Cyclosporine Does not Inhibit the Process of Revascularization of Pancreatic Islet Transplantation

The immunosuppressive drug cyclosporin-A (CsA) has been widely used to prevent pancreatic islet allograft rejection. Because it has been suggested that CsA may inhibit the process of revascularization of transplanted islets, the purpose of the study was to analyze by a double indirect immunofluorescence technique the revascularization process of isolated islets grafted in the liver and in the renal subcapsular space of rats treated with immunosuppressive doses of CsA. Lewis rats were grafted with either Lewis (isografts) or Wistar (allografts) pancreatic islets obtained by collagenase digestion. Rats were killed at different days after implantation and the liver and kidney bearing the grafted islets were snap frozen and immunohistochemically stained with a double immunofluorescence technique using a rabbit antifactor-VIII antiserum (which labels endothelial cells) and a guinea pig antiinsulin antibody. Islets implanted into nonimmunosuppressed hosts completed revascularization by days 3-7 after transplantation, as shown by the detection of endothelial cells within and surrounding the islets. The identical staining pattern of revascularization was observed in nonrejecting allografts as well as in isografts treated with CsA. We conclude that CsA did not inhibit the process of revascularization of rat islets after free transplantation. This finding is relevant for human islet transplantation, where CsA is currently employed to prevent kidney and islet allograft rejection. Copyright © 1997 Elsevier Science Inc.

Effect of Fusidic Acid on Pancreatic Islet Allograft Rejection

We examined in fully mismatched rats, the survival of pancreatic islet allografts in recipients treated with either fusidic acid (FA), an antistaphyllococcal antibiotic that has been shown to possess an immunosuppressive effect in vitro and in vivo, or cyclosporin-A (CsA). Islets were isolated by collagenase digestion, separated from acinar tissue by handpicking under a dissecting microscope and transplanted into the liver by portal vein injection of streptozotocin(STZ)-induced diabetic rats. The results indicated that while a temporary immunosuppression with CsA achieved an indefinite islet allograft survival, FA administered to recipients daily was not able to prevent islet allograft rejection across a major histocompatibility barrier. We conclude that despite the fact that fusidic acid has been claimed to act as an immunosuppressant drug in vitro with effects similar to those of CsA, unlike CsA, FA given either orally or by s.c. injection was not effective to prolong islet allograft survival in vivo. Copyright © 1997 Elsevier Science Inc.

Phase I trial of gefitinib with concurrent radiotherapy and fixed dose-rate gemcitabine infusion, in locally advanced pancreatic cancer

4105

Background: Pancreatic cancers are resistant to radiotherapy (RT) and current chemotherapy agents. Epidermal growth factor receptor (EGFR) is over-expressed in pancreatic cancer and in vitro studies have shown that EGFR inhibitors can overcome radio- and chemo-resistance. The aim of the study was to determine the maximally tolerated dose of gefitinib, in combination with RT and gemcitabine for patients with locally advanced pancreatic carcinoma (LAPC). Methods: Eighteen patients with pathological proven LAPC, due to major vascular invasion based on helical computed tomography and endoscopic ultrasound, were entered. The targeted irradiated volume included the tumor and 2 cm-margin. Prophylactic irradiation of regional nodes was not allowed. Patients with >500 cc of planned tumor volume (PTV) were excluded. An initial cohort of 6 patients was treated with RT (45 Gy/25 fractions/5 weeks) plus concomitant gefitinib (250 mg/day). Successive cohorts of patients received 100, 150 and 200 mg/m2/day of gemcitabine in a 2 hour infusion over weeks 1,2,3,4, and 5 with gefitinib (250 mg/day) and RT. Gefitinib was continued after RT until progression. A pharmacodynamic study of angiogenic markers (VEGF and IL-8) was also performed. Results: Mean PTV was 293cc (range 137–462 cc). There were no dose-limiting toxicities on study. Common toxicities were mild neutropenia, asthenia, diarrhea, cutaneous rash and nausea/vomiting. One patient showed a partial response of 13 months in duration, and 7 patients showed disease stabilization. Median progression free survival (PFS) was 3.7 months and median overall survival (OS) was 7.5 months. No patients have a reduction in VEGF levels >50%. Reduction in VEGF serum levels >25% and IL-8 levels >50% had no impact on PFS and OS. Conclusion: Our results support thatthe combination of gefitinib, RT and gemcitabine showed an acceptable toxicity but with modest activity in LAPC.

