Is distal pancreatectomy with en-bloc celiac axis resection effective for patients with locally advanced pancreatic ductal adenocarcinoma? -Multicenter surgical group study

OBJECTIVES

We retrospectively investigated the operative outcomes of patients who underwent distal pancreatectomy (DP) for invasive pancreatic ductal adenocarcinoma (PDAC) located at the body and tail.

METHODS

Data from 395 patients with PDAC who underwent DP with margin-negative resection (R0 or R1) were collected from seven high-volume centers in Japan from 2001 to 2012. Among them, 72 patients underwent DP with en-bloc celiac axis resection (DP-CAR). The remaining 323 patients underwent conventional DP with splenectomy (DP-S). To determine the efficacy of DP-CAR, clinicopathological data were compared between the DP-CAR and the DP-S groups.

RESULTS

The DP-S group consisted mainly of patients with resectable disease (93%), and conversely, all patients in the DP-CAR group had borderline resectable or unresectable disease. The overall morbidity was significantly higher in the DP-CAR group than in the DP-S group (63% vs 47%, respectively; P = 0.017). The median survival time (MST) of the DP-CAR group was significantly shorter than that of the DP-S group (17.5 vs 28.6 months, respectively; P = 0.004). However, the MST of patients in the DP-CAR group (n = 61, 85%) who received adjuvant therapy was significantly longer than that of patients in the DP-S group (n = 65, 20%) who underwent R1 resection (21.9 vs 16.7 months, respectively; P = 0.024).

CONCLUSION

DP-CAR followed by adjuvant chemotherapy provided an acceptable overall survival rate in patients with highly advanced PDAC, but should be performed with great caution because of high morbidity. Patients with a high risk of positive surgical margins with DP-S may be candidates for DP-CAR.

Inflammatory cytokine cascade released by leukocytes in cerebrospinal fluid after subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) elicits an inflammatory response in the subarachnoid space, which is mediated by the release of various cytokines. To assess their involvement in post-hemorrhagic complications, we determined the source and time-course of the release of inflammatory cytokines and acute-phase proteins in cerebrospinal fluid (CSF) following SAH. Concentrations of interleukin (IL)- 1beta, IL-6, transforming growth factor-beta1 (TGF-beta1) and C-reactive protein (CRP) in CSF of 36 patients with SAH were measured by enzyme-linked immunoabsorbent assay (ELISA). Floating cells collected from the CSF were centrifuged four to six days after SAH, and examined immunohistochemically. Intracellular IL-1beta and IL-6 were examined by flow cytometric analysis. The molecular weight of TGF-beta1 in CSF of 30 patients was examined by Western blot analysis. The TGF-beta1 levels of patients who had undergone ventriculoperitoneal (VP) shunt (n = 19) was significantly higher than nonshunt group (n = 16). The CRP levels of VP shunt group was significantly higher than nonshunt group. IL-6 concentration was maximal within day 0-1 and it was secreted by neutrophils and monocytes. ELISA showed consistently low levels of IL-1beta, whereas a proportion of monocytes and lymphcytes were IL- 1beta-positive by flow cytometric analysis. TGF-beta1 levels were also maximal on day 0-1 according to ELISA, although it tended to be in the inactive form derived from platelets. A 25 kDa band of TGF-1 was detectable for at least 13 days after SAH, which may have been secreted in part by neutrophils and monocytes. CRP levels in CSF peaked on day 2-3. The present results suggest that leukocytes induced by SAH play an important role in post-hemorrhagic inflammation in the subarachnoid space by releasing IL-6 and TGF-beta1. The CRP and TGF-beta1 levels in CSF are strongly concerned with communicating hydrocephalus after SAH.

Anticoagulant activity of sulfatide and its anti-thrombotic effect in rabbit

The mechanism of anticoagulant activity of sulfatide (galactosylceramide I3-sulfate), which exists in serum lipoproteins of various mammals except rodents, was investigated, together with the pharmacological effects of the glycolipid on the blood coagulation system in rabbits. The sulfatide was shown to be an effective anticoagulant when it was added in vitro in the form of pure micelle without auxiliary lipids such as phosphatidylcholine and/or cholesterol. The anticoagulant activity of synthetic galactosylceramide I6-sulfate, a positional isomer with respect to the sulfate group, was stronger than that of the sulfatide. The anticoagulant activity was specifically inhibited by anti-sulfatide antibody. The study on the pharmacological effects of sulfatide showed that the fibrin-precipitation time after single injection of the lipid (10 mg/kg body weight) into rabbits increased 2.5-fold compared with the normal level, and the maximum effect was observed 1 h after the injection. The half-life of anticoagulant activity was 5 h. These results suggest that sulfatide may be effective for the prevention of thrombosis. Sulfatide may be safer than other anticoagulant drugs, because it is a natural component of serum lipoproteins. Further, it may well play an essential role as an endogenous anticoagulant in mammals. Unlike heparin, sulfatide failed to inhibit thrombin and coagulation factor Xa activities in the presence of antithrombin III, indicating that the anticoagulant mechanism of sulfatide is independent of antithrombin III. These results indicate that the anticoagulant activity of sulfatide is potent and specific, and the lipid may be available as a useful and safe antithrombotic drug.