Plasma Collection Using Nafamostat Mesilate and Dipyridamole as an Anticoagulant

Nafamostat mesilate (FUT-175) is a strong protease inhibitor and is used as an anticoagulant in extracorporeal circulation. In the present study, we administered FUT and dipyridamole as anticoagulants during donor plasmapheresis, and the additional effect of dipyridamole was examined. In dogs weighing about 15 Kg, donor plasmapheresis was performed using a cellulose triacetate membrane plasmaseparator (PEX-15, Nipro), and 300 ml of filtrated plasma was obtained within 30 minutes. These dogs were divided into two groups, 50 mg/h of FUT alone was infused (group A, n=10), and the same dose of FUT and 25 mg/h of dipyridamole were infused (group B, n=5) during plasmapheresis. Changes of the coagulation system, blood cell counts and complement system were investigated. In clinical cases, an artificial liver support therapy using FUT as an anticoagulant was performed on 8 patients with acute liver failure, and blood compatibility was examined.

In dogs, RBC counts and hematocrits were almost stable, but WBC counts were decreased to about 70% of the previous value. Platelets counts were about 60% and 80% of the previous value, in group A and group B, respectively, at the end of the plasmapheresis (P<0.01). Clotting factor VIII was diminished to about 20% and 35% of the previous value in group A and B, respectively. In clinical cases, all patients received the plasma exchange combined with hemodialysis using FUT as an anticoagulant, and no distinct side effect was observed during plasma exchange.

Effect of Oral Adsorbent on Blood Metabolites in Hepatic Failure Dogs

AST-120 is a specially synthesized carbonaceous adsorbent for oral use. It mainly adsorbs low to middle molecules in the alimentary tract. In the present study, AST-120 was administered to hepatic failure dogs, and blood metabolites were analyzed by high performance liquid chromatography (HPLC).

Thirty adult mongrel dogs underwent posta-cavae (P-C) shunts with 40% and 70% hepatectomies. They were divided into two groups, the AST group (n= 19) and control group (n=11). The AST group received about 0.5 g/kg of the adsorbent intermittently with diet after the operation. The control group was fed the ordinary diet. Body weight, blood ammonia, plasma bile acids were measured, and blood metabolites were analyzed by the multi-column HPLC system.

P-C shunt dogs with 70% hepatotectomies died within three months showing about 40–50% body weight loss. HPLC analysis of their plasma showed some specific peaks for middle molecules, about 3000–5000 daltons. After administration of the adsorbent, these peaks were not detected, so it was considered that these substances had been adsorbed.

Long live the health care system in Japan

In Japan, a cost-containment policy has been implemented with health care system reform. Increasing medical expenses are inevitable due to aging of the population, health transitions, and expanded and advanced medical services. Policies such as the introduction of regressive reimbursement for inpatient services as part of social insurance, the reduction in the number of hospital beds, fewer medical examinations, and curtailed usage of medical tests have jeopardized the accessibility and quality of medical services, especially for the elderly. Compared to other developed countries, both the proportion of the government's payment of health expenses and the proportion of health expenses in proportion to GDP are lower in Japan. To confront the challenges of an aging society in terms of finances and the health care system, policymakers from the Ministry of Health should take a comprehensive approach instead of a mere cost-containment policy.

Characteristics of pancreas transplantation currently performed in japan

The Pancreas Transplantation (tx) Program under the Japanese Organ Transplant Act was started in 2000. PTx is indicated for type 1 diabetic patients on hemodialysis therapy. As of April 2003 93 patients are listed as candidates. Ten cases of PTx with enteric or bladder-drained technique were performed during the last 3 years as well as nine SPK and one PAK. Of 10 cases, nine recipients are insulin-free with HbA1c values ranging from 4.4% to 5.7%, although exogenous insulin was required in six cases temporarily, namely for a median 63 days (12 to 225 days). One case was lost due to pancreatic graft thrombosis. All 10 kidney grafts are functioning. Based on the experiences with 14 cases of pancreas tx using non-heart-beating (NHB) donors, we defined the criteria of NHB donor as: age younger than 40 years and cessation of respiratory support. One case of SPK with graft of NHB donor was done, and the recipient is off insulin. Pancreas and kidney are allocated for SPK if the recipient shares at least one HLA-DR antigen. Marginal donors were defined as higher mean donor age, median 37 (range 18 to 58 years); mean 38 +/- 12 years), and no death cause of by trauma. The revascularization of gastroduodenal artery to the pancreatic graft was performed in eight cases to minimize the risk of ischemic injury to the pancreatic graft and technical failure in cases of marginal donor.

Increased insufflation pressure enhances the development of liver metastasis in a mouse laparoscopy model: possible mechanisms

BACKGROUND

The effect of different insufflation pressures and durations of CO2 pneumoperitoneum on the growth of liver metastasis was investigated in a mouse model. The possible mechanisms involved in the pressure-related enhancement of liver metastasis were also examined.

METHODS

Mice inoculated intraportally with colon 26 cells underwent CO2 pneumoperitoneum at different pressures (5,10, or 15 mmHg) for 30 or 60 min, or received no treatment other than tumor cell inoculation (control). The subsequent growth of liver metastases was examined. Mice injected intraportally with 111In-oxine-labeled colon 26 cells underwent pneumoperitoneum at three different pressures or served as controls. The radioactivity of the liver was determined to evaluate tumor accumulation in the liver. Mice received pneumoperitoneum at three different pressures or received trocar placement alone. Changes in plasma interleukin-6 levels were determined.

RESULTS

The growth of liver metastases on day 14 was influenced by increased insufflation pressures (p < 0.05) rather than the prolonged duration of pneumoperitoneum without significant interaction. The 15-mmHg pneumoperitoneum group showed a higher (p < 0.05) accumulation of radioactivity in the liver compared with the 5-mmHg pneumoperitoneum group and controls. Pneumoperitoneum groups with 5 and 10 mmHg showed higher (p < 0.05) peak levels of IL-6 compared with controls.

