Partial hepatectomy for metastatic seeding complicating pancreatoduodenectomy

We present a case report of metastatic seeding at the percutaneous transhepatic biliary drainage tract in a 68 year-old man who previously underwent pancreatoduodenectomy with bile duct resection for distal bile ductal carcinoma. Three years and 5 months after the initial operation, dilation of the left lateral segmental bile ducts was detected by abdominal ultrasonography. Percutaneous transhepatic cholangiography disclosed a stricture at the confluence of the ventral and dorsal branches of the left lateral anterior segmental duct. This region corresponded to the punctured point of the previous percutaneous transhepatic biliary drainage. Implantation of the bile duct carcinoma at the percutaneous transhepatic biliary drainage sinus tract was diagnosed, and the recurrent tumor was successfully resected by an extended left hepatic lobectomy with a total caudate lobectomy. Currently, 8 years and 3 months after the second surgery, the patient is in good health without any signs of tumor recurrence. This case report discusses the entity of metastatic seeding, a rare but serious complication of percutaneous transhepatic biliary drainage. An aggressive surgical approach is important for recurrent biliary tract malignancies.

Location of cysteine and cystine residues in S-ribonucleases associated with gametophytic self-incompatibility

S-Ribonucleases (S-RNases) that cosegregate with S-alleles in the styles of solanaceous and rosaceous plants are associated with gametophytic self-incompatibility (GSI). The amino acid sequences of many S-RNases have been derived from cDNA sequences, but the state of half-cystines has not been clarified. We report the locations of the two free cysteine residues and four disulfide bridges of tobacco S6-RNase and of the four disulfide bridge of Japanese pear S4-RNase. The protein was first S-pyridylethylated at a low pH to selectively modify the free cysteines without thiol-disulfide exchange. The S-pyridylethylated protein (PE-protein) was digested with Achromobacter protease I (API) at pH 6.5 then analyzed by liquid chromatography/electrospray-ionization mass spectrometry (LC/ESI-MS). This analysis showed that tobacco S6-RNase has two free cysteine residues, Cys77 and Cys95, and four disulfide bonds at Cys16-Cys21, Cys45-Cys94, Cys153-Cys182 and Cys165-Cys176. Similarly, four disulfide bonds were identified for pear S4-RNase, which bears no free cysteine, at Cys15-Cys22, Cys48-Cys92, Cys156-Cys195 and Cys172-Cys183. The eight cysteines forming these four disulfide bonds are conserved in all the known S-RNases, indicative that these cross-links are important in stabilizing the tertiary structures of the self-incompatibility-associated glycoproteins in the solanaceous and rosaceous families. The LC/ ESI-MS analysis also provided some structural informations regarding sugar chains attached to the S-RNases.

Molecular cloning and expression of rat liver aminopeptidase B

We isolated, by immunological screening of a Uni-ZAP XR cDNA library constructed from rat liver mRNAs, a cDNA clone with 2212 base pairs encoding aminopeptidase B (EC 3.4.11.6). The open reading frame encodes a 649-amino acid protein with a theoretical molecular mass of 72,545 Da and bears the consensus sequence of the zinc metalloexopeptidases, indicating that the enzyme belongs to this family, which includes aminopeptidase A, aminopeptidase N, and leukotriene-A4 hydrolase. Escherichia coli SOLR cells infected with the pBluescript phagemid excised from the Uni-ZAP XR vector containing the aminopeptidase B cDNA had a high L-arginyl-beta-naphthylamidase activity. The recombinant protein was purified to homogeneity from the recombinant E. coli extracts. The enzyme had Cl--dependent aminopeptidase activity specifically restricted to the Arg and Lys derivatives and contained 1 mol of zinc per mol of the enzyme.