[Table: see text]

Correlates of cognitive impairment in elderly residents of long term care institutions in the metropolitan area of Guadalajara, Mexico

AIM

To determine the prevalence of cognitive impairment and to examine the correlation between demographic and social factors, the activities of daily living (ADL), and depression with cognitive function in elderly Mexicans living in nursing homes.

DESIGN

Cross-sectional.

SETTING

Fourteen nursing homes in Guadalajara.

PARTICIPANTS

Data were drawn from a random sample of 451 elderly, aged 60-104 years.

MEASUREMENTS

The Spanish versions of MMSE (Folstein), ADL index (Barthel), and the Geriatric Depression Screening (GDS) (Yesavage); demographic factors were obtained.

RESULTS

The prevalence of cognitive impairment was 52.3%, with a cut-off of 19/20 (Bohnstedt). Cognitive impairment was significantly related to gender, educational level, activity participation, pension, ADL, and depression.

CONCLUSION

The results indicate a higher prevalence of cognitive impairment than in other Mexican studies. The data are consistent with previous findings that cognitive impairment in the elderly is more common among females, those with a low level of education, the lack of participation in social/leisure activities, ADL dependencies, and depression.

European Study Group for Pancreatic Cancer-1 interim results: a European randomized study to assess the roles of adjuvant chemotherapy and chemoradiation in resectable pancreatic cancer

Background

Pancreatic cancer affects 8–12 per 100 000 population per year in Europe. Following resection, the long-term survival rate is only 10–15 per cent and the role of adjuvant treatment is uncertain. The aims of the study were to answer two questions: (1) whether there is a role for chemoradiation (40 Gy and 5-fluorouracil (5-FU), and (2) whether there is a role for chemotherapy (5-FU–folinic acid (FA)) weekly).

Methods

A multicentre European prospective randomized controlled trial was organized by the European Study Group for Pancreatic Cancer (ESPAC). A 2 × 2 factorial design was used, asking both questions of the same patient, and a pragmatic design asking only one of the two questions of each patient. The data were reviewed at regular intervals by the Independent Data and Safety Monitoring Committee (IDSMC).

Results

Some 531 patients with pancreatic ductal adenocarcinoma were randomized from 80 clinicians in 11 countries. Randomization was stratified by resection margin involvement; 82 per cent of patients were negative. Some 239 patients (45 per cent) are alive to date, at a median follow-up of 9 (interquartile range 1–24) months. Preliminary results show no evidence of a benefit for chemoradiation treatment (median survival 14 months with chemoradiation versus 15·7 months without; P = 0·24). There is some evidence of a survival benefit for patients having chemotherapy (median survival 19·5 months versus 13·5 months with no chemotherapy; P = 0·003). The effect is reduced when taking into account whether patients received radiotherapy (P = 0·01), indicating that radiotherapy may reduce the overall benefit of the chemotherapy. The IDSMC recommended closing recruitment to the chemoradiotherapy arm.

Conclusion

There is no role for adjuvant chemoradiotherapy in pancreatic cancer, but there may be a role for chemotherapy. ESPAC-3 is now randomizing between (1) surgery alone, (2) 5FU–FA and (3) gemcitabine.

Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial

OBJECTIVE

To assess the influence of resection margins on survival for patients with resected pancreatic cancer treated within the context of the adjuvant European Study Group for Pancreatic Cancer-1 (ESPAC-1) study.

