Asymmetric adiabatic pulses for NH selection

Many types of NMR experiments demand the use of frequency-selective pulses to invert magnetization within discrete frequency limits. For certain experiments, only one side of the inversion band must be sharply demarcated, in which case this transition bandwidth can be narrowed when using an asymmetric adiabatic full passage. In the present study, a highly efficient asymmetric adiabatic full passage was created from a combination of two adiabatic half passages which used different modulation functions (HS12 and tanh/tan). Each adiabatic half passage occupied a different amount of time in the total pulse and performed one-half of the inversion. On one side, HS12 produced a sharp transition between inverted and noninverted states which was approximately 2.5 times narrower than the transition bandwidth afforded by a symmetric hyperbolic secant pulse of equal length. On the other side of the narrow transition band, the tanh/tan pulse achieved broadband inversion. These asymmetric pulses were applied to select NH groups immediately adjacent to the water signal in water-flip-back HSQC experiments using a double spin echo for the reverse INEPT step.

Microvascular prefabricated free skin flaps for esophageal reconstruction in difficult patients

BACKGROUND

Reconstruction of the esophagus for complicated benign stricture or after resection of malignant lesion is still a challenge for surgeons. When abdominal viscera cannot be used, skin flaps are selected for esophageal reconstruction. However, skin flaps for esophageal reconstruction are notorious for leakage, and have not been widely accepted. Prefabrication before microvascular transfer to its final site can improve the result of esophageal reconstruction when skin flaps are used.

METHODS

Eight patients with complicated corrosive esophagitis had been treated with prefabricated skin flaps for esophageal reconstruction. The procedures are described in detail.

RESULTS

All patients healed well without leakage. The barium study showed smooth passage. There was no dysphasia or regurgitation after education. Pulmonary complication happened in only 1 patient. Revision for the distal anastomosis was required in 1 patient due to narrowing. When the skin tube is long, the patients need water (or soup) to facilitate swallowing and occasionally use their hand to help the food passage. This method has the following advantages: (1) healing of the long suture line before transfer to withstand the intestinal juice; (2) reliable viability in the distal part of the flap, especially when an extended length of the flap is required; (3) more length of stable tissue for two-layered, tension-free anastomosis at the junction of skin and gastrointestinal mucosa to prevent leakage; and (4) the flap can be placed in the substernal position to meet the aesthetic requirement of young patients. The disadvantage was the staged operations. However, after prefabrication the transfer becomes safe and free of leakage. The overall morbidity is minimal.

CONCLUSIONS

In rare situations when skin flaps are used for esophageal reconstruction, prefabrication provides advantages over conventional one-stage methods, although it needs additional procedures. This method is a combination of conventional technique and microsurgery.

Value of magnetic resonance cholangiopancreatography in demonstrating major bile duct injuries following laparoscopic cholecystectomy

BACKGROUND

Conventionally, recognition of bile duct injuries after laparoscopic cholecystectomy largely relies on endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC). However, these invasive procedures are not without risk. Preliminary experience with use of magnetic resonance cholangiopancreatography (MRCP) to identify these injuries is reported.

METHODS

The medical records of five patients who had undergone laparoscopic cholecystectomy and had suspected major bile duct injuries were reviewed. All five patients underwent MRCP, followed by conventional cholangiography: either ERCP or PTC, or both. The findings of MRCP and conventional cholangiography were compared.

RESULTS

Four patients had proven bile duct injuries. The remaining patient had gallstones dislodged into the common bile duct (CBD) during laparoscopic cholecystectomy, which presented as transient jaundice mimicking a bile duct injury. The MRCP images were of higher diagnostic value than conventional cholangiographic images in four patients with frank bile duct injury. For these patients, ERCP showed only the cut-off sign of the CBD, and PTC was needed to visualize the upper biliary system. MRCP, however, demonstrated the entire biliary system proximal and distal to the amputated or stenotic sites simultaneously. In the remaining patient with dislodged gallstones, the two techniques yielded similar diagnostic information.

CONCLUSION

This preliminary study suggests that MRCP is an ideal diagnostic test whenever bile duct injury following laparoscopic cholecystectomy is suspected.

Arginine-nitric oxide pathway in plasma membrane of rat hepatocytes during early and late sepsis

OBJECTIVE

To study the transported L-arginine in rat hepatocytes during different stages of sepsis.

DESIGN

A prospective, controlled study.

SUBJECTS

Thirty-six Sprague-Dawley male rats (250 to 300 g) were anesthetized and studied.

INTERVENTIONS

Early sepsis was produced 9 hrs after cecal ligation and puncture (CLP) and late sepsis developed 18 hrs after CLP. The control group underwent sham operation. Plasma membrane of rat hepatocytes was prepared by differential centrifugation. The [3H] L-arginine uptake of plasma membrane vesicles during sepsis was measured and inhibition studies employing omega-nitro-L-arginine methyl ester (L-NAME) and aminoguanidine were performed.

MEASUREMENTS AND MAIN RESULTS

L-arginine transport was saturable, increased linearly with plasma membrane protein concentration, and increased with uptake time up to 5 mins. [3H] L-arginine uptake increased by 77% to 121% (p < .05) during early sepsis, with no significant changes during late sepsis. Comparing inhibitors of nitric oxide synthase, L-NAME was effective in inhibiting L-arginine transport while aminoguanidine was not.

CONCLUSIONS

L-arginine transport was enhanced in rat hepatocytes during the early stage of sepsis. The increased uptake of L-arginine could contribute to the increase production of nitric oxide by hepatocyte during sepsis.

Prognostic factors in node-negative breast cancer patients: the experience in Taiwan

BACKGROUND

Adjuvant chemotherapy has improved the length of disease-free survival and overall survival in node-negative breast cancer patients. It has been a common practice to select only the patients with higher rates of recurrence for adjuvant therapy. Therefore, it is essential to define the risk factors in node-negative breast cancer patients.

MATERIALS AND METHODS

Two hundred fifty-five patients with axillary node-negative breast cancers without adjuvant chemotherapy or hormonal therapy at Chang Gung Memorial Hospital between 1981 and 1986 were included in this study. Tissue blocks for DNA flow cytometry study was available in the tumors of 145 patients.

RESULTS

The median follow-up period was 121 months and the percentages of patients with 10 years of disease-free survival (DFS) and overall survival (OS) were 75.1% and 82.2%, respectively. The significant poor prognostic factors for 10 years of OS were a tumor size larger than 3 cm, negative estrogen and progesterone receptor status, and having a non-diploid tumor (p value = 0.0176, 0.048 and 0.016, respectively). The patients with frozen section, high mitotic rate, and Scarff-Blood-Richardson (SBR) grade II and III tumors had a worse prognosis than the others, but this trend did not reach statistical significance. The patients with positive estrogen receptor status had a 10-year disease-free rate (DFR) of 94%, and these with tumors less than 2 cm plus SBR grade I had a 10-year DFR of 92%.

CONCLUSION

The node-negative breast cancer patients with a low risk of recurrence were those who had estrogen receptor positive, tumor less than 2 cm with SBR grade I, and intraductal carcinomas. Adjuvant chemotherapy would be no benefit for these patients.