Participation of endodermal epithelial cells on the synthesis of plasma LDL and HDL in the chick yolk sac

We ultrastructually examined the chick yolk sac endodermal epithelium and evaluated our findings in combination with the biochemical analysis of serum and yolk lipoproteins. Twenty-five to 30 nm-sized particles were demonstrated to be a principal element of the extracellular yolk mass and these were determined to be yolk very low density lipoprotein (VLDL). The particles were shown to be taken up by the epithelial cells via coated pits and engulfed by plasma membrane invaginations together with yolk subdroplets, another element of the yolk mass. Through apical vacuoles, the two yolk elements were incorporated into yolk drops, which were identified to be one of the lysosomal structures by a cytochemical procedure using acid phosphatase (AcP)ase activity. During the last week of incubation, which is the final third of the incubation period, the digestion seemed to progress rapidly in the yolk drops, which came to resemble lipolysosomes; lipoprotein production became active as expressed by an enlarged Golgi apparatus. The newly produced lipoprotein particles were electron-lucent and irregular in size (50-120 nm). They were sequestered in secretory vacuoles and secreted from the vascular surface of the epithelial cells. Finally, the particles were thought to be taken into the vitelline circulation as plasma lipoproteins. The major component of lipoprotein in serum was determined to be low density lipoprotein (LDL) and high density lipoprotein (HDL), while cholesterol content was found to increase during incubation. We concluded that endodermal epithelial cells participate the synthesis of plasma LDL and HDL. For this synthesis the cells probably apply lipids and apo-protein generated from yolk VLDL degradation.

Selective percutaneous transhepatic embolization of the portal vein in preparation for extensive liver resection: the ipsilateral approach

The ipsilateral approach was used at preoperative portal vein embolization in 38 patients with hepatobiliary malignancy. The right anterior portal branch was punctured. Two different 5.5-F triple-lumen balloon catheters were used, and fibrin glue and iodized oil were injected. Portal vein embolization was successful in all cases (right lobe, 24 patients; left lobe and right anterior segment, six; right lobe and left medial segment, three; right posterior segment, two; right anterior segment, one; left lobe, one; and right and caudate lobes, one).

Biliary cystadenocarcinoma resected by segment 3 and 4 hepatectomy

We describe a case of biliary cystadenocarcinoma of the liver in a 72 year-old woman presented to our hospital with abdominal fullness. Laboratory data showed an elevation of alkaline phosphatase and a decreased excretion of Indocyanine green (ICG). CT revealed a cystic tumor with papillary projections, measuring 13A approximately 15cm, in the left medial segment of the liver (S4). Percutaneous transhepatic cholangioscopy (PTCS) disclosed the tumor in the dorsal subsegmental duct of S4 and the cholangioscopic biopsy from the tumor revealed papillary adenocarcinoma. PTCS showed the left lateral posterior segmental bile duct (B2) joined the common tract of the left medial (B4) and left lateral anterior (B3) segmental bile duct, and the tumor involved B4 and B3 but not the common tract of B4 and B3. A radical surgery, which included segment 4 and 3 resection with preservation of the left hepatic duct and the segment 2 was performed. The histopathological examination revealed that the tumor did not involve the liver parenchyma and had no lymph node metastasis. Postoperative course was unremarkable and the patient at present time, 4 years after the operation, is doing well. This case report discusses the importance of preoperative evaluation by PTCS for a rational surgical procedure.

[Perioperative management for partial resection of a lymphangioma of the tongue]

Twelve month old boy had been suffering from a neck lymphangioma. Partial resection was carried out in his newborn period at another hospital, and he was obliged to be tracheostomied because of severe airway obstruction due to postoperative edema. He was scheduled for partial glossectomy since his tongue had increased in mass, which could easily be injured by teeth, and he had difficulties in swallowing recently. His airway was not obstructive even during sleep and preoperative MRI showed adequate space around the larynx. We induced anesthesia by a mask and he was subseqently intubated with a fiberscope via his nose because his huge and less mobile tongue could not allow the insertion of a laryngoscope and this might cause bleeding. We did not extubate the endotracheal tube for fear of airway obstruction attributable to postoperative edema. Marked edema around the neck persisted longer than we expected. We tried to evaluate the degree of diminution of edema with MRI twice to decide when extubation could be attempted. However, examination with MRI could not give us useful informations. Consequently we evaluated the timing of extubation by examining whether he could close his mouth or not, whether his tongue could move freely and the degree of edema. We realized lymphangioma caused marked and extensive edema after the operation and we should keep in mind that lymphangioma of the tongue might cause various anesthetic problems especially on airways.

