.8%) in group 3. Although the incidence of cervical lymph node metastasis as determined by US examination was high in groups 4 and 5, almost none of the patients died of cervical lymph node metastasis.

CONCLUSIONS

Ultrasound examination plays a useful role in the decision to perform cervical lymph node dissection in patients with esophageal carcinoma, particularly in those with potentially curative dissection.

T cell proliferation-augmenting activities of the gene 3 protein derived from a phage library clone with CD80-binding activity

We have isolated a phage clone, F2, by panning a phage library with a CTLA4-conformation recognizing mAb (anti-CTLA4 mAb). The unique sequence of 15 amino acids with an internal disulfide bond was inserted in the gene 3 proteins of F2 phage clone (F2-g3p). We show here that 1) F2-g3p was recognized with anti-CTLA4 mAb but not with anti-CD28 mAb, and 2) F2-g3p bound to CD80 but not to CD86. The surface plasmon resonance analysis showed that F2-g3p strongly bound CD80. F2-g3p inhibited the binding of CTLA4 to CD80 but not to CD86. In contrast, F2-g3p weakly inhibited the binding of CD28 with CD80. When hen egg lysozyme (HEL)-primed lymph node cells were stimulated with HEL in the presence of F2-g3p in vitro, cell proliferation was highly potentiated. In the absence of antigenic stimulation, F2-g3p induced no T cell proliferation, indicating the costimulatory nature of F2-g3p. The T cell-augmenting activity of the F2 clone was eliminated when the F2 clone was preincubated with CD80-Ig before the addition to the cultures, indicating the involvement of CD80-binding in the F2-g3p-mediated immunopotentiation. Thus, the F2 motif conferred CD80-binding activity and an immunoregulatory function to the g3p.

Efficacy of repeated percutaneous isolated liver chemoperfusion in local control of unresectable hepatocellular carcinoma

BACKGROUND/AIMS

Percutaneous isolated liver chemoperfusion (PILP) with hepatic venous isolation and charcoal hemoperfusion (HVI-CHP) enables high-dose intraarterial infusion of cytotoxic agents while reducing systemic toxicity. We report here the effect of repeated PILP with HVI-CHP on local control of unresectable hepatocellular carcinoma (HCC).

METHODOLOGY

After placement of a hepatic arterial infusion (HAI) catheter, a 4-lumen-2-balloon catheter (24F) was introduced into the retrohepatic inferior vena cava through the femoral vein, and the balloons were inflated to accomplish HVI. During HAI of adriamycin (60-150 mg/m2), total hepatic venous outflow was captured via fenestrations of one major lumen between the balloons and pumped out into CHP filters. The filtered blood was returned to the right atrium through the end opening of another major lumen of the catheter. Of 30 patients, 8 had repeated PILP in a range of 2-4 treatments, and 22 had a single treatment.

RESULTS

Eleven (52%) of 21 evaluable patients in the single PILP group and 7 out of 8 patients (88%) in the repeated PILP group had partial or complete response. Median durations of response in responding patients were 6 and 21 months in the single and the repeated PILP groups, respectively (p=0.02). The 1- and 2-year survival rates (single vs. repeated) were 57% vs 88%, and 29% vs 70%, respectively (p=0.05).

CONCLUSIONS

Repeated PILP could be performed safely in patients with advanced HCC and significantly prolonged the duration of remission in patients with unresectable HCC.

Successful nerve regeneration and persistence of donor cells after a limited course of immunosuppression in rat peripheral nerve allografts

BACKGROUND

The origin of Schwann cells and effect of a limited course of immunosuppression using cyclosporine (CsA) were examined in rat peripheral nerve allotransplants.

METHODS

Phenotypes of Schwann cells in groups without, with continuing, and with limited (12 weeks) CsA treatment were examined immunohistochemically in allogeneically and syngeneically transplanted animals from 4 to 36 weeks after transplantation.

RESULTS

In the group receiving no CsA, little nerve regeneration was obtained; donor Schwann cells were rejected and replaced by recipient cells. In continuing and limited-course CsA groups, successful nerve regeneration was achieved at postoperative week 36, as was also observed in the syngeneic group. Schwann cells in the continuing CsA group remained donor-derived. In the limited-course CsA group, graft rejection and loss of function occurred after the withdrawal of CsA, and donor Schwann cells were replaced by recipient cells in the part of the graft where rejection had been complete. However, many donor Schwann cells remained at week 36, when the rejection response subsided.

CONCLUSION

Possible clinical use of a limited course of immunosuppression was supported by this demonstration of long term persistence of donor Schwann cells.