CONCLUSIONS

An elevated insufflation pressure plays an important role in the enhancement of liver metastases, and this pressure-related adverse effect may be partly relevant to facilitating accumulation of tumor cells in the liver.

Increased insufflation pressure enhances the development of liver metastasis in a mouse laparoscopy model

Despite the widespread use of laparoscopic techniques for colorectal cancer surgery, little is known about the potential risk of liver metastasis following CO2 pneumoperitoneum. We investigated the effect of different insufflation pressures and durations of CO2 pneumoperitoneum on the growth of liver metastasis in a mouse model. Six- to 7-week old male BALB/C mice were intraportally inoculated with 2 x 10(4) Colon 26 cells and randomly allocated to receive either CO2 pneumoperitoneum at different pressures (5 mmHg, 10 mmHg, or 15 mmHg), xiphoid-pubic laparotomy, or no treatment other than tumor cell inoculation. Mice undergoing pneumoperitoneum or laparotomy were then subdivided by the duration of treatment (30 minutes or 60 minutes). Cancer nodules on the liver surface from a total of 122 mice were evaluated on the 14th postoperative day. Similar to full laparotomy, CO2 pneumoperitoneum at 10 mmHg and 15 mmHg for 60 minutes, and pneumoperitoneum at 15 mmHg for 30 minutes significantly promoted the growth of cancer nodules on the liver surface. Enhancement of tumor growth was influenced by increased insufflation pressures (p < 0.05) rather than the prolonged length of pneumoperitoneum (p = 0.53) without significant interaction (p = 0.49). These results suggest that an increased insufflation pressure promotes the growth of liver metastases as well as laparotomy in this animal model. growth of liver metastases in a mouse laparoscopy model, following different pressures and durations of CO2 pneumoperitoneum, which is used most often in laparoscopic procedures.

[Tumoral levels of thymidine phosphorylase and dihydropyrimidine dehydrogenase in elderly colorectal cancer patients]

Fluoropyrimidine therapy for elderly colorectal cancer patients remains controversial. Tumoral levels of thymidine phosphorylase (TP), dihydropyrimidine dehydrogenase (DPD), and the ratio of TP to DPD determined by an enzyme-linked immunosorbent assay were compared between colorectal cancer patients aged 75 or over (elderly group, n = 25) and those 74 years or less (control group, n = 87), in order to examine the characteristics of colorectal cancers in the elderly from the viewpoint of metabolic and anabolic pathways of fluoropyrimidines. The level of TP was 78.4 +/- 47.0 unit/mg protein in the elderly group and 82.4 +/- 70.9 unit/mg protein in the control group (p = 0.86). The level of DPD was 53.7 +/- 43.1 unit/mg protein in the elderly group and 52.6 +/- 37.7 unit/mg protein in the control group (p = 0.73). The ratio of TP to DPD was 2.0 +/- 1.2 in the elderly group and 1.8 +/- 0.9 in the control group (p = 0.44). These three parameters did not differ between the groups when divided according to Dukes' stage (Dukes' A.B versus Dukes' C.D). These results suggest that there are no age-specific characteristics in relation to conversion of fluoropyrimidines such as capecitabine and doxifluridine to 5-fluorouracil (FU) and degradation of 5-FU in colorectal cancers.

[Training in specialties and subspecialties of surgery: current system in Japan and a proposal for the future]

The maintenance of quality care of surgical patients is the primary concern of surgeons. The Japan Surgical Society has taken the responsibility for establishing standards for the quality care of patients in surgery and surgical subspecialties. The society introduced training systems for surgeons and developed qualifying examinations after 4 years of training in general surgery in 1984, but after 24 years, in response to the demands from surgeons and patients, new training, certification, and recertification programs are under investigation by the Japan Surgical Society and its related societies of subspecialties. Currently, a 3-year training system and subsequent qualifying examination for gastroenterological surgery, pediatric surgery, cardiovascular surgery and pulmonary surgery are being proposed after completing 4-year training and qualifying examination in general surgery. The pros and cons of this system are discussed and a more desirable system for the future is proposed.

Liver metastasis following pneumoperitoneum with different gases in a mouse model

BACKGROUND

The validity of using CO2 in laparoscopic tumor surgery has not yet been established. To address this question, we investigated the growth of liver metastases following insufflation with different gases in a mouse laparoscopy model.

METHODS

Male BALB/C mice inoculated intraportally with colon 26 cells were randomized to undergo pneumoperitoneum with CO2 (n = 16), helium (n = 16), argon (n = 16), or air (n = 17), or to act as controls without insufflation (n = 17).

RESULTS

The growth of cancer nodules on the liver 14 days after surgery was greater in mice following insufflation with CO2 (p < 0.01), helium (p < 0.01), argon (p = 0.01), and air (p = 0.07) than in control mice. No significant differences were found between the four insufflation groups in the growth of liver metastases.

CONCLUSION

These results suggest that insufflation plays an important role in the development of liver metastases but that the choice of gas may not affect their growth.

Creation, evaluation, and continuing assurance of excellence of the certified surgical specialist

A position paper on the subject of certified surgical specialists was published in 1966 under the direction of Professor Charles Wells of Liverpool, England. President John Terblanche of the International Federation of Surgical Colleges brought together leaders in surgical education from four nations (Australia, Japan, South Africa, United States) to update current "state-of-the art" views. Presentations were made at the 38th Congress of the International Society of Surgery, August 18, 1999 in Vienna, Austria. After careful review of the four presentations, it was clear that surgeons all over the world have made great improvements in the many facets of surgical education. Yet the advances remain spotty, with gaps noted when viewed from an international perspective.