The relation between crossed cerebellar blood flow and severities of hemiplegia: a technetium-(99m) hexamethylpropylene amine oxine SPECT study using Patlak plot method

Crossed cerebellar diaschisis (CCD), decrease in crossed cerebellar blood flow (CCBF) (ml/100g/min), is often observed in the cerebral blood flow imaging of hemiplegic patients. We studied the relations between severities of hemiplegia and degrees of CCD. Severities of hemiplegia were evaluated by Brunnstrom stages (Br. stage) of lower limbs. Degree of CCD was evaluated as CCBF and asymmetry index (ASI) (%) of CCBF, which were calculated from technetium-(99m) hexamethylpropylene amine oxine ((99m)Tc HMPAO) SPECT study using Patlak plot method (Matsuda et al. 1992, 1993). We have studied twenty consecutive patients. The CCBF was significantly different between Br. stage II and IV (p = 0.0357), III and IV (p < 0.001) and III and V (p < 0.001). ASI was significantly different between II and IV (p = 0.0357), III and IV (p < 0.001) and III and VI (p = 0.0238). Both of CCBF and ASI of the group of II and III were significantly lower than those of the group of IV, V and VI (p = 0.0033 for CCBF and p = 0.0087 for ASI). We conclude that this study indicate a close correlation between the sevreties of hemplegia and the degrees of CCD.

Preoperative intrahepatic segmental cholangitis in patients with advanced carcinoma involving the hepatic hilus

BACKGROUND

Major hepatic resection for biliary tract carcinoma continues to be a risky operation. In this study we examined the influence of preoperative intrahepatic segmental cholangitis on posthepatectomy mortality.

METHODS

We analyzed retrospectively the clinical features of 118 patients who underwent liver resection including more than two segments for biliary tract carcinoma involving the hepatic hilus.

RESULTS

Intrahepatic segmental cholangitis was encountered before operation in 22 cases. The morbidity and mortality rates for these patients were significantly higher than those of patients without preoperative cholangitis. Selective percutaneous transhepatic biliary drainage was performed before operation in 11 patients for segmental cholangitis. The morbidity rate of patients after hepatectomy was significantly lower than that of patients treated without percutaneous transhepatic biliary drainage.

CONCLUSIONS

The presence of preoperative intrahepatic segmental cholangitis is a major prognostic factor in the outcome of major hepatic resection for biliary carcinoma. Selective percutaneous transhepatic biliary drainage for preoperative intrahepatic segmental cholangitis plays an important role in reducing complications after major hepatic resection.

Changes in glucose transporter 2 and carbohydrate-metabolizing enzymes in the liver during cold preservation and warm ischemia