Regional pharmacokinetics of doxorubicin following hepatic arterial and portal venous administration: evaluation with hepatic venous isolation and charcoal hemoperfusion

We evaluated the regional pharmacokinetics of doxorubicin after hepatic arterial infusion (HAI) and portal venous infusion (PVI) using a novel system for hepatic venous isolation and charcoal hemoperfusion (HVI-CHP). The HVI-CHP system was used to determine directly the doxorubicin plasma concentration in the hepatic vein and the hepatic venous flow rate, and simultaneously, to eliminate hepatic re-entry of the drug. Beagles received doxorubicin (1 mg/kg) through either the hepatic artery (HAI group, n = 6) or the portal vein (PVI group, n = 6). In both groups, hepatic venous blood was completely isolated and directed to the CHP filter. The filtered blood was returned through the left jugular vein. During HVI-CHP, the hepatic venous flow rate was monitored and plasma doxorubicin concentrations were serially measured in prefilter (= hepatic venous), postfilter, and systemic blood. The hepatic tissue uptake of doxorubicin was determined based on the blood flow rate and doxorubicin level in the hepatic vein. The hepatic extraction ratio of doxorubicin was defined as the percentage hepatic tissue uptake to the amount of drug administered. During drug infusion, similarly in either group, HVI-CHP produced a 66-87% reduction of the postfilter doxorubicin level as compared with the prefilter level. The prefilter drug level was significantly lower in HAI group than in PVI group (P < 0.01). Thus, the area under the time concentration curve for the prefilter drug level in the HAI group (6.90+/-0.96 microg min/ml) was significantly lower than that in the PVI group (18.10+/-2.90 microg min/ml, P < 0.01). Conversely, the hepatic extraction ratio in the HAI group (84.6+/-2.9%) was significantly higher than that in the PVI group (58.1+/-3.4%, P < 0.01). We conclude that in the beagle, doxorubicin is more effectively extracted by the liver when administered via the hepatic artery than when administered via the portal vein. These results indicate that HAI of doxorubicin is superior to PVI in terms of reduction of systemic drug exposure and systemic toxicity.

Pretransplant virological markers hepatitis C virus genotype and viremia level are not helpful in predicting individual outcome after orthotopic liver transplantation

BACKGROUND

Recurrence of hepatitis C viremia after orthotopic liver transplantation (OLT) is nearly universal, leading to variable outcome from no to severe recurrent disease. In the present study, the prognostic relevance of hepatitis C virus (HCV) genotypes and viremia for the development and severity of graft hepatitis was investigated.

METHODS

A total of 79 patients with chronic hepatitis C who could be followed for 1 to 78 months (mean: 30 months) after OLT were included in this study. HCV RNA concentrations were measured before OLT, 1 month after OLT, as well as in the long-term follow-up after OLT in 54 of the 79 patients.

RESULTS

Graft hepatitis could be documented in 40 of the 79 patients (51%), and 7 of them (9%) progressed to liver cirrhosis. More severe forms of graft hepatitis predominated in patients with subtype 1b infection, and all seven patients with progression to liver cirrhosis had subtype 1b (P=NS). Neither the pretransplant nor the posttransplant HCV RNA levels were significantly associated with the occurrence of graft hepatitis. However, there was a trend of more severe recurrent disease in subtype 1b-infected patients with high level viremia in the early course after OLT.

CONCLUSIONS

Pretransplant HCV virological markers are not helpful to predict the outcome after OLT. However, it should be further investigated whether estimation of HCV genotype and viremia levels very early after OLT, i.e., within the first weeks, may be a better approach to recognize high-risk patients.

Percutaneous isolated liver chemoperfusion for treatment of unresectable malignant liver tumors: technique, pharmacokinetics, clinical results

We have developed a single-catheter technique for percutaneous isolated liver chemoperfusion (PILP) with hepatic venous isolation and charcoal hemoperfusion (HVI-CHP) for the treatment of malignant liver tumors. We report here the surgical technique, pharmacokinetics, and effectiveness of PILP in multiple advanced liver tumors. Twenty-eight patients with hepatocellular carcinoma (HCC) and 18 with metastatic liver tumors underwent a total of 61 PILPs with HVI-CHP. HVI-CHP was accomplished mainly by the single-catheter technique using a novel four-lumen, two-balloon catheter; it was used to isolate and capture total hepatic venous outflow and, at the same time, to direct the filtered blood to the right atrium. Under HVI-CHP, either doxorubicin 960-150 mg/m2) or cisplatin (150-200 mg/m2) was infused via the hepatic artery. The PILP was completed successfully in all 61 trials. Two of forty-six patients died early; one of necrotizing pancreatitis and the other of hepatic arterial thrombosis. Both deaths were related directly to the hepatic arterial catheter. Excluding these two deaths, the treatments were well tolerated. The major side effects were mild to moderate chemical hepatitis and reversible myelosuppression. Of the 27 evaluable HCC patients, 17 (63%) had an objective tumor response (5 complete and 12 partial responses). In 15 patients with colorectal hepatic metastases (CHM), 7 had a sharp decrease in serum carcinoembryonic antigen (CEA) levels (to < 50% of their pretreatment levels) after treatment. However, a single PILP had limited efficacy in terms of the durability of remission (< or = 6 months in most CHM patients, as assessed by CEA levels). These results indicate that PILP with HVI-CHP has high efficacy in most patients with multiple advanced liver tumors. In addition, the results suggest a role of multiple treatment courses of PILP in the induction of long-term remission, especially for patients responsive to the first treatment.