SUMMARY BACKGROUND DATA

Pancreatic cancer is associated with a poor long-term survival rate of only 10% to 15% after resection. Patients with positive microscopic resection margins (R1) have a worse survival, but it is not known how they fare in adjuvant studies.

METHODS

ESPAC-1, the largest randomized adjuvant study of resectable pancreatic cancer ever performed, set out to look at the roles of chemoradiation and chemotherapy. Randomization was stratified prospectively by resection margin status.

RESULTS

Of 541 patients with a median follow-up of 10 months, 101 (19%) had R1 resections. Resection margin status was confirmed as an influential prognostic factor, with a median survival of 10.9 months for R1 versus 16.9 months months for patients with R0 margins. Resection margin status remained an independent factor in a Cox proportional hazards model only in the absence of tumor grade and nodal status. There was a survival benefit for chemotherapy but not chemoradiation, irrespective of R0/R1 status. The median survival was 19.7 months with chemotherapy versus 14.0 months without. For patients with R0 margins, chemotherapy produced longer survival compared with to no chemotherapy. This difference was less apparent for the smaller subgroup of R1 patients, but there was no significant heterogeneity between the R0 and R1 groups.

CONCLUSIONS

Resection margin-positive pancreatic tumors represent a biologically more aggressive cancer; these patients benefit from resection and adjuvant chemotherapy but not chemoradiation. The magnitude of benefit for chemotherapy treatment is reduced for patients with R1 margins versus those with R0 margins. Patients with R1 tumors should be included in future trials of adjuvant treatments and randomization and analysis should be stratified by this significant prognostic factor.

Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial

BACKGROUND

The role of adjuvant treatment in pancreatic cancer remains uncertain. The European Study Group for Pancreatic Cancer (ESPAC) assessed the roles of chemoradiotherapy and chemotherapy in a randomised study.

METHODS

After resection, patients were randomly assigned to adjuvant chemoradiotherapy (20 Gy in ten daily fractions over 2 weeks with 500 mg/m(2) fluorouracil intravenously on days 1-3, repeated after 2 weeks) or chemotherapy (intravenous fluorouracil 425 mg/m(2) and folinic acid 20 mg/m(2) daily for 5 days, monthly for 6 months). Clinicians could randomise patients into a two-by-two factorial design (observation, chemoradiotherapy alone, chemotherapy alone, or both) or into one of the main treatment comparisons (chemoradiotherapy versus no chemoradiotherapy or chemotherapy versus no chemotherapy). The primary endpoint was death, and all analyses were by intention to treat. Findings 541 eligible patients with pancreatic ductal adenocarcinoma were randomised: 285 in the two-by-two factorial design (70 chemoradiotherapy, 74 chemotherapy, 72 both, 69 observation); a further 68 patients were randomly assigned chemoradiotherapy or no chemoradiotherapy and 188 chemotherapy or no chemotherapy. Median follow-up of the 227 (42%) patients still alive was 10 months (range 0-62). Overall results showed no benefit for adjuvant chemoradiotherapy (median survival 15.5 months in 175 patients with chemoradiotherapy vs 16.1 months in 178 patients without; hazard ratio 1.18 [95% CI 0.90-1.55], p=0.24). There was evidence of a survival benefit for adjuvant chemotherapy (median survival 19.7 months in 238 patients with chemotherapy vs 14.0 months in 235 patients without; hazard ratio 0.66 [0.52-0.83], p=0.0005). Interpretation This study showed no survival benefit for adjuvant chemoradiotherapy but revealed a potential benefit for adjuvant chemotherapy, justifying further randomised controlled trials of adjuvant chemotherapy in pancreatic cancer.

Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas

BACKGROUND

Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas.

METHODS

Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30-85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay.

RESULTS

All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58+/-22 min for unilateral left splanchnicectomy and 93.5+/-15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8-10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2-5).

CONCLUSIONS

We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short.