Multiple-pulse mixing sequences that selectively enhance chemical exchange or cross-relaxation peaks in high-resolution NMR spectra

Rotating-frame NMR experiments which either emphasize or suppress cross relaxation, and which simultaneously suppress TOCSY, COSY, and zero-quantum peaks in NMR spectra, are presented and analyzed. The new experiments rely on mixing sequences which follow naturally from the transverse-ROESY (Tr-ROESY) sequence of Hwang and Shaka, and which are applicable to larger molecules in solution (spin diffusion limit). In the first variant a modified Tr-ROESY sequence, called multiple-pulse ROESY (MP-ROESY), is used to enhance cross-relaxation peak intensity compared to Tr-ROESY; in the second, called phase-modulated CLEAN chemical exchange (CLEANEX-PM), cross-relaxation peaks are greatly attenuated. The two methods are thus complementary: MP-ROESY is used to observe Overhauser peaks, and CLEANEX-PM is used to eliminate them, permitting clear observation of chemical exchange peaks alone. The new techniques are examined by theory and experiment. Practical guidelines that will result in high-quality spectra are given, including the judicious use of continuous weak static magnetic field gradients.

Comparison of two soluble guanylyl cyclase inhibitors, methylene blue and ODQ, on sodium nitroprusside-induced relaxation in guinea-pig trachea

To clarify further the role of cyclic GMP in mediating the relaxant response in guinea-pig trachea induced by sodium nitroprusside (SNP), the effects of soluble guanylyl cyclase inhibitors, methylene blue and 1H-[1,2,4]oxadiazolo[4,3,-a]quinoxalin-1-one (ODQ) on SNP-induced muscle relaxation and cyclic GMP accumulation were determined. SNP (0.3-100 microM) evoked a concentration-dependent relaxation of guinea-pig isolated tracheas precontracted with 0.3 microM carbachol. Preincubation of the preparations with methylene blue (10, 30 and 100 microM) resulted in a slight but concentration-dependent prevention of the relaxant response to SNP. In contrast, the relaxation to SNP was extensively prevented by 3 microM ODQ and almost abolished by 10 microM ODQ. SNP (30 microM) induced a significant elevation of cyclic GMP accumulation (from 1.34+/-0.14 to 5.39+/-0.28 pmol mg(-1) protein, n= 5; P<0.001), which was partially attenuated by 100 microM methylene blue (3.11+/-0.51 pmol mg(-1) protein, n=5; P<0.05), whereas completely abolished by 10 microM ODQ (1.31+/-0.28 pmol mg(-1) protein, n = 5; P<0.001). Methylene blue, but not ODQ and Nomega-nitro-L-arginine methyl ester (L-NAME), caused a concentration-dependent contraction in the tracheal preparation. The tension produced by 100 microM methylene blue was 41.8+/-4.3% (0.3 microM carbachol as 100%; n = 12). Moreover, the non-selective muscarinic receptor antagonist atropine and the M3-selective antagonist 4-diphenylacetoxy-N-methylpiperidine methiodine greatly inhibited the contractile effect evoked by methylene blue (100 microM). In conclusion, this study provides substantial evidence that SNP-induced muscle relaxation in guinea-pig trachea is completely via a cyclic GMP-dependent mechanism. Furthermore, ODQ, but not methylene blue, will likely become an important tool in differentiating between cyclic GMP-dependent and -independent effects of nitric oxide.

Hepatocellular carcinoma complicated with coexisting hepatolithiasis: pitfalls in diagnosis and management

Nineteen patients with hepatocellular carcinoma associated with hepatolithiasis were retrospectively analyzed. Eleven of the 19 patients presented with hepatolithiasis-related biliary infection. Diagnosis was erroneously assumed to be hepatolithiasis alone, liver abscess, or cholangiocarcinoma in five of 11 patients before surgery was attempted. Middle-age, male sex, liver cirrhosis, hepatitis B or C infection, abnormal alpha-fetoprotein, and negative carcinoembryonic antigen raised the suspicion of associated hepatocellular carcinoma rather than cholangiocarcinoma in patients with hepatolithiasis. Antibiotics and nonoperative methods to resolve biliary infection first, followed by hepatectomy, in selected cases, to eradicate hepatocellular carcinoma and hepatolithiasis simultaneously provides the best chance for long-term survival. Otherwise, patients often died of hepatolithiasis-related biliary sepsis rather than hepatocellular carcinoma per se in the long run.

Clinical analysis of inflammatory masses of the pancreatic head region

BACKGROUND/AIMS

Inflammatory masses of the pancreatic head are a dilemma for surgeons, especially when the differences between these lesions and pancreatic head carcinoma are not so clear. The surgical management of these inflammatory benign lesions is also a topic with conflicting opinions. A clinical analysis was performed in an attempt to differentiate between these lesions and malignancy. The results of our observatory strategy of these lesions are also presented.

METHODOLOGY

From 1992 to 1994, 73 patients with ultrasonographically (US) or computed tomographically (CT) heterogenous pancreatic head lesions were diagnosed at the Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan. Forty-nine of these lesions were neoplastic (Group I), but the remaining 24 patients had inflammatory non-neoplastic lesions (pancreatic inflammatory masses, IPM, Group II), which were diagnosed during laparotomy by core needle biopsy. Surgery and outcome were reviewed. Ten of the 24 patients in group II received biopsy only, and the remaining 14 patients received bypass procedures. At follow-up of at least 16 months of the surviving patients (n=21), only 9.5% were with residual lesions. All cases in group II revealed shrinkage of masses. We focused on the clinical features, hematology, biochemistry, image study, serum CEA and CA 19-9, and compared these variances between the 2 groups.

RESULTS

Three clinical features were statistically different between groups I and II: mean age at presentation of disease (group I vs II = 53.3 vs 65.1), the tendency of a past history of alcoholism (Group II), and presence of abdominal pain (Group II). Group II also showed a higher level of serum alkaline phosphatase and a lower level of total bilirubin as well as a lower level of CA19-9. These inflammatory masses could not be distinguished from the true neoplasms pre-operatively on endoscopic appearance, US, or CT.

CONCLUSIONS

Pre-operative differentiation between these pancreatic lesions may be difficult but laparotomy and core needle biopsy remain safe and reliable procedures. Our short-term follow-up justified the bypass surgery and that observatory strategy is enough for those patients with pancreatic head inflammatory masses.

Cell proliferation in human prostatic smooth muscle cells involves the modulation of protein kinase C isozymes

We have examined the role of protein kinase C in the regulation of foetal-calf serum-stimulated cell proliferation in human prostatic smooth muscle cells. The data showed that the proliferative effect to foetal-calf serum (10%, v/v) was partially inhibited by 12-(2-cyanoethyl)-6,7,12,13-tetrahydro-13-methyl-5-oxo-5H-indolo (2,3-a) pyrrolo (3,4-c)-carbazole (Go-6976), a selective Ca2+-dependent protein kinase C inhibitor, suggesting that Ca2+-dependent protein kinase C isozymes might play roles in this proliferative regulation. Additionally, foetal-calf serum caused a significant translocation of protein kinase C-betaII and -epsilon from a cytosolic to a membrane distribution. These findings combined with the aforementioned functional experiments suggest that foetal-calf serum-stimulated cell proliferation might involve the activation of protein kinase C-betaII in human prostatic smooth muscle cells; however, the role of protein kinase C-epsilon in mediating cellular functions other than cell proliferation remains further investigation in these cells.