In order to examine glucose metabolism in liver grafts during cold preservation (24 and 48 hr), warm ischemia (60 and 120 min), a combination of the two and reperfusion, the amount of protein and mRNA of glucose transporter 2 and the activities of enzymes in glycolysis (glucokinase, phosphofructokinase, pyruvatekinase), gluconeogenesis (glucose 6-phosphatase, fructose 1,6-bisphosphatase), and the pentose phosphate pathway (glucose 6-phosphate dehydrogenase) were measured. It appeared that glucose transport, the pentose phosphate pathway, and gluconeogenesis were maintained during cold preservation and warm ischemia. The activity of glucokinase significantly decreased from the control value of 1.33 +/- 0.23 IU/g protein to 0.70 +/- 0.17 (24 hr, P<0.05) and 0.57 +/- 0.12 (48 hr, P<0.01) only during cold preservation. However, the activity of phosphofructokinase significantly decreased from the control value of 4.37 +/- 0.06 IU/g protein to 2.67 +/- 0.15 (60 min, P<0.0001) and 1.53 +/- 0.06 (120 min, P<0.0001) only during warm ischemia. This indicates that glycolysis deteriorates during both cold preservation and warm ischemia and demonstrates further that the balance between glycolysis and gluconeogenesis shifts to gluconeogenesis. Even when cold preservation was combined with warm ischemia, the activity of glucokinase decreased only during cold preservation and the activity of phosphofructokinase decreased only during warm ischemia. Furthermore, these changes were time-dependent. It is suggested that they can be used as a clock to measure the durations of cold preservation and warm ischemia separately and that the magnitude of an ischemic injury to a liver and a liver graft's viability can be indirectly estimated before transplantation.

In vivo uptake of lecithin-coated polystyrene beads by rat hepatocytes and sinusoidal endothelial cells

BACKGROUND

While phagocytosis by Kupffer cells (stellate perisinusoidal macrophages) is well known and that by endothelial cells also is thought to occur under certain conditions, the uptake of large particles by hepatocytes has not been well studied. We reported previously the selective phagocytic uptake of material by hepatocytes using egg lecithin-coated silicon particles. In the present work, we describe more precisely this process following the injection of lecithin-coated polystyrene beads. Additionally, we consider the possible significance of the transcytotic action by endothelial cells.

METHODS

Polystyrene latex beads (240 nm in diameter) composed of two layers of polystyrene and methyl methacrylate with a central void cavity and diameter of 140 nm were injected into male Wister-Imamichi rats. The injections were administered through the hepatic portal vein in a volume of 3 ml (concentration of the lecithin-coated or uncoated beads was 2 mg/ml). Controls received the lecithin alone at a concentration of 2 mg/ml. Liver samples were taken 5, 10, or 15 min after injection, fixed, and processed for ultrastructural analysis.

RESULTS

Both lecithin-coated and noncoated beads were mainly incorporated in the Kupffer cells as well as in the endothelial cells. Bristle-coated invaginations were observed in the uptake by both cell types; however, noncoated invaginations were also active in the endothelial cells, especially on the surface facing the perisinusoidal space of Disse. Only coated beads were observed within the space or in the hepatocytes. Once taken up by the hepatocytes, the lecithin-coated beads were found either within lysosomes or in a free state in the cytoplasm.

CONCLUSIONS

Uptake of 240 nm lecithin-coated polystyrene beads was observed by Kupffer cells, endothelial cells and hepatocytes. These beads were considered to be transported across the endothelial cells by transcytosis. Pseudopodia and bristle-coated invaginations were not employed by the hepatocytes when incorporating the beads.

Fungal metabolites. XXI. Characteristics of low energy collision induced dissociation of [M + 2H]2+, [M + H + Na]2+ and [M + 2Na]2+ of peptaibols using electrospray ionization mass spectrometry

The mass spectral characteristics of selected peptaibols were investigated using electrospray ionization in conjunction with low-energy collision-induced dissociation (CID). Protonated and sodiated molecular species were selected as precursor ions and the resulting CID spectra are discussed with respect to fragmentation characteristics related to the structures of peptaibols. The CID spectra of peptaibols with acetylated N-terminus and with the sub-sequences of Aib-Pro were similar. The CID spectra of [M + 2Na]2+ provided structural information more than those of [M + 2H]2+ and [M + H + Na]2+. The CID of [M + 2Na]2+ can be used to deduce complete sequence information for peptaibols.