[Preliminary experiences with endoscopic parathyroidectomy]

Since the advent of extraperitoneal approaches for laparoscopic surgery, the creation of extraperitoneal virtual spaces has spread rapidly. We describe our preliminary experience with selective neck exploration and endoscopic parathyroidectomy in 4 women, aged 57-74, with primary hyperparathyroidism. Preoperative localization of parathyroid adenoma was assessed by technetium-sestamibi scanning and cervical ultrasonography. A cervical work space was created by the introduction of a trocar with an inflatable balloon-tip and maintained with low-pressure CO2 insufflation. All procedures were completed endoscopically. There were no intraoperative complications. Mean operative time was 40 minutes and cosmetic results were very satisfactory. We found endoscopic parathyroidectomy a feasible and safe option and particularly appropriate for the surgical treatment of primary hyperparathyroidism. Further refinements in technique will enhance its practicability in exploring the mediastinum for ectopic parathyroid glands and in those with secondary hyperparathyroidism.

[Thoracoscopic splanchnicectomy for intractable pancreatic pain]

Intractable pain is the most distressing symptom in nonresectable pancreatic carcinoma and in chronic pancreatitis. Recently, thoracoscopic splanchnicectomy has been advocated as a minimally invasive method of pain control in these patients. Between May 1995 and April 1998, 24 patients with nonresectable pancreatic cancer and 4 with chronic pancreatitis, underwent 43 thoracoscopic splanchnicectomies. All suffered from intractable pain, were opiate-dependent and unable to perform normal daily activities. Unilateral left splanchnicectomy was done in 13 and bilateral in 15. All procedures were completed thoracoscopically. Operative time ranged from 25 to 60 min and mean hospital stay was 3 days. Median pain intensity was reduced by 50% in 24 and no further narcotics or analgesics were required. We found thoracoscopic splanchnicectomy a safe and effective procedure for intractable pancreatic pain.

[Extraperitoneal laparoscopic adrenalectomy]

Laparoscopic adrenalectomy has recently been shown to be safe and effective for a variety of benign adrenal tumors, such as aldosterone adenoma, pheochromocytoma, nonfunctioning adenoma, Cushing's adenoma and Cushing's syndrome. Recently, laparoscopic surgeons adopted an extraperitoneal approach in which a space is created by the introduction of a trocar with an inflatable balloon tip. This technique with a minimal access procedure provides direct access to the adrenal glands without interfering with intraperitoneal organs. Laparoscopic adrenalectomy using the extraperitoneal approach was completed in 18/20 consecutive patients. Mean operative time was 95 min (range 80-120) and median hospital stay 3 days. Blood transfusion was not required, and there were no postoperative complications.

Prolonged pneumoperitoneum at 15 mmHg causes lactic acidosis

BACKGROUND

Acute increases in intraabdominal pressure (IAP) induce systemic and regional circulatory changes. Besides, mechanical compression on the capillary beds may decrease oxygen availability to the tissues. The purpose of this clinical study was to analyze the effects of increased IAP on acid-base disturbances and plasma lactate levels during prolonged carbon dioxide pneumoperitoneum.

METHODS

Twenty-eight patients undergoing laparoscopic sigmoidectomy were included in this study. Fourteen of them (group A) had IAP of 15 +/- 1 mmHg while the remaining 14 (group B) had IAP of 10 +/- 1 mmHg. The control group included six patients undergoing conventional sigmoidectomy.

RESULTS

A progressive significant increase in PaCO2 was observed in the laparoscopic groups (p < 0.01). Plasma lactate levels in group A significantly increased 90 min after insufflation (p < 0.05) and reached the highest value 1 h after deflation (9.9 +/- 1 vs 31.9 +/- 2.5 mg/dl, p < 0.005). Simultaneously, arterial pH decreased in all groups; however, at 1 h after surgery, it was significantly lower (p = 0.02) in group A. There was a significant correlation between acid concentration due to lactate and lactate concentration (GA: R2 = 0.717, p = 0.03; GB: R2 = 0.879, p = 0.006 and GC: R2 = 0.853, p = 0.008).