Leukocyte-endothelial adherence correlates with pancreatic nitric oxide production in early cerulein-induced pancreatitis in rats

The role of nitric oxide (NO) in microcirculation during the development of acute pancreatitis was not clear. An in vivo microscopic technique was used for evaluating leukocyte-endothelial adherence in the pancreatic microcirculation after induction (cerulein) of acute pancreatitis. Microdialysis was performed to detect pancreatic nitrate concentration (NO level) by high-performance liquid chromatography. Cerulein caused significantly reduced flow velocity in 1 h (31 %) and increased the number of sticking leukocytes in 2 h; both persisted for at least 3 h. Pancreatic NO level was found to be significantly elevated (2.5-fold) in 1 h and also persisted for 3 h. Both microcirculatory changes and NO elevation were significantly alleviated in cerulein-induced animals pretreated with NO synthase inhibitor (NG-nitro-L-arginine), indicating that elevation of NO could precede and account for a major portion of the observed microcirculatory changes. Furthermore, there was a strong positive correlation between numbers of adherent leukocytes and pancreatic NO level, suggesting that during the development of acute pancreatitis, NO could play an adverse role in microcirculation.

Fast broadband inversion by adiabatic pulses

Despite the advantages of compensation for resonance offset and B1 inhomogeneity, adiabatic pulses are not yet in general use in high-resolution NMR, often because of the conception that these pulses require longer time or increased power to perform. We show that adiabatic pulses with tangential frequency sweeps and other frequency-modulation functions can be optimized to accomplish 13C and 1H broadband inversion using pulse lengths of 192 and 64 micro(s), respectively, at B1 strengths available with modern high-resolution probes.

Concurrent primary carcinoma of the gallbladder and acute cholecystitis

BACKGROUND/AIMS

Primary carcinoma of the gallbladder is rare and associated with a late diagnosis and poor prognosis. Concurrent acute cholecystitis frequently obscures the presence of carcinoma. The information regarding gallbladder carcinoma with acute cholecystitis is limited. In order to better understand the presentation of gallbladder carcinoma with acute cholecystitis, we retrospectively reviewed the data of patients with primary carcinoma of the gallbladder.

METHODOLOGY

The data of 86 patients with primary carcinoma of the gallbladder treated between 1979 and 1994 were compiled and reviewed. The patients were divided into 2 groups: Group 1 (with acute cholecystitis, 21 patients) and Group 2 (without cholecystitis, 65 patients). Clinicopathological comparisons were made and evaluated between these two groups

RESULTS

The average age of Group 1 patients was older than that of Group 2 patients (75+/-2 years vs. 63+/-2 years; p<0.05). Three Group 1 patients presented with sepsis. The interval between the onset of symptoms and hospital admission in Group 2 patients was significantly (p<0.05) longer than that in Group 1 patients (243+/-95 days vs. 20+/-11 days). Leukocytosis (>11,000/mm3) was more common in Group 1 patients than in Group 2 patients (47.6% vs. 15.4%). Jaundice was more common in Group 2, and fever was common in Group 1. The majority of Group 2 gallbladder cancers were stage V (75.4%). In contrast, 52.4% of Group 1 gallbladder cancers were stage III and 38.1% were stage V. The 30-day postoperative mortality rate in Group 1 and Group 2 patients was 9.5% and 7.7%, respectively. The cumulative survival of Group 1 patients was not different from that of Group 2 patients (log-rank test, p>0.05).

CONCLUSIONS

Age, the interval of symptoms prior to admission, the location of abdominal pain, fever, leukocytosis, and the absence of jaundice suggested the presence of acute cholecystitis in gallbladder carcinoma. A high index of suspicion of the disease, intraoperative examination of gallbladder specimens, and more aggressive surgical treatment may improve patient survival.

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.

Hepatocellular carcinoma presenting as pyogenic liver abscess: characteristics, diagnosis, and management

We performed a 17-year retrospective analysis of 10 cases of hepatocellular carcinoma presenting as pyogenic liver abscess. Spontaneous tumor necrosis and biliary obstruction caused by tumor thrombi, superimposed with bacterial infection, were the two major pathogeneses. Exact diagnosis of the underlying hepatocellular carcinoma was made for five of the 10 patients before management was attempted. Main clinical manifestations included fever, chills, right-upper-quadrant pain, malaise, anorexia, jaundice, and hepatomegaly. Characteristics such as middle age and male sex, seropositivity for hepatitis B and/or hepatitis C, chronic liver disease, unexplained anemia, marked weight loss, and a severely inversed albumin/globulin ratio raise suspicions about the underlying hepatocellular carcinoma. Management strategies included percutaneous drainage (n = 3), surgical drainage (n = 4), and hepatectomy (n = 3) in addition to administration of parenteral antibiotics in all cases. The prognosis was dismal, with a mean survival of 3.5 months (range, 8 days to 6 months).

Antiproliferative effect in human prostatic smooth muscle cells by nitric oxide donor

We obtained a primary culture of prostatic cells through explantation from patients with benign prostatic hyperplasia. Structural morphology, immunohistochemical staining, and growth characteristics of these cells demonstrate that they are consistent with the population of smooth muscle cells (SMCs). We examined the influence of a nitric oxide donor, sodium nitroprusside (SNP), on the regulation of human prostatic SMC proliferation. SNP exhibited a concentration-dependent (0.1-10 microM) inhibition of fetal calf serum-induced proliferation in human prostatic SMCs. In addition, growth-inhibitory responses to 8-bromo-cGMP (1-30 muM) were observed. However, the responses to SNP were significantly diminished by the presence of 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (3 microM; a selective guanylate cyclase inhibitor). Furthermore, SNP induced an increased concentration-dependent accumulation of intracellular cGMP in human prostatic SMCs. After 48-hr period of deprivation of serum, cells were restimulated with serum to permit cell cycle progression. The addition of SNP (10 microM) at various times after the addition of serum to serum-deprived cells showed maximal inhibition of cell proliferation even when added 6 hr after the serum. This blocking effect of cell cycle progression was lost gradually as the delay from serum to SNP application increased from 6 to 18 hr. The membrane-associated protein kinase C (PKC) activity was studied in human prostatic SMCs; results showed that fetal calf serum (10%, v/v) significantly increased membrane-associated PKC activity. SNP (10 muM), which had little effect on basal kinase activity, completely abolished serum-induced augmentation of PKC activity. Therefore, we suggest that SNP mediates its antiproliferative effect by the inhibition of PKC activity on human prostatic SMCs; furthermore, its antiproliferative effect occurs at the early G1 phase of the cell cycle.

Pyogenic liver abscesses in patients with malignant disease: a report of 52 cases treated at a single institution

BACKGROUND

Prognosis of pyogenic liver abscesses in patients with malignant disease is generally considered poor. The discrepancy between the outcomes of liver abscesses caused by hepatopancreatobiliary malignant disease and those caused by other malignant diseases, however, to our knowledge has never been investigated.

OBJECTIVES

To clarify the clinical course of pyogenic liver abscess in patients with different types of cancer, and to compare outcomes in abscesses caused by hepatopancreatobiliary malignant disease and other malignant disease.

DESIGN

Retrospective review of case series in our experience from 1980 through 1993.

SETTING

Tertiary care university teaching hospital.

PATIENTS

Fifty-two patients with pyogenic liver abscess related to the underlying cancer were divided into 2 groups. Group 1 (n=32) was composed of patients with cancer originating from the hepatic parenchyma, bile duct, and pancreas; group 2 (n=20) was composed of patients with cancer originating from other sites.

INTERVENTIONS

Parenteral antibiotics, percutaneous drainage, surgical drainage, or hepatectomy, in combinations, were employed.