Polyamide microcapsules containing alginic acid: extractability of metal ions and surface characterization by XPS

Polyamide microcapsules containing alginic acid as a water-soluble macromolecular ligand (Alg-MC) were prepared by the interfacial polycondensation of sebacoyldichloride with hexamethylenediamine in a w/o emulsion system. The mean diameter of the microcapsules was 1.2 microns. The extractabilities of Cu(II), Ni(II), Co(II) and Ag(I) into the Alg-MC were examined and the highest uptake was found for Cu(II). It was ascertained that not only the inner ligand solution but also the membrane can accumulate the metal ions. The surface composition of the microcapsules was characterized by X-ray photo-electron spectroscopy (XPS) and it was found that some functional groups of alginic acid were present at the surface penetrating the membrane.

Activation of polymorphonuclear leukocytes in oleic acid-induced lung injury

OBJECTIVE

Oleic acid (OA) can produce a lung injury similar to the adult respiratory distress syndrome (ARDS). Elastase and superoxides are thought to have an effect in ARDS. However, the effect that elastase and superoxide have in OA lung injury is unclear. To examine their involvement in OA lung injury, we tested the effects of methoxysuccinyl-alanyl-alanyl-prolyl-valyl chloromethyl ketone (MAAPVCK), an elastase inhibitor, and N-acetyl-L-cysteine (NAC), an active oxygen scavenger, on the increase in pulmonary vascular permeability caused by OA. We also examined whether OA stimulated elastase and/or superoxide release from polymorphonuclear leukocytes (PMNs).

DESIGN

Prospective trial.

SETTING

University laboratory.

INTERVENTIONS

(1) Guinea pigs were anesthetized. MAAPVCK (2.5 mg/ kg) or NAC (150 mg/kg) was infused over OA (15 microl/kg) injection. Evans blue was used to measure vascular permeability. (2) PMNs were isolated from the blood of guinea pigs and rats. Elastase release was measured with MeO-Suc-Ala-Ala-Pro-Val-7-amino-4-methylcoumarin. Superoxide production was measured by the ferricytochrome c reduction method.

MEASUREMENTS AND RESULTS

OA caused pulmonary hemorrhage and an increase in vascular permeability. MAAPVCK and NAC significantly attenuated the increase in vascular permeability in distal bronchus and trachea, respectively. OA induced superoxide production from PMNs in guinea pigs, but elastase release from PMNs was not detected.

CONCLUSIONS

These results suggest that elastase and superoxide are involved in OA lung injury.

[The long-term results of percutaneous isolated hepatic perfusion for patients with advanced hepatocellular carcinoma]

We studied the long-term outcome of percutaneous isolated hepatic perfusion (PIHP) for patients with hepatocellular carcinoma. This study included 31 patients with Stage IVA and 5 with IVB disease treated by PIHP until December, 1997. The mean age and tumor diameter were 55 and 7.7 cm, respectively. Twenty-two had portal vein invasion, 13 had hepatic vein invasion, and all patients had multiple intrahepatic metastases of more than 5 tumor foci. The PIHP with adriamycin or cisplatin was undertaken in a total of 50 treatments in these 36 patients. CR was observed in 6 and PR in 13 with an overall response rate of 59%, excluding 4 patients who were not evaluable. Five of 6 patients with CR remain free of disease at 7 to 54 months after the first treatment. The overall survival rate was 67% at 1 year and 32% at 5 years. The survival rates of Stage IVA patients (1-year = 71%, 5-year = 36%) were higher than Stage IVB patients (1-year = 20%, 5-year = 0%). The 5-year survival rates of patients with vascular invasion (Vp1-3 = 23%, Vv1-3 = 8%) were lower than those without it (Vp0 = 47%, Vv0 = 51%). These results indicated that PIHP achieved a 5-year survival rate of approximately 40% in patients with multiple advanced hepatocellular carcinoma in the absence of distant organ metastases and marked vascular invasion, and yielded complete long-term remission in some of these patients.