[Clinical significance of determinations of dihydropyrimidine dehydrogenase levels in primary and hepatic lesions of colorectal cancer patients]

Dihydropyrimidine dehydrogenase (DPD) levels were determined by enzyme-linked immunosorbent assay in primary tumors and adjacent normal mucosa from 114 colorectal cancer patients, including 9 with synchronous liver metastases. The level of intratumoral DPD was 55.0 +/- 38.7 unit/mg protein (n = 114) and that of mucosal DPD was 55.0 +/- 38.7 unit/mg protein (n = 114). The ratio of intratumoral DPD to mucosal DPD was 1.8 +/- 0.8 in patients developing metachronous liver metastases (n = 7), 1.0 +/- 0.5 in patients without recurrence (n = 61), and 1.0 +/- 1.1 in patients with synchronous liver metastases (n = 31) (p = 0.01, metachronous liver metastasis group versus recurrence-free and synchronous liver metastasis groups). The levels of DPD were higher in primary lesions than in synchronous liver metastasis (n = 9, p < 0.05). These results indicate that: (1) degradation of 5-fluorouracil (5-FU) is enhanced in hepatic lesions more than in primary lesions, which is consistent with previous findings showing the therapeutic advantage of hepatic arterial infusion over intravenous infusion in relation to the treatment of 5-FU for liver metastases of colorectal cancer patients; and (2) predicting the effectiveness of hepatic arterial infusion of 5-FU for patients with metachronous liver metastases is difficult based on DPD determination of primary lesions alone.

[Combination chemotherapy with irinotecan hydrochloride plus carboplatin for patients with advanced or recurrent colorectal cancer--a pilot study]

A pilot study was performed to evaluate the feasibility and efficacy of irinotecan hydrochloride (CPT-11) plus carboplatin (CBDCA) for treatment of advanced or recurrent colorectal cancer. Fifteen patients with colorectal cancer (nonresectable, 1; noncurative resection, 5; recurrent disease, 9) were treated with CPT-11 (40-50 mg/m2) plus CBDCA (70-100 mg/m2) once a week for 2-3 weeks followed by a one-week rest. This treatment was repeated until disease progression or severe toxic effects were found. The total dose of CPT-11 ranged from 135 to 1,214 (median, 467) mg/m2 and that of CBDCA ranged from 267 to 2,022 (median, 933) mg/m2. Adverse effects included nausea (grade 2) in 2 (13.3%) diarrhea (grade 2) in 2 (13.3%), leukopenia (grade 3) in 2 (13.3%), thrombocytopenia (grade 1) in one (6.7%), and hair falling (grade 3) in one (6.7%). The response rate of 14 evaluable patients was 14.3% (CR, 1; PR,1; NC,7; PD,5). The median survival time of all patients was 405 days from the start of chemotherapy. The survival time of patients with CR, PR, and NC (n = 9) tended to be longer than that of those with PD (n = 5) (p = 0.06). The median time to disease progression was 105 days. These results suggest that this combination chemotherapy is feasible and effective in the treatment of advanced or recurrent colorectal cancer.

[Problems concerning the prices of surgical operations in Japan. Union of Social Medical Insurance Committee Members of Surgical Societies in Japan]

The Union of Social Medical Insurance Committee Members of Surgical Societies in Japan was established in 1967. The union has tried to develop scientific methods to assess the price of surgical operations in Japan and proposed a tentative plan for the assessment of the price of operations. The price of an operation includes personnel expenses and other costs such as the prime costs to repay loans for land and buildings, and taxes. Personnel expenses are calculated by the grade of technical difficulties, the number of doctors and nurses and the duration of the operation. A more precise method to judge the difficulties of the operation seems to be necessary. To examine the recent increase in expenses for surgical materials, the cooperation of main hospitals authorized by surgical societies will be necessary. The prices of surgical operations presented by the Ministry of Health and Welfare of Japan correlated well with the prices proposed by the Union.

Effect of CO(2) pneumoperitoneum on growth of liver micrometastases in a rabbit model

Little is known about the risk of metachronous liver metastases following laparoscopic resection for gastrointestinal malignancies. The effect of CO(2) pneumoperitoneum on the growth of established liver micrometastases was investigated in a rabbit model. Male Japanese white rabbits weighing 2.8 to 3.3 kg were randomized to three groups (n = 15 per group) 3 days following intraportal inoculation of a tumor suspension containing 5 x 10(4) cells of VX(2) cancer. In the pneumoperitoneum group, insufflation with CO(2) was maintained at a pressure of 10 mmHg for 30 minutes. In the laparotomy group the abdominal cavity remained open through a 45 mm midline incision for 30 minutes; in the control group no treatment other than anesthesia was performed. Cancer nodules on the liver surface were compared among the three groups on day 17. There was no difference in the number of cancer nodules among the groups (p = 0. 72). A significant difference in the total area of cancer nodules (mean +/- SEM) was found only between the pneumoperitoneum group (696.0 +/- 177.0 mm(2)) and the control group (247.2 +/- 60.7 mm(2)) (p < 0.05). The frequency of cancer nodules larger than 3.0 mm in maximal diameter tended to be highest in the pneumoperitoneum group (p = 0.053). These results suggests that CO(2) pneumoperitoneum may promote the growth of established liver micrometastases in this animal model.

The influence of different insufflation pressures during carbon dioxide pneumoperitoneum on the development of pulmonary metastasis in a mouse model

BACKGROUND

The effects of different insufflation pressures on the development of pulmonary metastasis was investigated in a mouse laparoscopy model.

METHODS

BALB/C mice intravenously inoculated with colon 26 cells were randomized to one of five treatment groups (10 mice per group): pneumoperitoneum at different pressures of 5, 10 or 15 mmHg; full laparotomy for 60 min; or anesthesia control. Cancer nodules on the lung surface 19 days postoperatively were compared between groups.