MAIN OUTCOME MEASURES

Patient characteristics, symptoms, laboratory data, abscess characteristics, microbiological study, management, and outcome of the 2 groups were analyzed.

RESULTS

Thirteen patients (41%) in group 1 and 16 patients (80%) in group 2 had undergone prior anticancer treatment. Jaundice was encountered more often in group 1 than in group 2 (29 patients [91%] vs 6 patients [30%], respectively, P=.001), whereas nausea and vomiting were more frequently seen in group 2 than in group 1 (17 patients [52%] vs 6 patients[31%], respectively, P=.04). Leukocytosis, hypoalbuminemia, hyperbilirubinemia, and reversed albumin-globulin ratio were more pronounced in group 1 than in group 2 (P=.001, .02, .003, and .03, respectively). Abscesses communicating with the intrahepatic biliary tree were more frequently encountered in group 1 than in group 2 (11 patients [34%] vs 2 patients [10%], respectively, P=.03). Escherichia coli and Klebsiella pneumoniae predominated in group 1, while the bacteria species in group 2 were more diverse. The hospital mortality rates of group 1 and group 2 were 28% (9 of 32 patients) vs 10% (2 of 20 patients) (P=.04), respectively. Twenty-three patients (72%) of group 1 died of uncontrolled biliary sepsis or progressive cancer or both within 6 months after the diagnosis, while 17 patients (85%) of group 2 survived longer than 1 year without relapse of the abscess and continued with anticancer treatment.

CONCLUSIONS

Pyogenic liver abscess could be a presentation of hepatopancreatobiliary malignant disease at the preterminal stage, and carries a grave prognosis. Pyogenic liver abscess in patients with nonhepatopancreatobiliary malignant disease has a better chance of favorable outcome.

Accurate quantitation of water-amide proton exchange rates using the phase-modulated CLEAN chemical EXchange (CLEANEX-PM) approach with a Fast-HSQC (FHSQC) detection scheme

Measurement of exchange rates between water and NH protons by magnetization transfer methods is often complicated by artifacts, such as intramolecular NOEs, and/or TOCSY transfer from C alpha protons coincident with the water frequency, or exchange-relayed NOEs from fast exchanging hydroxyl or amine protons. By applying the Phase-Modulated CLEAN chemical EXchange (CLEANEX-PM) spin-locking sequence, 135 degrees (x) 120 degrees (-x) 110 degrees (x) 110 degrees (-x) 120 degrees (x) 135 degrees (-x) during the mixing period, these artifacts can be eliminated, revealing an unambiguous water-NH exchange spectrum. In this paper, the CLEANEX-PM mixing scheme is combined with Fast-HSQC (FHSQC) detection and used to obtain accurate chemical exchange rates from the initial slope analysis for a sample of 15N labeled staphylococcal nuclease. The results are compared to rates obtained using Water EXchange filter (WEX) II-FHSQC, and spin-echo-filtered WEX II-FHSQC measurements, and clearly identify the spurious NOE contributions in the exchange system.

Activation of muscarinic K+ channels by extracellular ATP and UTP in rat atrial myocytes

The effects of extracellular adenine and pyrimidine nucleotides on the acetylcholine-activated K+ channels (KACh) in rat cardiac myocytes were compared and examined by using the patch-clamp technique. In perforated-patch whole-cell recording experiments, extracellular adenosine triphosphate (ATP) reversibly caused an increase in K+ current. 8-Cyclopentyl-1,3-dipropylxanthine (CPX; 1 microM), a potent A1-adenosine-receptor antagonist, only partially antagonized the ATP-induced increase in K+ current, whereas glibenclamide (30 microM) had no effect. In cell-attached mode, adenosine and ATP activated single channels that had nearly identical conductance (29 pS) and open time (1.53 ms). These results suggest that adenosine and ATP can activate the same population of K+ channels. Uridine triphosphate (UTP; 100 microM) also caused an increase in steady-state K+ current. In cell-attached mode, the addition of UTP to the recording pipette solution (not in the bath solution) activated the channel current. The single-channel conductance and open time for UTP-induced channel current were 27 pS and 1.57 ms, respectively. These values were similar to those for the K+ channels activated by adenosine or ATP. The rank order of potency for the activation of KACh channels was adenosine = ATP > UTP. The addition of CPX (1 microM) to the pipette solution attenuated the ATP-induced channel activity by approximately 70% and fully prevented activation by AMPCPP, a less hydrolyzable ATP analog but did not cause any effect on UTP-induced channel activity. In pertussis toxin-treated cardiac myocytes, no any activity of UTP-induced KACh-channel current was observed. Our results demonstrate that extracellular ATP and UTP can directly activate KACh-channel current. This activation also was linked to pertussis toxin-sensitive G protein. The effect of extracellular ATP is mainly caused by the action on binding to A1-adenosine receptor, whereas the effect of extracellular UTP may be mediated possibly by P2u-purinergic (or 5'-nucleotide) receptor.

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.

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).

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.

Changes of adenosine triphosphate-dependent calcium uptake in microsomal fractions of rat liver during sepsis

BACKGROUND

Intracellular calcium concentration is an important regulator of cellular metabolism. Endoplasmic reticulum membranes play an important role in the regulation of cytoplasmic calcium in the mammalian liver. The characterization of the changes of calcium uptake in endoplasmic reticulum may contribute to the potential intracellular mechanisms for cellular dysfunction during sepsis.

METHODS

The effects of sepsis on the calcium uptake in rough endoplasmic reticulum of rat liver were studied. Sepsis was induced by means of cecal ligation and puncture (CLP). The control rats underwent sham operation. Microsomal fractions were isolated from the liver with differential centrifugation.

RESULTS

The calcium uptake by liver endoplasmic reticulum was decreased by 30% to 35% (p < 0.05) during early sepsis (9 hours after CLP) and by 38% to 43% (p < 0.05) during late sepsis (18 hours after CLP), respectively. The maximum velocity values for adenosine triphosphate (ATP) and for Ca2+ were also decreased by 25% to 37% (p < 0.05) during early sepsis and by 35% to 42% (p < 0.05) during late sepsis. The Michaelis-Menten constant for ATP and Ca2+ transport had no difference among three groups. The magnesium stimulation and vanadate inhibitory activity were also decreased by 17% to 38% (p < 0.05) during early sepsis and by 34% to 50% (p < 0.05) during late sepsis.

CONCLUSIONS

These data demonstrate that ATP-dependent calcium uptake in rough endoplasmic reticulum of rat liver was impaired during early and late sepsis. Because the low intracellular calcium concentration plays an important role in the regulation of cellular function, an impairment in the ATP-dependent calcium uptake by endoplasmic reticulum during early and late sepsis may have a pathophysiologic significance in contributing to the development of altered hepatic metabolism during sepsis.