Amyloid beta-protein ending at Thr43 is a minor component of some diffuse plaques in the Alzheimer's disease brain, but is not found in cerebrovascular amyloid

The distribution of amyloid beta-protein ending at 40 (A beta 40), 42 (A beta 42), and 43 (A beta 43) were immunocytochemically examined in Alzheimer's brains. A large number of diffuse plaques were stained with A beta 42 antibody (S42), but some were weakly labeled with A beta 43 antibody (S43). Immature and mature plaques were labeled with A beta 40 antibody (S40), S42, and S43. Thus, A beta 42 is the major component of diffuse plaques, the initial phase of plaque formation, and A beta 43 is present as a minor component. Only A beta 40 is present in cerebrovascular amyloid.

Laparoscopic splenectomy in children. Preliminary results and comparison with the open technique

To determine the safety and efficacy of laparoscopic splenectomy (LS) in children, a retrospective review of our preliminary experience using LS was compared to results in patients who previously underwent open splenectomy (OS). From July 1993 to January 1995, we performed eight LS procedures in six children with hereditary spherocytosis (HS) and two with immune thrombocytopenic purpura (ITP). Laparoscopic cholecystectomy was simultaneously done in one case with HS. There were 4 males and 4 females who ranged in age from 5 to 15 years--an average age of 8.8 years. Two cases in the early series required a counterincision because of bleeding. Eleven patients who previously underwent OS in our department were used to compare demographics, operative courses, and surgical outcomes. The ages, genders, diseases, body weights, and spleen weights were comparable between LS group and OS groups. The operative time for the LS group was statistically longer than for the OS group (226 +/- 24 min vs 101 +/- 8 min, P < 0.001). The estimated blood loss in the LS group was similar to that of the OS group (100 +/- 39 ml vs 73 +/- 11 ml. P = 0.97). There were no peri- or postoperative complications in two groups. The postoperative hospital stay of LS group was statistically shorter than that of the OS (6.8 +/- 0.6 days vs 10.4 +/- .05 days, P < 0.0001). LS provided better cosmesis and minimized trauma in children over OS. LS appears to be a safe and effective procedure in children, and is useful in the management of pediatric patients with HS or ITP.

Quantitative analysis of synthetic human calcitonin by liquid chromatography-mass spectrometry

The quantitative analysis of synthetic human calcitonin (hCT) by micro-liquid chromatography-electrospray ionization mass spectrometry (micro-LC-ESI-MS) is reported. hCT was extracted from plasma by an immobilized antibody column and separated by a micro-LC system. The molecular mass of hCT is 3417, and m/z 1140, corresponding to the [M + 3H]3+ ion, was observed by ESI-MS. This ion was monitored in the selected-ion monitoring mode; rat calcitonin, which is highly homologous to hCT, was used as an internal standard. The calibration curve for the quantification of hCT was linear in the range 10 ng/ml to 1 microgram/ml of plasma.

Three cases of primary biliary cirrhosis associated with bronchial asthma

The association of primary biliary cirrhosis (PBC) and bronchial asthma was observed in three patients. All of these patients were female (53, 54, and 41 years old, respectively), and were positive for antimitochondrial antibodies. The patients fulfilled the diagnostic criteria of both PBC and bronchial asthma. Bronchial asthma preceded PBC in two patients, and the reverse order was seen in the other. Patient the clinical symptoms were mainly due to the bronchial asthma. Two patients had asymptomatic PBC and the third patient complained of pruritus. The liver histology showed mild to moderate eosinophilic infiltration in addition to the ductal and hepatic parenchymal changes characteristic of PBC. A survey of 266 cases of PBC referred to us disclosed that, in 6 of these, the PBC was associated with bronchial asthma, while no association with bronchial asthma was the material of found in 166 patients with viral hepatitis in our liver biopsy files. The 3 present cases we experienced suggest that bronchial asthma may be included in the list of extrahepatic diseases associated with PBC. The significance of this association is unclear and may merit further study. Steroid therapy, which is known to cause adverse effects in PBC, was employed for bronchial asthma in these 3 patients. Another therapeutic approach will have to be considered in patients with bronchial asthma associated with PBC.