RESULTS

(a) As compared with the control group, pneumoperitoneum at 10 and 15 mmHg and laparotomy enhanced the growth of pulmonary metastases (p < 0.01). (b) The growth of metastases also was greater in laparotomy group mice than in mice undergoing pneumoperitoneum at 5 and 10 mmHg (p < 0.05).

CONCLUSIONS

These results suggest that the effects of different insufflation pressures on the growth of pulmonary metastases are not identical, and that pneumoperitoneum with high pressure may promote pulmonary metastases similar to those with laparotomy.

[Future of surgery]

Most current surgical techniques were developed in the 20th century, especially during the past 50 years. Open heart surgery, vascular surgery, neonatal surgery, organ transplantation and artificial organs, microsurgery, intravenous hyperalimentation, and, more recently, endoscopic surgery emerged during the past five decades. Many of the dreams of surgeons in the past have now been realized. These advances in surgery were made possible by the development of new technologies and instrumentation, but most importantly were initiated by the pioneering spirit of surgeons. This will continue on in the next century, since history shows that classical or conventional treatment modalities are constantly changing and being replaced by new ones based on new ideas and technologies. In this age of molecular biology, gene therapy, computer science, and the Internet, the pace of change in medicine and surgery will accelerate. Systems for training and communications, and even medical ethics, will inevitably change. We may not be able to predict precisely the future changes in surgery and surgeons, but we must be prepared for them and steer the future of surgery for the benefit of patients.

Pneumoperitoneum with carbon dioxide enhances liver metastases of cancer cells implanted into the portal vein in rabbits

BACKGROUND

Little is known about the role of the CO2 pneumoperitoneum on tumor cells that spread from the portal system into the liver during laparoscopic surgery for gastrointestinal malignancies. Therefore, we designed a study to investigate the effect of CO2 pneumoperitoneum on cancer cells implanted in the portal vein in a rabbit model.

METHODS

Immediately after intraportal inoculation of 2.5x10(5) cells of VX2 cancer, the rabbits received either CO2 pneumoperitoneum at a pressure of 10 mm Hg for 30 min (pneumoperitoneum group, n = 14) or laparotomy alone for 30 min (laparotomy group, n = 14).

RESULTS

The number (p<0.01) and area of cancer nodules (p = 0.045) on the liver surface on day 17 were greater in the pneumoperitoneum group than in the laparotomy group. The frequency of cancer nodules >3.0 mm in diameter was higher in the pneumoperitoneum group than in the laparotomy group (p<0.001).

CONCLUSIONS

Compared with laparotomy, CO2 pneumoperitoneum enhanced the development of liver metastases in this experimental model.

The facilitation of peritoneal dissemination of a tumor by laparotomy in a rabbit model

The effects of conventional laparotomy and laparoscopic surgery on the peritoneal dissemination of VX2 tumors were evaluated in a rabbit model. Either 5 x 10(3) or 5 x 10(4) of VX2 tumor cells were inoculated into the peritoneal cavities of rabbits which were divided into three groups according to the procedure performed, namely, a conventional laparotomy group (group 1), a laparoscopy group (group 2), and a control group (group 3). All the animals were killed 2 weeks after the treatment to examine the spread of the VX2 tumor in the omentum. In the experiment in which 5 x 10(3) tumor cells were inoculated, no significant difference was found in the number of metastases among the three groups. Conversely, after inoculating 5 x 10(4) tumor cells, the mean numbers of metastatic colonies greater than 1 mm in diameter in the greater omentum were 14.4+/-4.7 in group 1, 9.9+/-2.4 in group 2, and 3.3+/-1.1 in group 3, with a significant difference between groups 1 and 3, and between groups 2 and 3, but not between groups 1 and 2. In conclusion, conventional laparotomy facilitated the greatest peritoneal dissemination of a VX2 tumor in this animal model when 5 x 10(4) tumor cells were inoculated. Furthermore, laparoscopic surgery influences tumor growth to almost the same degree as conventional laparotomy.

Influence of trocar placement and CO(2) pneumoperitoneum on port site metastasis following laparoscopic tumor surgery

BACKGROUND

The mechanisms involved in the development of port site metastasis following laparoscopic tumor surgery remain controversial. Therefore, we decided to investigate the influence of trocar placement and CO(2) pneumoperitoneum on abdominal wound implantation in relation to intraperitoneal tumor growth in a rabbit model.

METHODS

Rabbits received either CO(2) pneumoperitoneum with insertion of nine trocars (pneumoperitoneum group, n = 15), insertion of nine trocars alone (nonpneumoperitoneum group, n = 15), or nine abdominal incisions (control group, n = 13) 3 days after intraperitoneal inoculation of VX(2) cancer cells.

RESULTS

The frequency of overall wound implantation on day 17 in the pneumoperitoneum group (24.4%) and nonpneumoperitoneum group (27.4%) tended to be higher than that in the control group (15.3%) (p = 0. 06). There was no significant difference among the three groups in the growth of cancer nodules on the omentum.

CONCLUSIONS

The presence of a trocar may be a factor contributing to port site metastasis but CO(2) pneumoperitoneum appears not to be a factor.