Ionic mechanisms of tetrandrine in cultured rat aortic smooth muscle cells

The ionic mechanism of tetrandrine, an alkaloid extracted from the Chinese medicinal herb Radix stephania tetrandrae, was investigated in A7r5 vascular smooth muscle cells. The nystatin-perforated whole-cell voltage-clamp technique was performed to examine the effects of tetrandrine on ionic currents. Tetrandrine (1-100 microM) reversibly caused an inhibition of L-type voltage-dependent Ca2+ current (I(Ca,L)) in a concentration-dependent manner. Tetrandrine did not cause any change in the overall shape of the current-voltage relationship of I(Ca,L). The IC50 value of tetrandrine-induced inhibition of I(Ca,L) was 5 microM. In the presence of Bay K 8644 (3 microM) or cyclopiazonic acid (30 microM), tetrandrine still produced a significant inhibition of I(Ca,L). The inhibitory effects of tetrandrine on I(Ca,L) exhibited tonic and use-dependent characteristics. Moreover. tetrandrine (3 microM) shifted the steady-state inactivation curve of I(Ca,L) to more negative membrane potentials by approximately -15 mV. These results indicate that tetrandrine directly inhibits the voltage-dependent L-type Ca2+ current in vascular smooth muscle cells, which may predominantly contribute to the vasodilatory actions of tetrandrine.

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.

Peritoneal nitric oxide is a marker of peritonitis in patients on continuous ambulatory peritoneal dialysis

Nitric oxide plays an important role in mediating the inflammatory process. The aim of this study was to evaluate if nitric oxide production was increased during peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD), and the association with the prognosis. The study population comprised 21 patients with 22 episodes of peritonitis. Fifteen patients without peritonitis were controls. Nitrate was measured by HPLC and nitrite by the Griess method, to reflect nitric oxide production. Peritoneal dialysate effluent and plasma were collected from six patients during peritonitis and 1 week after treatment to study changes in dialysate:plasma ratio. In 15 patients, nitrite was measured during peritonitis and every 3 days for 2 weeks or until normalized for evolutional changes. The dialysate:plasma ratios of nitrate and nitrite during peritonitis were reduced 26% and 41.5%, respectively, after 1 week of treatment, indicating the peritoneal production of nitric oxide during peritonitis. In the evolutional study, a 5.1-fold increase of peak nitrite levels in bacterial peritonitis (n = 13) and a 2.5-fold increase in fungal peritonitis (n = 3) were observed compared to controls. Nitrite gradually declined to control levels (9.3 +/- 7.2 days) after effective antibiotic treatment, but took longer than to normalize leukocyte count in the peritoneal dialysate effluent (3.9 +/- 1.9 days). In four patients with refractory peritonitis (Candida infection in three, Acinetobacter infection in one), the nitrite levels remained elevated 2-fold despite treatment, and the catheters were removed. It is concluded that nitrite levels in peritoneal dialysate effluent may serve as a marker to assess treatment efficacy in CAPD patients with peritonitis.

The effect of gabexate mesilate on pancreatic and hepatic microcirculation in acute experimental pancreatitis in rats

Microcirculatory derangements are important early features in many organs during the process of acute pancreatitis. However, dynamic evaluation of these factors has been difficult. Antiprotease has long been used for the treatment of acute pancreatitis, although its effects and mechanism have not been fully elucidated. The involvement of proteases and microcirculatory derangement early in the course of acute pancreatitis are the main concern of this study. A severe acute pancreatitis model in male Sprague-Dawley rats (225-275 g) was established by adding caerulein (15 microg/kg/ hr) in intravenous infusion fluid and intraductal injection of 0.1 ml glycodeoxycholic acid (5 mM). Gabexate mesilate [GM; ethyl-4-(6-guanidinohexanoyloxy)benzoate methanesulfonate], a synthetic antiprotease, was infused intravenously in doses of 0.01, 0.1, 1, and 10 mg as a therapeutic intervention in this model. Pathology hematocrit, serum amylase level, and glutamic-oxaloacetic transaminase (GOT) levels were used to confirm the severity of disease and effect of therapy. In vivo microscopic technique was used as a investigating tool in this study of microcirculatory derangement in pancreas and liver, 8 hr after induction of acute pancreatitis. GM can significantly improve pathologic criteria and changes of serum amylase levels in the range of 1-10 mg/kg/hr. The severity of changes of hematocrit and GOT was significantly lessened with GM in the range of 0.1-10 mg/kg/hr. This agent also could improve the microcirculatory environment in pancreas and liver after induction of acute pancreatitis according to the parameters, such as flow velocity and rolling leukocyte phenomenon, in the range of 1-10 mg/kg/hr. According to our observation, severity of hyperpermeability had not changed with the treatment of GM. These results indicated the beneficial effects of GM on pancreatic and hepatic microcirculation early in the course of acute pancreatitis. The beneficial effects were noted in serum parameters and hematocrit. The importance of protease activation and remote organ dysfunction is emphasized in the course of acute pancreatitis from this study.

Surgical treatment of choledochal cyst in adults: results and long-term follow-up

BACKGROUND/AIMS

Results of the surgical management of 60 adults with choledochal cysts at Chang Gung Memorial Hospital Taipei are presented.

PATIENTS AND METHODS

All patients were diagnosed and surgically managed during the period between March 1979 and December 1992. There were 47 females and 13 males, with ages ranging from 16 to 81 years (mean age = 31.9 years). Of the total, there were 41 Type I, one Type II, 14 Type IV, and four Type V choledochal cysts classified according to Todani's classification system. The definite surgical procedures were cyst excision and hepatico-jejunostomy in 43 cases in type I and IV diseases, one cyst excision in type II disease, two hepatectomy for type V disease, cyst enterostomy in seven cases, and T-tube choledochocystostomy in seven cases.

RESULTS

The operative mortality rate was 3.3% and the complication rate related to the surgical procedure was 20%. Early postoperative complications include wound infection, leakage of anastomosis, acute pancreatitis, septic shock, left pleural effusion, and intra-abdominal abscessing. Reoperations were needed in the early postoperative days in two cases due to hepatico-jejunostomy leakage and intraabdominal abscess formation. Long-term surgical outcome, concerning recurrence of symptoms, was related to the following factors, excluding the factors of surgery: presence of bile duct lithiasis, common channel less than 22 mm, presence of preoperative pancreatitis and acute angle type pancreaticobiliary unions. Only common channel less than 22 mm is statistically significant. The percentage of recurrence of the symptoms after resectional surgery was 32.5% in the long term follow-up period. Most of the cases responded well to an antibiotics treatment. Three of the cases required a second operation or PTCD as well as dilatation to treat the recurrent cholangitis.

CONCLUSION

Although the recurrence of symptoms is not uncommon and satisfactory explanation of the analysed factors is still the treatment of choice for adult patients with choledochal cysts.

Brain SPECT with dipyridamole stress to evaluate cerebral blood flow reserve in carotid artery disease

This is a preliminary study of SPECT brain scan using dipyridamole as a stress agent to assess cerebral blood flow reserve in six patients with severe carotid artery disease.

METHODS

We performed SPECT scanning of the brain, with and without dipyridamole stress. Dipyridamole (0.57 mg/kg) was given intravenously 3 min before infusion of 99mTc-HMPAO. Patients were studied 30 min later using a rotating head gamma camera. The scans were analyzed qualitatively and semiquantitatively. An acetazolamide stress SPECT image was also obtained in two patients.

RESULTS

All patients had at least 80% stenosis in one internal carotid artery, three of them also had contralateral carotid stenosis. The dipyridamole SPECT showed an increased region of hypoperfusion in the hemisphere ipsilateral to the severe carotid disease in four patients. That suggests poor perfusion reserve and the potential risk of regional ischemia. In four of six patients, side-to-side asymmetry increased from the baseline condition after injection of dipyridamole. The asymmetry index increased more after dipyridamole than after acetazolamide injection in two patients.