CONCLUSION

High IAP causes lactic acidic accumulation in patients undergoing prolonged laparoscopic procedures.

ESPAC-1 trial progress report: the European randomized adjuvant study comparing radiochemotherapy, 6 months chemotherapy and combination therapy versus observation in pancreatic cancer

At the joint International Association of Pancreatology and European Pancreatic Club meeting at King's College, London (July 9-12, 1997), a satellite meeting of the European Study Group for Pancreatic Cancer (ESPAC) met to discuss the progress of the ESPAC-1 trial. This study will address which, if any, of the following adjuvant treatments are of benefit in patients with resectable pancreatic cancer: radiotherapy (40 Gy with 5-fluorouracil as a sensitising agent); 6 months chemotherapy (5-fluorouracil and folinic acid), or a combination of these treatments. The study, which commenced in 1994, had already recruited 348 patients into the 3 treatment arms and 1 control arm of the study by May 31, 1997. This is the largest study of its kind in pancreatic cancer and should definitively address the question of the role of conventional methods of adjuvant treatment in pancreatic cancer.

Effect of fusidic acid on pancreatic islet allograft rejection

We examined in fully mismatched rats, the survival of pancreatic islet allografts in recipients treated with either fusidic acid (FA), an antistaphyllococcal antibiotic that has been shown to possess an immunosuppressive effect in vitro and in vivo, or cyclosporin-A (CsA). Islets were isolated by collagenase digestion, separated from acinar tissue by handpicking under a dissecting microscope and transplanted into the liver by portal vein injection of streptozotocin(STZ)-induced diabetic rats. The results indicated that while a temporary immunosuppression with CsA achieved an indefinite islet allograft survival, FA administered to recipients daily was not able to prevent islet allograft rejection across a major histocompatibility barrier. We conclude that despite the fact that fusidic acid has been claimed to act as an-immunosuppressant drug in vitro with effects similar to those of CsA, unlike CsA, FA given either orally or by s.c. injection was not effective to prolong islet allograft survival in vivo.

Cyclosporine does not inhibit the process of revascularization of pancreatic islet transplantation

The immunosuppressive drug cyclosporin-A (CsA) has been widely used to prevent pancreatic islet allograft rejection. Because it has been suggested that CsA may inhibit the process of revascularization of transplanted islets, the purpose of the study was to analyze by a double indirect immunofluorescence technique the revascularization process of isolated islets grafted in the liver and in the renal subcapsular space of rats treated with immunosuppressive doses of CsA. Lewis rats were grafted with either Lewis (isografts) or Wistar (allografts) pancreatic islets obtained by collagenase digestion. Rats were killed at different days after implantation and the liver and kidney bearing the grafted islets were snap frozen and immunohistochemically stained with a double immunofluorescence technique using a rabbit antifactor-VIII antiserum (which labels endothelial cells) and a guinea pig antiinsulin antibody. Islets implanted into nonimmunosuppressed hosts completed revascularization by days 3-7 after transplantation, as shown by the detection of endothelial cells within and surrounding the islets. The identical staining pattern of revascularization was observed in nonrejecting allografts as well as in isografts treated with CsA. We conclude that CsA did not inhibit the process of revascularization of rat islets after free transplantation. This finding is relevant for human islet transplantation, where CsA is currently employed to prevent kidney and islet allograft rejection.