[A case of diffusely infiltrating carcinoma of the sigmoid colon associated with lymphangitis carcinomatosa effectively treated with sequential MTX.5-FU and 5'-DFUR]

A 37-year-old man was diagnosed as having a diffusely infiltrating carcinoma of the sigmoid colon associated with lymphangitis carcinomatosa. Sequential methotrexate (MTX).5-fluorouracil (5-FU) therapy with oral administration of doxifluoridine (5'-DFUR) was started. After 9 cycles of the MTX.5-FU therapy (total dose: MTX = 900 mg/body, 5-FU = 7,500 mg/body), radiographic examinations showed a partial response in the primary and pulmonary lesion, and paraaortic lymph nodes. Histological evaluation of the resected specimen by Hartmann's operation showed a grade 2 effect in the primary lesion and metastatic lymph nodes. This chemotherapy was repeated postoperatively. The patient died of pulmonary disease, deteriorating rapidly 60 days postoperatively. Diffusely infiltrating carcinoma of the large-bowel is generally far advanced at the time of diagnosis. The results suggest that sequential MTX.5-FU therapy and oral administration of 5'-DFUR are worth performing in clinical trials for patients with diffusely infiltrating carcinoma of the large-bowel.

[A case of liver metastases of rectal carcinoid successfully treated with hepatic arterial infusion of methotrexate and 5-fluorouracil]

Standard therapy for liver metastasis from colorectal carcinoid remains controversial because of the rarity of the disease. We report herein a case of rectal carcinoid with multiple liver metastasis successfully treated with hepatic arterial infusion of methotrexate (MTX) and 5-fluorouracil (5-FU). A 65-year-old woman underwent posterior pelvic exenteration and hepatic arterial catheterization for rectal carcinoid involving the vagina associated with multiple liver metastases. Hepatic arterial infusion of MTX (50 mg/body) and 5-FU (500 mg/body) was started and repeated with a frequency of twice a week postoperatively. After 40 cycles of this chemotherapy, all but the largest metastatic lesion disappeared, and the largest decreased in size by 53%. The partial response was maintained for 7 months. Her performance status did not deteriorate throughout the period of the chemotherapy. These results suggest that hepatic arterial MTX/5-FU is safe and worth trying in patients with liver metastases from colorectal carcinoid.

[Clinical trial of prophylactic hepatic arterial chemotherapy for liver metastases in patients with Dukes' C colorectal cancer]

Preliminary results of a prospective non-randomized trial of prophylactic hepatic arterial chemotherapy for liver metastases from colorectal cancer are presented. Twenty-two colorectal cancer patients (infusion group) in Dukes' C stage were given hepatic arterial infusion of 5-FU (500 mg/body for 1 hr per week, repeated 50 times) and peroral UFT-E (2.0 g/body, daily). Informed consent was obtained from all patients. Adverse effects and postoperative recurrence in the infusion group were compared with those of patients with UFT-E alone (control group). Complications related to hepatic arterial infusion in the infusion group were also demonstrated. There was no adverse effect in the control group, while diarrhea (grade 1) developed in one patient (5%) and pigmentation in five (24%) in the infusion group. Complications related to infusion were found in five patients (5%). Three patients in the infusion group presented with metachronous hepatic lesions, two of which were resected successfully. In the control group, one patient died of marked hepatic metastases, and one developed ovarian metastasis with lymph node involvement. Our regimen appears hematologically safe, however, the high frequency of pigmentation should be kept in mind. The oncological benefit of this chemotherapy would be clarified by a larger series of cases and longer follow-up.

A new simple technique for performing intraoperative endoscopic resection of small-bowel polyps in patients with Peutz-Jeghers syndrome

We describe herein a simple method for performing intraoperative endoscopic resection of small-bowel polyps associated with Peutz-Jeghers syndrome, using a corrugated anesthetic tube. A 34-year-old man with Peutz-Jeghers syndrome underwent emergency surgery for an ileo-ileo-colic intussusception. A sterile corrugated anesthetic tube was inserted into the small-bowel, proximal to the affected lesion. The small bowel was then telescoped sequentially over the tube using a pleating technique. Consequently, a colonoscope inserted through the tube was easily able to reach the duodeno-jejunal junction, and ten small-bowel polyps were removed using a wire snare and electrocauterization. All resected specimens were washed out by the instillation of saline through a nasogastric tube, then collected on gauze placed near the outlet of the tube. Our technique has the following merits: it is feasible even in emergency surgery; it prevents contamination of the surgical field; and it facilitates the easy collection of polypectomized specimens.

Laparoscopic gastropexy for acute gastric volvulus: a case report

A 7-year-old girl presented with an acute gastric volvulus that was reduced with a nasogastric catheter. An anterior gastropexy was undertaken laparoscopically. The gastrocolic omentum was deficient along most of the greater curvature, which had allowed organoaxial volvulus. Two years later, gastric volvulus has not recurred. Laparoscopy is an acceptable approach for the evaluation and treatment of children with acute gastric volvulus.

[CBDCA, etoposide and epirubicin high-dose combination chemotherapy supported by peripheral blood stem cell transplantation (PBSCT) in metastatic breast cancer]

Six metastatic breast cancer patients, including one brain metastasis, one lung metastasis, three local recurrences and one bone metastasis, underwent multidrug chemotherapy with CBDCA, Etoposide (ETP) and Epirubicin (EPI). Each patient received two courses of PBSC mobilization chemotherapies and subsequently received high-dose chemotherapies for at least two courses. CBDCA AUC 4, ETP 300 mg/m2 and EPI 40 mg/m2 were administered intravenously as a PBSC mobilization chemotherapy, and high-dose chemotherapies were performed under the regimen of CBDCA AUC 8, ETP 900 mg/m2 and EPI 60 mg/m2. Severe bone marrow suppression due to high-dose chemotherapies was off sct by autologous peripheral blood stem cell transplantation (PBSCT). The PBSC mobilization chemotherapies resulted in one CR, three PR, one NC and one PD in the six patients. The PD patient died before high-dose chemotherapy. Consequently, the remaining five patients received the high-dose chemotherapies, which achieved three CR, one PR and one PD in the five patients. The response rate of high-dose chemotherapy was 80% (4/5 cases). In overall outcome, three patients have continued 16, 12 and 10 months tumor-free survival, and three patients died of cancer progression. High-dose chemotherapy with CBDCA, ETP and EPI has led to increased CR rates in metastatic breast cancer, and such therapy has desirable effect on the patient's prognosis.