CONCLUSION

This study suggests that dipyridamole stress SPECT is useful in assessing cerebral blood flow reserve. It demonstrates the region of poor vascular reserve in patients with severe carotid artery disease. Dipyridamole SPECT scans show more extensive hypoperfusion than acetazolamide in the two cases.

Surgical treatment of hepatolithiasis: long-term results

BACKGROUND

Hepatolithiasis is a common disease in East Asia and is prevalent in Taiwan. Surgical and nonsurgical procedures for management of hepatolithiasis have been discussed, but long-term follow-up results of surgical treatment of hepatolithiasis are rarely reported.

METHODS

We conducted a retrospective study of case records of patients with hepatolithiasis who underwent surgical or nonsurgical percutaneous transhepatic cholangioscopy treatment. Of 614 patients with hepatolithiasis seen between January 1984 and December 1988, 427 underwent follow-up after surgical (380) or percutaneous transhepatic cholangioscopy (47) treatment for 4 to 10 years and constituted the basis of this study.

RESULTS

Long-term results of 427 patients with hepatolithiasis after surgical and nonsurgical treatment within 4 to 10 years of follow-up were recurrent stone rate 29.6% (105 of 355), repeated operation 18.7% (80 of 427), secondary biliary cirrhosis 6.8% (29 of 427), late development of cholangiocarcinoma 2.8% (12 of 427), and mortality rate 10.3% (44 of 427). The patients with hepatectomy had a better quality of life (symptom-free) with a lower recurrent stone rate (9.5%), lower mortality rate (2.1%), and lower incidence of secondary biliary cirrhosis (2.1%) and cholangiocarcinoma (0%) than did the nonhepatectomy group (p < 0.01). The patients without residual stones after choledochoscopy had a better quality of life than did the residual stone group (p < 0.01).

CONCLUSIONS

Long-term follow-up study of hepatolithiasis after surgical treatment revealed a high recurrent stone rate (29.6%) that required repeated surgery and a high mortality rate (10.3%) resulting from repeated cholangitis, secondary biliary cirrhosis, and late development of cholangiocarcinoma. Patients who received hepatectomy or without residual stones after choledochoscopy had a good prognosis and quality of life.

Surgical results of corrosive injuries involving esophagus to jejunum

BACKGROUND/AIM

Severe corrosive injury involving esophagus to jejunum remains an unique surgical problem which is associated with high mortality and morbidity.

MATERIAL AND METHODS

Herein we report the outcomes of 28 caustic patients who underwent resections of the stomach, duodenum, a segment of jejunum, and adjacent involving organs.

RESULTS

In all of these patients except one, esophagectomy was also performed. The concomitant procedures included pancreaticojejunostomy (n = 24), choledochojejunosotmy (n = 4), cholecystostomy (n = 4), common bile duct or pancreatic duct drainage, feeding and drainage jejunostomies, and cervical esophagostomy. Major complications consisted of bile leakage (n = 10), bile-bronchial fistula (n = 2), internal bleeding due to vessel necrosis (n = 5), peritonitis (n = 4), acute renal failure (n = 4), and septicemia (n = 4). There were 13 hospital deaths (46.4%) and three late deaths. Eight out of 12 survivors underwent subsequent reconstruction of esophagus. The remaining four survivors depended on jejunostomy feeding.

CONCLUSIONS

Early approaches and appropriate procedures can save a number of patients with corrosive injury involving esophagus to jejunum.

Factors influencing survival after hepatectomy for peripheral cholangiocarcinoma

BACKGROUND/AIMS

Radical resection for patients with peripheral cholangiocarcinoma is rare. Prognostic factors related to survival with peripheral cholangiocarcinoma after hepatectomy have not yet been reported.

MATERIALS AND METHODS

Of 41 hepatectomized patients with peripheral cholangiocarcinoma, a computer analysis of 14 clinicopathological factors on patients survival was performed with univariate and multivariate analysis.

RESULTS

Median and mean survival times for patients with peripheral cholangiocarcinoma after hepatectomy were 12.0 and 22.8 months. The 1-, 2-, 3-, 4- and 5-year survival rates were 53.7%, 39.0%, 36.6%, 26.8%, and 26.8% respectively. Univariate analysis of overall survival involving all patients identified 7 factors that were associated with a significantly outcome: mucobilia (p = 0.043), capsular invasion (p = 0.007), tumor spreading type (p = 0.0003), section margin (p = 0.001), histologic type (p = 0.008), macroscopic and microscopic vascular involvement (p = 0.031), and lymphatic invasion (p = 0.004). With multivariate analysis using the COX stepwise proportional hazards model, only mucobilia, tumor spreading type and section margin were significantly related to prognosis.

CONCLUSIONS

Intrahepatic bile duct carcinoma patients with mucobilia, intraductal papillomatosis and a tumor-free margin after hepatectomy had a better prognosis.

Predilection of brain metastasis in gray and white matter junction and vascular border zones

BACKGROUND

The purpose of this study was to asses the importance of the vascular border zone and the gray and white matter junction on the distribution of brain metastases.

METHODS

We reviewed the medical records, computed tomography (CT) of magnetic resonance imaging (MRI) of 105 patients with secondary brain tumors. The metastatic lesions noted on CT scans of MRI ere matched with a predetermined standard sheet containing axial images with shading on the border zones. To be included in the border zones, the center on more than 50% of the lesion had to be situated within these zones.

RESULTS

Among 100 evaluable patients, there were 302 metastatic brain lesions. Of the 302 lesions, 210 lesions were 2 cm or smaller in greatest dimension and located in the cerebral and cerebellar hemispheres. The major vascular border zones were the site of predilection for 103 lesions (62%) although the border zones constitute only 29% of the area. Gray and white matter junction was the preferred site for 135 lesions (64%).

CONCLUSION

The results demonstrated that brain metastasis occurs in the vascular border zone regions and the gray and white matter junction more frequently than previously recognized, and also supported the notion that metastatic emboli tend to lodge in an area of sudden reduction of vascular caliber (gray/white matter junction) and in the area most distal vascular field (border zone).

Surgical treatment of gastric outlet obstruction after corrosive injury--can early definitive operation be used instead of staged operation?

For the comparison of advantage and outcome, thirty six patients with corrosive upper GI injury resulting in only distal gastric outlet obstruction and failing to receive endoscopic balloon dilatation underwent prospective randomized different surgical treatments in the past years. Sixteen patients (Group A) received early definitive treatment with antrectomy or pyloroplasty for their gastric outlet obstruction, only 3 (18.8%) of them needed a second operation for the delayed esophageal stricture. The long-term follow-up for these patients revealed the stricture resolved after the antrectomy or pyloroplasty. All of the other 20 patients (Group B) who received gastrostomy plus feeding jejunostomy during their first operation required a second operation. Among the 20 patients receiving a second operation, delayed esophageal stricture was the reason in only 4 patients. It meant that 16 patients (80%) of Group B were able to avoid the second operation if early definitive treatment for their gastric outlet obstruction was performed during the first operation. We concluded that the early definitive treatment of gastric outlet obstruction can give patients a better quality of life, avoid a second operation in about 80% of them and save operative time in those who need a second operation for final esophageal reconstruction.

Secural pancreaticojejunal anastomosis for the pancreaticoduodenectomy

BACKGROUND/AIMS

This report presents the results of two methods for minimizing complications following a Whipple operation.