Follow-up study of the revascularization process of cryopreserved islets of Langerhans

Cryopreservation of islets of Langerhans is a necessary procedure since human pancreatic islet transplantation has become a reality for the clinical treatment of Type I, insulin-dependent diabetes mellitus. Although successful cryopreservation of rodent and human islets is a well-established technique for islet storage after isolation and purification, little is known about the influence of the freeze-thaw procedure on the islets' potential to induce angiogenesis and revascularization, a major process necessary for the viability of grafted cells. In this study, the revascularization process of cryopreserved islets transplanted in the liver and in the renal subcapsular space of diabetic and nondiabetic rats is analyzed by a double indirect immunofluorescence technique. Frozen-thawed pancreatic islets were cooled slowly to -40 degrees C, stored at -196 degrees C, and thawed rapidly. Lewis rat were grafted with either Lewis (isografts) or Wistar (allografts) overnight-cultured and frozen-thawed islets obtained by collagenase digestion. Rats were killed different days after implantation, and the livers and kidneys bearing the grafted islets were snap-frozen and immunohistochemically stained with a double immunofluorescence technique using a rabbit anti-factor VIII antiserum (which labels endothelial cells) and a guinea pig anti-insulin antibody. Overnight-cultured islet grafts completed revascularization by Days 4-7 after transplantation, as shown by the detection of endothelial cells within and surrounding the islets. The identical staining pattern of revascularization was observed in islets frozen-thawed before transplantation. It is concluded that islet cryopreservation is a suitable technique for long-term storage prior to transplantation since it does not interfere with the neovascularization process of islet grafts.

Serum amino-terminal propeptide of type III procollagen levels in chronic pancreatitis

The severity of pancreatic fibrosis, a characteristic feature of patients with chronic pancreatitis (CP), can be assessed only by direct histologic analysis of pancreatic tissue. Since serum levels of the amino-terminal type III procollagen propeptide (PIIIP) can reflect the degree of fibrogenic activity in several diseases associated with fibrosis, the current study was aimed at investigating whether PIIIP are increased in chronic pancreatitis, the relationship between PIIIP and pancreatic fibrogenic activity, and the influence of pancreatectomy, pancreatic exocrine function, and duration of disease on PIIIP levels. Serum PIIIP was measured in 18 patients with CP (15 without liver disease and three with cholestasis) and in 21 healthy controls. The effect of pancreatectomy on PIIIP was evaluated in seven patients, in whom PIIIP was measured immediately before and 2 months after surgery. Prolylhydroxylase (PHase) activity as an index of pancreatic fibrogenesis was evaluated in pancreatic tissue from 11 patients who had undergone subtotal pancreatectomy and from 11 organ donors. The bentiromide (BT)-PABA test as an index of exocrine pancreatic function was measured in all patients. PIIIP was significantly higher in patients who had or had not undergone pancreatectomy (17.3 +/- 4.0 and 25 +/- 11.4 ng/ml, respectively) than in controls (12.3 +/- 3.1 ng/ml) (p < 0.001). PIIIP decreased significantly after pancreatectomy (before, 32.0 +/- 9.3 ng/ml; after, 18.4 +/- 4.8 ng/ml; p = 0.005). PHase was significantly higher in patients (773 +/- 250 cpm/mg protein) than in controls (405 +/- 121 cpm/mg protein) (p < 0.001). PIIIP was correlated with pancreatic PHase (r = 0.7, p = 0.001) but not with BT-PABA or with the duration of the disease. In conclusion, serum PIIIP levels are increased in patients with CP and reflect the severity of pancreatic fibrogenic activity. No relationship between the serum PIIIP levels and the pancreatic exocrine function and duration of disease was found.

DNA ploidy and S + G2M fraction (proliferative index) as prognostic determinants in human periampullary cancer

BACKGROUND/AIMS

The aim of the present study was to investigate the relationship between pathological factors, DNA ploidy patterns, proliferative index and survival in a population of patients undergoing resection for adenocarcinoma of periampullary region.

MATERIALS AND METHODS

DNA ploidy and proliferative index of periampullary cancer tissue was measured by flow cytometry in 73 patients who had undergone pancreatoduodenectomy.