Bromodeoxyuridine uptake by early liver metastases in rats: a comparison of the hepatic artery and portal vein infusion routes

Liver metastases generated by the intraportal inoculation of ascites hepatoma cells in Donryu rats were labeled with bromodeoxyuridine (BrdU) through the hepatic artery, or through the portal vein with or without ligation of the hepatic artery, 3, 6, or 9 days after tumor inoculation. The distribution of BrdU-labeled cells was evaluated in 174 metastases, 110-1640 microm in diameter, by immunohistochemical methods. When a dual blood supply from the portal vein and hepatic artery existed, the BrdU-labeled cells were diffusely found in the metastases regardless of their size and the route of BrdU infusion. When blood supply to metastases larger than 610 microm in diameter was from a single source, namely the portal vein, the BrdU-labeled cells were located within 90-290 microm from the margin of the metastases. These results indicate first, that drug uptake by the inner part of the early metastatic liver tumors is achieved through the hepatic artery, and second, that drug uptake by early liver metastases through the portal vein is limited to within the extent of portal diffusion regardless of the size of the metastases. Thus, we conclude that prophylactic treatment against liver metastases would be more effective when given via the hepatic artery route rather than via the portal vein route.

[Intra-arterial infusion chemotherapy for unresectable or recurrent breast cancer]

Epirubicin and 5-FU were administered through an indwelling catheter inserted into the internal mammary artery and/or subclavian artery employing an implantable infusion port system for the treatment of unresectable advanced breast cancer and recurrent breast cancer. Intraarterial infusion chemotherapy proved to be an effective treatment modality for unresectable advanced breast cancer and recurrent breast cancer.

[Adjuvant chemotherapy with UFT or UFT with OK-432 to patients with gastric and colorectal cancer. Kanto Adjuvant Study Group]

In Japan, long-term oral therapy with tegafur in combination with immunopotentiators is commonly used as adjuvant therapy after curative resection of gastric or colorectal can for gastric and colorectal cancer. When the outcome was analyzed in terms of the relative performance (R.P.) and the individual dose intensity (I.D.I.) of OK-432, gastric cancer patients with a R.P. of 0.5 or higher tended to have a better survival curve. There were no marked differences in lymphocytes subsets, except that the Leu 7 level at 3 months after gastric cancer resection was significantly higher (p < 0.05) in group B than in group A. Thus, no inhibition of the anticancer effect of UFT was noted during long term combination therapy with UFT and an immunopotentiator as postoperative adjuvant therapy for patients who underwent curative resection of gastric or colorectal cancer. The results suggest that UFT combined with long-term OK-432 maintenance therapy may contribute to improve survival rates in gastric cancer patients.

[A case report of neoadjuvant intra-arterial injection chemotherapy combined with peripheral blood stem cell reinfusion in an advanced breast cancer patient]

A seventy-one year-old woman suffered from Stage IIIb advanced breast cancer complicated with direct thoracic invasion and skin eruption. An indwelling intra-arterial catheter was inserted into the subclavian artery for the administration of anti tumor agents. After three courses of neoadjuvant chemotherapy combined with G-CSF and/or PBSCT reinfusion, the breast cancer revealed a remarkable size reduction and was absent from direct thoracic and pectoral muscle, invasion within the physical status and visual analysis by CT scan. Thereafter, the patient underwent a radical mastectomy. In the pathological findings of the operation specimen, despite a remarkable tumor collapse, the microscopic invasion remained in the shallow layer of the pectoral muscle. Thus, the patient should be given additional postoperative irradiation. The patients has had six months of stable tumor-free survival since the mastectomy.

Oral vancomycin hydrochloride therapy for postoperative methicillin-cephem-resistant Staphylococcus aureus enteritis

The postoperative development of methicillin-cephem-resistant Staphylococcus aureus (MRSA) enteritis can be fatal unless it is detected at an early stage and treated with effective antibacterial agents. We report herein a Japanese multicenter collaborative clinical study on the efficacy and safety of oral vancomycin hydrochloride (VCM) in the treatment of MRSA enteritis. A total of 49 patients who had been diagnosed as having, or were strongly suspected of having, MRSA enteritis during the early postoperative period, were given oral VCM as four standard doses of 0.5 g per day. The VCM concentrations in the blood, urine, and feces were then measured. No side effects were observed and the clinical efficacy of oral VCM in the 31 evaluable patients was excellent. There was a 100% clinical response rate and a 95.8% bacterial elimination rate in the feces. The clinical complete response (CR) rate to oral VCM differed significantly between patients in whom MRSA was detected only in the feces (100%) and those in whom MRSA was isolated from an additional source (57%) (P < 0.01). Although VCM concentrations in the stools were extremely high, the levels in the blood and urine were very low. These results demonstrate that oral VCM should be the treatment of choice for postoperative MRSA enteritis due to its safety and efficacy.