MATERIALS AND METHODS

In the past five years, continuous duct to mucosal suture with end to side anastomosis of the pancreaticojejunostomy was utilized in 30 patients. Another 50 patients received interrupted duct to mucosal suturing with end to side anastomosis of the pancreaticojejunostomy in the past five to ten years.

RESULTS

None of the first set of 30 patients suffered leakage after the operation. Ten of the 50 patients (20%) developed leakage postoperatively and 3 (6%) died. The group with continuous duct to mucosal suture had significantly less complications than those with interrupted duct to mucosal suturing (P < 0.05). Late follow up of the patients with continuous duct to mucosal suture using echogram, no one had stricture of the anastomosis.

CONCLUSION

The continuous duct to mucosal suture of the pancreaticojejunostomy is a very safe procedure, minimizing the operative morbidity and mortality of the Whipple operation.

Effect of serum from partially hepatectomized cirrhotic and noncirrhotic rats on liver regeneration with primary hepatocyte cultures

The effects of serum from cirrhotic and noncirrhotic rats after 33% and 70% partial hepatectomy on the hepatocyte culture were studied. Liver cirrhosis was produced by weekly intragastric feeding with carbon tetrachloride (CCl4) for 12-16 weeks. The serum was prepared with blood withdrawn from the rats 2 and 48 h after partial hepatectomy or sham operation. The incorporation of [3H]thymidine in the hepatocyte culture after addition of rat serum (1.0 +/- 10(5) cells/ml) was assessed. We found that the mitogenic effect of the serum at 2 and 48 h after partial hepatectomy was not significant. In the 70% hepatectomy group, the serum from cirrhotic rats had a stronger stimulatory effect to induce hepatocytes in primary culture entering DNA synthesis than that from noncirrhotic rats; but the difference was not statistically significant. The mitogenic effect of the serum from noncirrhotic rats after 33% hepatectomy was significantly lower than that from cirrhotic rats after 33% hepatectomy (p < 0.05). In this series, the serum from the cirrhotic rats after 33% hepatectomy had the strongest mitogenic effect; the serum from the partially hepatectomized rats with cirrhotic and non-cirrhotic livers increased [3H]thymidine uptake into hepatocyte DNA significantly more than control serum or plasma.

Surgical treatment of pancreatic adenocarcinoma: Taiwan experience

A retrospective study of 155 patients with tissue proven ductal adenocarcinoma of the pancreas treated between January 1981 and December 1991 was performed. Locations of the pancreatic tumors were: pancreatic head in 109 cases (70.3%), head and body or diffusely throughout the gland in 24 patients (15.5%), body and/or tail in another 22 (14.2%). All of the patients were stratified by TNM staging (I, 13.6%; II, 8.4%; III, 34.8%; IV, 43.2%). Twenty-eight patients received pancreatectomies (18.1%), 87 patients had biliary-enteric bypass and/or gastrojejunostomies (56.1%), and another 40 received laparotomies with tumor biopsy only (25.8%). The overall operative mortality of pancreatic cancer surgery was 9.0% with the pancreatectomy, bypass, laparotomy group mortalities at 7.1%, 5.7%, and 17.5% respectively. The risk factors of postoperative mortality were age > or = 70 years, serum albumin 3.0 g% and hemoglobulin < 12.0 g% (p < 0.05). The overall long term survival for pancreatic cancer was: 1y, 17.1%; 2y, 8.5%; 3y, 7.6%; 4y, 5.7%; and 5y, 4.8%; respectively. The mean survival time for the resection group was 23.6M (range 1-108M) with survival rates being: 1y, 42.3%; 2y, 34.6%; 3y, 30.8%; 4y, 23.1%; and 5y, 19.2%; respectively. Stage I cancer and radical resection are two important factors related to long-term survival in patients with pancreatic adenocarcinoma.

Liver regeneration following partial hepatectomy and stimulation by hepatic stimulatory substance in cirrhotic and non-cirrhotic rats

The effects of hepatic stimulatory substance (HSS) on cirrhotic and non-cirrhotic rats were studied after 70% partial hepatectomy. Liver cirrhosis was produced by weekly intragastric infusion of chloroform for 12-16 weeks. The HSS was prepared by extraction from the livers of weanling mice. Rats in the experimental group were injected with 5 ml HSS after 70% partial hepatectomy, and those in the control group received normal saline. The results showed that the 3H-thymidine incorporation was higher in the HSS group 24 h after partial hepatectomy in both cirrhotic and non-cirrhotic rats, and persistently higher in the non-cirrhotic rats at 48 h. Total DNA was significantly higher in the HSS group of non-cirrhotic rats 24 and 48 h after partial hepatectomy. The restituted liver volume and weight was significantly higher in non-cirrhotic rats 48 h after partial hepatectomy, while there was no significant difference between the HSS and the control groups in the cirrhotic rats. The HSS induced significant effects on 3H-thymidine incorporation in the non-cirrhotic liver, resulting in increasing liver weight, volume and total DNA 48 h after partial hepatectomy. In cirrhotic rats, the 3H-thymidine incorporation was higher in the HSS group at 24 h after partial hepatectomy, though not showing any increase at 48 h, but the regeneration of liver weight, volume and total DNA at 48 h showed no difference between the HSS group and the control group.

Density of muscarinic receptors in rat myocardium during early sepsis

The muscarinic receptor changes in two subcellular fractions of rat myocardium during sepsis, the sarcolemma (SL) and light vesicles (LV), were studied. [3H]-quinuclidinyl benzilate ([3H]-QNB) was used as a radioligand. Sepsis was induced by cecal ligation and puncture (CLP). The septic rats had higher pulse rates and slightly higher blood glucose levels than control rats. The marker enzyme assays revealed that the SL fraction was enriched with 5'-nucleotidase and the Na(+)-K(+)-ATPase activity increased over 20-fold, while the LV fraction showed very little enrichment when compared with the homogenate. [3H]-QNB binding studies showed that Bmax increased by 58.8% in SL with no changes in LV during early sepsis (9 h post-CLP), but there was no significant change in the Kd value. These data indicate that muscarinic cholinergic receptors in rat heart SL increase during early sepsis. Since the muscarinic cholinergic receptors mediate parasympathetic modulation of myocardial contractility, changes in the number of muscarinic receptors in the cardiac SL may have a pathophysiologic significance in the development of hemodynamic changes during sepsis.

Surgical results for severe acute pancreatitis--comparison of the different surgical procedures

BACKGROUND/AIMS

We compared the outcome of surgery for the patients with severe acute pancreatitis using different surgical procedures to find risk factors for mortality.

PATIENTS AND METHODS

Records of eighty six patients with severe acute pancreatitis who underwent different surgical procedures in the past five years were retrospectively reviewed.

RESULTS

The patients were found to have severe acute pancreatitis during operation. The morbidity and mortality of three different surgical procedures were compared. The risk factors related to the mortality were analyzed. Thirty one patients considered as group A received debridement and closed sump drainage. Forty patients considered as group B receiving necrosectomy with open packing of the peripancreatic space. The other 15 patients considered as group C received debridement and continuous lavage of the lesser sac. The patients in group A had highest mortality (48.4%) and those in group B had lowest (15%).

CONCLUSIONS

The significant risk factors of mortality included high Ranson's signs, peripancreatic necrosis, pancreaticogenic ascites and bacterial infection. The open packing or marsupialization of group B provided an easy way to perform repeated debridement after the first operation, resulting in the lower mortality for severe acute pancreatitis than other surgical procedures. The procedure with closed sump drainage resulted in higher incidence of postoperative bleeding and sepsis. The patients with higher Ranson's signs, peripancreatic necrosis, pancreatic ascites or positive bacterial infection should be treated more aggressively.