RESULTS

Seventy-four percent (n = 54) of cancers were diploid and 26% (n = 19) were aneuploid. The median survival time of patients with diploid cancers was 30.1 (s.d. 5.1) months and with aneuploid cancers was 16.0 (s.d. 2.9) months (p = 0.02). Kaplan-Meier survival curves showed that the patients with aneuploid cancers succumbed to recurrent disease within 40 months after surgery whereas 20% of patients with diploid cancers survived longer than 40 months. In patients with long survival (3 years) there was a significant difference between aneuploid and diploid cancers (p < 0.001). In the multivariate analysis, tumor location and tumor size are independent prognostic variables for the length of survival after resection of periampullary cancer.

CONCLUSIONS

DNA ploidy pattern appears to be one important prognostic predictor in patients with "long term" survival after successful pancreatoduodenectomy for periampullary cancers.

Pheochromocytoma: laparoscopic approach with CO2 and helium pneumoperitoneum

A number of different surgical approaches have been devised for adrenalectomy in patients with pheochromocytoma. The anterior transabdominal approach was at one time considered a source of postoperative morbidity; the advent of laparoscopy however, may result in a resurgence in its use. The laparoscopic approach was used with a CO2 pneumoperitoneum in one patient with a left pheochromocytoma, and using a helium pneumoperitoneum in another with bilateral pheochromocytoma. The left adrenalectomy took 135 minutes to perform and the total bilateral adrenalectomy 330 minutes. No transfusion was necessary. The postoperative stay was 4 days for both patients. To prevent the risk of CO2 retention during extended laparoscopic procedures, helium can serve as an alternative gas, as was documented in the patient who underwent total adrenalectomy. Unilateral or bilateral resection of pheochromocytoma can safely be performed laparoscopically and has the advantage of avoiding both the muscular trauma related to laparotomy and the rib resection necessary for the extraperitoneal approach.

Prostanoids and oxygen free radicals in early stages of experimental acute pancreatitis

The aim of this work is to establish a relationship between prostanoids and oxygen free radicals in the early stages of acute pancreatitis induced by sodium taurocholate and to study the possible cytoprotective effects of exogenous prostaglandin administration. Tissue prostanoid production (6-keto-prostaglandin F1 alpha, thromboxane B2, and prostaglandin E2) was studied after induction of an acute pancreatitis by intraductal administration of 3.5% sodium taurocholate (0.1 ml/100 mg). The effect of previous administrations of 16,16-dimethyl prostaglandin E2 (0.5 microgram/kg), indomethacin (20 mg/kg), or superoxide dismutase (13 mg/kg) was evaluated. Early pancreatitis induced significant increases of the three prostanoid levels as soon as 5 min after taurocholate administration. The administration of 16,16-dimethyl prostaglandin E2 was able to maintain the tissue prostanoid production at basal levels while superoxide dismutase treatment only partially prevented the increase of 6-keto-prostaglandin F1 alpha. On the other hand, indomethacin pretreatment, as expected, prevented the taurocholate-induced early prostanoid biosynthesis but increased the mortality, suggesting that endogenous prostanoids play a role in cellular defense mechanisms. The effect of superoxide dismutase suggests that oxygen free radicals are responsible, in part, for prostanoid enhanced biosynthesis in the earlier stages of necrohemorrhagic pancreatitis.

Role of zinc in the process of pancreatic fibrosis in chronic alcoholic pancreatitis

Zinc acts as a cofactor in many enzymatic processes, including collagen synthesis. The observation of increased activity of prolylhydroxylase (PHase), an enzyme that takes part in the synthesis of collagen, in zinc-depleted liver tissue suggests that zinc deficiency is associated with hepatic collagen deposition. The pancreatic zinc content in chronic alcoholic pancreatitis (CAP) is still unknown. The objectives of this study were (a) To assess zinc concentrations in the pancreatic tissue in CAP; (b) to establish a possible relation between pancreatic zinc content, fibrosis, and PHase activity; and (c) to evaluate the relation between serum and pancreatic zinc levels. Sixteen surgical specimens of pancreatic tissue from patients with CAP were analyzed; control pancreatic samples from 11 organ donors were also studied. Zinc concentration, PHase activity, and the amount of fibrous tissue were assessed in the pancreatic tissue of each individual. The amount of fiber deposited in the pancreas in CAP was 68.4 +/- 19.8%, and that of the control group, 5 +/- 2% (p < 0.001). PHase activity in CAP was 754 +/- 230 cpm/mg of protein and that of the control group was 405 +/- 151 cpm/mg of protein (p < 0.001). The amount of pancreatic zinc in the former was 15.0 +/- 9.7 micrograms/g of tissue and that of the latter was 28.1 +/- 18.1 micrograms/g of tissue (p = 0.023). Serum zinc levels were similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrastructural pathology of parathyroid glands in hyperparathyroidism: a report of 69 cases