Case of bile duct carcinoma of the hepatic hilus with segmental obstructive cholangitis

Cholangitis is a risk factor for posthepatectomy liver failure and therefore should be treated aggressively by urgent biliary drainage before definitive liver surgery for bile duct carcinoma. We present a case of bile duct carcinoma of the hepatic hilus with segmental cholangitis. The patient was a 38-year-old man. Percutaneous transhepatic biliary drainage (PTBD) was performed in the left anterior, right anterior, and right posterior segmental ducts to alleviate jaundice and to evaluate the biliary system. One month after PTBD, the patient developed high fever with leukocytosis, suggesting the onset of segmental cholangitis. An urgent repeat PTBD was carried out at the caudate and left medial segmental bile ducts. The bile juice was purulent, and the tube cholangiogram revealed miliary abscesses. After PTBD, cholangitis was subsided, and extended left hepatic lobectomy with caudate lobectomy was performed. The postoperative recovery was uneventful and the patient has been well for 13 months. We conclude that the onset of fever in patients with hilar bile duct cancer, PTBD catheters, and undrained biliary segments suggests the presence of segmental cholangitis.

Protective effect of heat shock pretreatment with heat shock protein induction before hepatic warm ischemic injury caused by Pringle's maneuver

BACKGROUND

Induction of heat shock proteins is thought to have a > cytoprotective effect against environmental stress and to result in a better ischemic tolerance. The protective ability of heat exposure and heat shock protein 72 (HSP 72) induction before warm ischemia caused by Pringle's maneuver was evaluated in rats.

METHODS

Heat exposed rats (HS) were compared with control animals (C). The gene expression (messenger RNA) of HSP 72 and HSP 72 were detected by Northern and Western blot analyses. During 40 minutes of in situ reperfusion, liver energy metabolism and levels of standard liver enzymes were evaluated. The survival rate was determined after postoperative day 7.

RESULTS

After heat exposure and recovery, messenger RNA of HSP 72 and HSP 72 can be detected strongly in HS group but not in C group. During reperfusion HS group exhibited a significantly (p < 0.01) improved energy metabolism, and the release of liver enzymes was significantly (p < 0.001) reduced compared with C group. Seven-day survival rate was 100% in HS group but at 50% was significantly impaired (p < 0.05) in C group.

CONCLUSIONS

Heat exposure associated with HSP induction has a significant protective effect against warm ischemic liver injury, which results in a relevant improvement of survival rate.

Analysis of serum protein precipitated with antiserum by matrix-assisted laser desorption ionization/time-of-flight and electrospray ionization mass spectrometry as a clinical laboratory test

Serum transferrin precipitated with specific antisera was analyzed by matrix-assisted laser desorption ionization/time-of-flight mass spectrometry (MALDI/TOF-MS) and electrospray ionization-mass spectrometry (ESI-MS). When analyzed by MALDI, transferrin showed signal peaks that clearly could be separated from ions of IgG present in the immunoprecipitate. By ESI-MS, when the immunoprecipitates were loaded through a microcapillary polymeric reversed-phase column connected to the electrospray ionization probe, the mass spectra of transferrin were observed with a high signal-to-noise ratio and good resolution. By MALDI/TOF-MS, the observed molecular weight of normal transferrin was ∼ 1.2 ku smaller when analyzed in the reflectron mode than in the linear mode. The observed molecular weight of transferrin treated with sialidase was approximately the same in both modes. A comparison between the results obtained in both modes may help to estimate the number of sialic acids on the protein molecule. A transferrin isoform with a molecular weight of ∼2.2 ku less than the normal species was identified in the serum of patients with a carbohydrate-deficient glycoprotein syndrome as well as in heavy alcohol consumers.