Changes in inositol 1,4,5-triphosphate binding in microsomal fractions from the rat liver during sepsis

Inositol 1,4,5-triphosphate has been proposed as a second messenger for calcium mobilization. The addition of inositol 1,4,5-triphosphate at a low concentration has been shown to cause calcium release from intracellular microsomal stores in rat hepatocytes. The effects of sepsis on the inositol 1,4,5-triphosphate binding from microsomal fractions of rat liver were investigated. Sepsis was induced by cecal ligation and puncture (CLP). Control rats were sham operated. Three microsomal fractions (rough, intermediate, and smooth I) were isolated from the rat liver. The study of inositol 1,4,5-triphosphate receptor binding was performed with tritium-labeled inositol 1,4,5-triphosphate. Our results showed that the Bmax of inositol 1,4,5-triphosphate binding in early septic, late septic, and control groups was 14.9 +/- .9 fmol/mg, 9.8 +/- 1.0 fmol/mg, and 17.2 +/- 1.3 fmol/mg, respectively. The binding activity was unaffected during early sepsis but was significantly depressed by 40-50% (p < .05, vs. control) during late sepsis (18 h after CLP) in all three subfractions of endoplasmic reticulum. Because the inositol 1,4,5-triphosphate binding plays an important role in the regulation of intra-cellular calcium homeostasis in hepatocytes, an impairment of the calcium release due to depressed inositol 1,4,5-triphosphate binding in the endoplasmic reticulum may have a pathophysiological significance in contributing to altered hepatic metabolism during septic shock.

Comparison for four techniques of catheter insertion in patients undergoing continuous ambulatory peritoneal dialysis

OBJECTIVE

To compare four different ways of implanting catheters for continuous ambulatory peritoneal dialysis (CAPD) in an effort to reduce the incidence of complications.

DESIGN

Retrospective study.

SETTING

Teaching hospital, Taiwan.

SUBJECTS

166 Patients who had 180 catheters inserted between 1985 and 1993.

INTERVENTIONS

49 Catheters were inserted through midline incisions (in 24 of which the catheter was fixed with an additional suture) and 131 were inserted through paramedian incisions (in 88 of which the catheter was fixed with an additional suture).

MAIN OUTCOME MEASURES

Morbidity, particularly the incidence of migration of the catheter and incisional hernia.

RESULTS

8/68 Catheters migrated in patients in whom no additional fixing suture had been used, compared with 2/112 in whom an additional suture had been used (p = 0.007). There were 4 incisional hernias in 49 midline, compared with 0/131 paramedian, incisions (p < 0.0001). Significantly more catheters had to be removed after midline than after paramedian incisions (35/49 compared with 56/131, p = 0.0008); chi square for independence 15.02, df 3, p = 0.0018.

CONCLUSION

For the implantation of catheters for CAPD the paramedian incision is associated with significantly fewer complications than the midline incision and the incidence is even lower if the catheter is fixed to the lower peritoneum with an additional suture.

Clinical experience with hepatic resection for ruptured hepatocellular carcinoma

BACKGROUND

Spontaneous rupture of a hepatocellular carcinoma (HCC) is an uncommon but fatal complication of this disease. Surgical treatment is aimed at controlling the intraperitoneal hemorrhage, which has been achieved by hepatectomy, hepatic arterial ligation, packing and suturing. However, hemostasis obtained by hepatic arterial ligation, packing and suturing is not particularly effective, and the rebleeding rate is high. Information on hepatectomy for ruptured HCC is sparse, and we therefore reviewed our experience with hepatic resection for this potentially fatal complication.

METHOD

The clinicopathological features of 23 patients with ruptured HCC who underwent hepatectomy during the past 15 years were reviewed. Morbidity, mortality and survival rates were analyzed.

RESULTS

Effective hemo-stasis was achieved by hepatectomy. Indications for operative treatment were acute abdomen necessitating immediate laparotomy in 12, and spontaneous hemoperitoneum in 11. Types of hepatectomy included left hemihepatectomy in 3, lateral segmentectomy in 6 and local excision in 14. Liver cirrhosis was the concomitant disease in 13 (56.5%). Hospital mortality rate was 4.3%. 1, 2, 3, and 5 year survival rates were 60%, 52%, 40.5% and 26.5%, respectively.

CONCLUSIONS

Hepatic resection is the treatment of choice for ruptured HCC. Long-term survival can be observed in a few patients without recurrence.

Ophthalmoplegia and facial numbness following treated squamous carcinoma of the forehead

A 62-year-old man presented with progressive diplopia, left ptosis, proptosis, complete ophthalmoplegia, facial numbness, and headache of 2 1/2 months' duration. The symptoms started 1 month after surgical resection of a squamous cell carcinoma in the left side of the forehead. Imaging studies helped localize the lesion, correlating with clinical features. The differential diagnosis is discussed. The final diagnosis was confirmed by autopsy.

Resectional therapy for a giant cavernous hemangioma of the liver

Twelve patients with cavernous hemangiomas of the liver were treated by surgical resection from 1982 to 1991. There were three male and nine female patients. Their ages ranged from 31 to 62 with a mean of 49. All except one with gall bladder polyp had abdominal pain. Preoperatively, dynamic computerized tomographic scans performed on three patients produced accurate diagnoses, while angiography was correct in only 2 out of 7 patients. The indications for operation were suspected hepatoma in five, symptomatic pain in three, intraperitoneal hemorrhage resulting from biopsy in one, intrahepatic stone with suspicion of cholangioma in one, abdominal mass mimicking a gastric leiomyosarcoma in one and incidental laparotomy in a final patient. Surgical treatment resulted in no operative mortalities apart from one delayed death from cirrhotic decompensation occurring four months postoperatively. Morbidity included one patient with a postoperative hemorrhage and one with bile leakage, however, both of them were discharged uneventfully. During the follow up period from 6 to 72 months, no more abdominal pain attacked in those three patients with preoperative symptomatic pain. Three patients developed multiple recurrent hemangiomas. No identifiable causes were readily apparent. We conclude that the preoperative differentiation between hemangioma and hepatoma in a hepatic lesion is very important. When necessary, such as a giant symptomatic hemangioma of the liver can be safely resected without significant complications.

Erythrocyte Ca2+ pump is defective during sepsis

Saturated Ca2+ extrusion rate through the Ca2+ pump of erythrocytes was determined by the cobalt-exposure method in normal subjects and septic patients. From 48 normal subjects, the value of Vmax of erythrocyte Ca2+ pump was 14.83 +/- 0.49 mmol/L cells/hr; from 29 sepsis patients, it was 9.49 +/- 0.59 mmol/L cels/hr, significantly (P < 0.001) lower than that from the erythrocytes of normal subjects. When the severity of sepsis was evaluated by the septic severity score (SSS), a significant correlation (P < 0.0001) was observed between the Vmax of Ca2+ pump and the patient's SSS, indicating that the inhibition of Ca2+ pump depended on the degree of the pathological development of sepsis. Since the ATP-dependent Ca2+ transport in rat liver plasma membrane is also reduced during the late stage of sepsis [Lau et al., Circ Shock 38:238-244, 1992], impairment of the activity of Ca2+ pump appears to have a general pathophysiological significance in the development of severe sepsis.