Hyperinsulinaemia accelerates accumulation of cholesterol ester in aorta of rats with transplanted pancreas

Hyperinsulinaemia may play a role in the development of atherosclerosis; however, the direct effect of endogenous insulin on the atherosclerotic process is not well understood. To clarify this situation we performed pancreas transplantation with systemic venous drainage in Wistar Shionogi (WS) and Spontaneous Hypertensive (SHR) rats. Both rats received syngeneic pancreaticoduodenal transplants from donor rats. SHR rats were used to observe the additive effects of both hypertension and hyperinsulinaemia on the atherosclerotic process. Peak blood insulin levels after a glucose load were approximately two times higher in transplanted rats than in non-transplanted WS and SHR rats. By contrast, there was no difference in plasma glucose responses between transplanted and non-transplanted rats. Hyperinsulinaemia was not related to dyslipidaemia and hypertension in transplanted rats. Nine months after transplantation, the cholesterol ester contents of the aortas of both WS and SHR transplanted rats were significantly higher than in the control rats (WS: 1.9 +/- 1.0 vs 3.8 +/- 2.1 mg/g dry tissue, p < 0.01; SHR: 1.7 +/- 1.3 vs 3.7 +/- 1.4 mg/g dry tissue, p < 0.05). No differences were demonstrated in the thickness of the intima or in the histology of the aortas of transplanted and control rats. To study the mechanism for cholesterol ester accumulation in the arterial wall, we measured neutral cholesterol ester hydrolase activities in vascular medial smooth muscle cells. Insulin significantly suppressed neutral cholesterol ester hydrolase activities in medial smooth muscle cells. Our results indicate that endogenous hyperinsulinaemia contributes to the development of atherosclerosis by accelerating cholesterol ester accumulation in the arterial wall.

[The history of the treatment for portal hypertension]

Until recently, the only effective treatment for bleeding esophageal varices was surgery, including portal-systemic shunts, nonshunting operations, and selective shunts. New operations were developed from the neccessity to find a better therapeutic modality for the treatment. This article describes the history of development of surgical treatment for portal hypertension as well as introducing the outline of several such procedures. The history of nonoperative treatments, especially endoscopic injection screlotherapy, is also described: Endoscopic sclerotherapy as a treatment for bleeding esophageal varices had been employed before many definitive surgical procedures. In accordance with the development of fiberoptic endoscopy, endoscopic sclerotherapy came into prominance. The less invasive treatment is appreciated and popularized even among surgeons today, who once believed that shunt operation (or nonshunting operation) was the best modality of treatment for esophageal varices. Finally, this article provides readers with a simplified guide to Japanese participation in the development of treatment for esophagogastric varices.

Hemodynamic analysis of findings in patients with portal hypertension: multicenter analysis in Japan. Japan Portal Hypertension Study Group

BACKGROUND/AIMS

A multicenter study was done to assess the pathophysiology of malcirculation with portal hypertension.

PATIENTS AND METHODS

Patients were admitted to 48 different institutes from 1990 to 1992.

RESULTS

Portal venous pressure was 345.9 +/- 72.1 mmH2O in patients with portal hypertension. In patients with liver cirrhosis, the diameter of the splenic artery, of the proper hepatic artery, of the left gastric artery and of the splenic vein was significantly larger (p<0.05) than seen in the controls without portal hypertension. In patients with idiopathic portal hypertension, the diameter of the splenic artery and of the vein was significantly larger (p<0.05) and that of the proper hepatic artery was significantly smaller (p<0.05) than seen in the cirrhotic patients. In the cirrhotic patients, blood flow volume was significantly larger (p<0.05) in the splenic vein. In patient with idiopathic portal hypertension, blood flow volume in the portal vein and splenic vein were significantly larger (p<0.05) and that of superior mesenteric vein showed an increasing tendency to enlarge.

CONCLUSION

This study shows that a hyperdynamic state is present in patient with portal hypertension.

Healing process of sutureless choledochojejunostomy in an experimental model

The healing characteristics and morphological features of sutureless choledochojejunostomy were investigated in a rat experimental model. The common bile duct of 34 conditioned Wistar rats was exposed, divided transversely and a choledochojejunostomy constructed with only a vinyl chloride tube positioned between the common duct and jejunum. The animals were killed 4, 12 and 52 weeks after surgery. Cholangiographic evaluation of the anastomosis in all three groups showed wide openings with dilatation of the extrahepatic bile duct. Microscopic examination of the anastomosis showed hyperplastic changes of the bile duct epithelium. The epithelial defect was completely covered with proliferative epithelium 12 weeks after operation. At long-term follow-up of 52 weeks there were no biliary strictures after the sutureless technique. This surgical approach may be useful for patients in whom sutured anastomosis of the bile duct might lead to stricture, such as those with a normal thin-walled bile duct.

Extensive subcutaneous emphysema and hypercapnia during laparoscopic cholecystectomy: two case reports

We report two cases of marked hypercapnia of more than 60 mm Hg (PaCO2) and extensive subcutaneous emphysema noted during laparoscopic cholecystectomy. The first case, a 55-year-old man was diagnosed as having cholecystolithiasis and had hypercapnia up to 83.5 mm Hg (PaCO2) during laparoscopic cholecystectomy. The patient resumed spontaneous respiration under controlled ventilation accompanied by persistent bigeminal pulse. Soon after deflation, CO2 returned to normal range, and extensive subcutaneous emphysema was detected in the recovery room. The second patient, a 53-year-old woman, had cholecystolithiasis and also underwent laparoscopic cholecystectomy. Both hypercapnia rising to 61.1 mm Hg (PaCO2) and extensive subcutaneous emphysema appeared just before completion of resection of the gallbladder. Mild hypercapnia during pneumoperitoneum of about 50 mm Hg (PaCO2) has been reported previously. As compared with cases in the literature, the present cases suggest that hypercapnia is due to extensive subcutaneous emphysema. The large absorption surface area in the subcutaneous tissue and the large difference in the partial pressure cause the extensive gaseous interchange of CO2 between subcutaneous tissue and blood perfusing into it at the moment between peritoneal cavity and blood perfused the peritoneum.

General rules for recording endoscopic findings of esophagogastric varices (1991). Japanese Society for Portal Hypertension

The general rules made in 1980 for recording endoscopic findings of esophageal varices have widely been used in Japan and in other countries. However, since the development of endoscopic sclerotherapy and other modalities of endoscopic treatment, these 1980 rules were found to be insufficient for recording mucosal changes after treatment. The general rules as revised in 1991 recognize mucosal changes such as erosion, ulcer, scar, thrombosed varices, and bleeding signs. These new 1991 rules, which seem useful for recording initial evaluation of gastroesophageal varices and for describing mucosal changes after sclerotherapy as well, are described here.

Evaluation of long-term results of Caroli's disease: 21 years' observation of a family with autosomal "dominant" inheritance, and review of the literature

A 5-year-old girl underwent laparotomy in 1972 because of hepatomegaly and mottled radiopacities shown by cholangiography. Polycystic segmental dilatation of the intrahepatic bile ducts, typical of Caroli's disease, was found. Thereafter she remained in good health for over 21 years with careful medical management. In 1972 mottled radiopacities of the hepatic parenchyma were also demonstrated by cholangiography in her 9-year-old brother, who, however, remained asymptomatic until hematemesis due to esophageal varices suddenly occurred in 1993. At the time of the pre-operative evaluation for esophageal transection, his condition was definitively diagnosed as Caroli's disease. Their father was in good health, but in 1993 was shown by CT to have the same disease. The mode of inheritance is likely to be autosomal dominant, although Caroli's disease or congenital hepatic fibrosis is generally considered autosomal recessive (McKusick number 263200) (1). If we had not examined the father, this particular family would have been accepted as an example of autosomal recessive inheritance. We suggest that further family studies are needed to exclude the autosomal dominant mode of inheritance, and that at least some of the recessive cases in the literature are, in fact, autosomal dominant. Well-documented cases of "classical" Caroli's disease in the literature were reviewed with special reference to the long-term results. In addition, an international questionnaire aimed at establishing the further clinical course of the patient was sent to authors who reported cases after 1968.(ABSTRACT TRUNCATED AT 250 WORDS)

Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy

OBJECTIVE

The authors used prolamine (Ethibloc, Ethicon GmBH, Norderstedt, Germany) for segmental obstruction of the pancreatic duct to prevent pancreatic fistula development after distal pancreatectomy combined with total gastrectomy for gastric malignancies.

SUMMARY BACKGROUND DATA

Although the initial clinical application of prolamine was pancreatic duct obstruction for patients with pancreatitis and undergoing pancreatic transplantation and pancreaticoduodenectomy for pancreatic cancer, there are no reports on prevention of pancreatic fistula formation after distal pancreatectomy.

METHODS

Prolamine (0.2 mL) was injected into the distal segment of the main duct in the remaining pancreata of 51 patients. Small pancreatic ducts on the cut surface, from which prolamine extravasates, were closed by ligation, the main duct was ligated doubly, and the transected pancreatic margin was closed 15 minutes after phenylpropanolamine hydrochloride injection.

RESULTS

No patient developed a pancreatic fistula or the complication of arterial bleeding due to prolonged infection.

CONCLUSION

Segmental obstruction of the pancreatic duct with prolamine is useful for preventing pancreatic fistula development after distal pancreatectomy.

Morphometry of sinusoids and portal hypertension in non-alcoholic cirrhosis

To examine whether structural changes in hepatocytes and/or sinusoidal areas contribute to the portal hypertensive state in non-alcoholic cirrhosis, a new method of morphometric analysis using a computer-aided color image analyzer was performed in 16 patients with non-alcoholic cirrhosis, which allowed quantitative evaluation of various morphometric parameters of sinusoids and hepatocytes. The sinusoidal pressure gradient was estimated theoretically with these and clearance parameters using Poiseulle's equation and compared with the hepatic venous pressure gradient measure by hepatic vein cannulation. A significant relationship was found between the hepatic venous pressure gradient and sinusoidal volumetric ratio (r = -0.598, p < 0.05), but not between mean hepatocyte volume and sinusoidal volumetric ratio (r = 0.416, NS), or the hepatic venous pressure gradient (r = 0.371, NS). The estimated sinusoidal pressure gradient showed a significant relationship with the hepatic venous pressure gradient (r = 0.637, p < 0.01). However, the absolute values of the former were much lower than those of the latter. Therefore, in non-alcoholic cirrhosis, although sinusoidal stenosis not caused by hepatocyte swelling may lead to increased vascular resistance, other factors must also play a significant role.

Study of new prognostic factors of esophageal variceal rupture by use of image processing with a video endoscope

BACKGROUND

We studied new prognostic factors of esophageal variceal rupture by analyzing electronic video images of esophageal varices in 30 patients with portal hypertension.

METHODS

Fifteen of the patients were emergency or elective cases (bleeders), and the remaining 15 were prophylactic cases (nonbleeders). A comparison was made between the bleeders and nonbleeders in terms of endoscopic findings and the image processing data, especially variceal color tone and red color sign.

RESULTS

Endoscopic findings based on the general rules prepared by the Japanese Research Society for Portal Hypertension showed no significant difference between the two groups. However, with regard to the image processing data, both the ratio of red signal and the ratio of value were significantly lower in bleeders than in nonbleeders. In addition, the area ratio of red color sign was significantly higher in the former than in the latter. A follow-up study of nonbleeders also indicated that image processing data were more reliable than traditional endoscopic rules.

CONCLUSIONS

By adding these image processing data to the traditional general rules for recording endoscopic findings, it is possible to select patients with varices that have a higher risk of rupture.

Therapeutic efficacy and toxicity of sequential methotrexate and 5-fluorouracil in gastric cancer

The therapeutic efficacy and toxicity of sequential methotrexate and 5-fluorouracil in 64 inoperable gastric cancer patients are reported. An intermediate-dose treatment was given to 48 patients, and a low-dose treatment to 16 patients. In the intermediate-dose treatment, leukopenia was observed in 11 patients, nausea and vomiting in six patients and diarrhea and stomatitis in two patients each. In the low-dose treatment, no patient developed toxic symptoms of grade 3 or 4. All 9 responders had adenocarcinoma of the poorly differentiated type and the response rate in patients who belonged to this type was 32.1%.