The ultrastructural features of 69 parathyroid glands from 43 patients with hyperparathyroidism were studied to distinguish between different parathyroid lesions causing hyperparathyroidism. Samples came from 44 cases of hyperplasia, 21 of adenoma, 3 of carcinoma, and 1 from a histologically normal gland. To establish the diagnosis we took into account intraoperative findings during surgery as well as light microscopic examination. Ultrastructural features, evaluated on a semiquantitative scale, were correlated with diagnostic, clinical, and biochemical parameters. Neoplastic glands were heavier than nonneoplastic ones, and carcinomatous glands were heavier than adenomatous glands. Our findings suggest that the cellular membrane of adenomatous glands shows more folding than that of hyperplastic glands, mainly in the capillary pole. Carcinomatous glands show the greatest degree of irregularity, with the formation of microvilli-like projections. Hyperplastic glands, in turn, are richer in glycogen deposition. Secretory granules appear in higher amounts when the serum calcium level is high. These findings are not of diagnostic value by themselves, but they can be taken in consideration to aid in differential diagnosis.

Effect of prostaglandins and superoxide dismutase administration on oxygen free radical production in experimental acute pancreatitis

Oxygen free radicals and prostaglandins are implicated in the pathophysiology of acute pancreatitis, although their mechanisms of action remain unclear. We have studied the effect of administration of exogenous 16,16-dimethyl prostaglandin E2 and superoxide dismutase on oxygen free radical production in acute pancreatitis. For this purpose, five experimental rat groups were studied: group I, control; group II, sodium taurocholate-induced acute pancreatitis; group III, same as group II but with previous administration of 16,16-dimethyl prostaglandin E2; group IV, same as group II but with previous administration of indomethacin; and group V, same as group II but with previous administration of superoxide dismutase. In sodium taurocholate-treated rats, xanthine dehydrogenase is completely converted to xanthine oxidase within the first 5 min with subsequent oxygen free radical production while in 16,16-dimethyl prostaglandin E2-treated rats this enzyme transformation does not occur. In the superoxide dismutase-treated group xanthine oxidase activation is partially prevented. These data suggest that xanthine oxidase is the main source of oxygen free radicals, which contribute to extending the cellular damage in sodium taurocholate-induced acute pancreatitis.

Cyclooxygenase and lipoxygenase metabolism in sodium taurocholate induced acute hemorrhagic pancreatitis in rats

Several studies have reported that prostanoids are involved in many of the physiopathological mechanisms underlying acute pancreatitis but their precise role in this disease remains to be established. The objective of this work is to evaluate the variation of local tissue production of prostanoids and lipoxygenase metabolites of arachidonic acid in acute pancreas inflammation induced by intraductal administration of 3.5% sodium taurocholate (0.1 ml/100 mg body weight) in rats. Pancreatic tissue levels of leukotriene B4 (LTB4), 15 hydroxyeicosatetraenoic acid (15-HETE), 6-keto prostaglandin F1 alpha (6-keto PGF1 alpha), thromboxane B2 (TXB2) and prostaglandin E2 (PGE2) were determined by HPLC-RIA techniques at 5 and 60 minutes after induction of acute pancreatitis (AP). Prostanoids increased significantly at 5 minutes and LTB4 and 15-HETE at 60 minutes. These data confirm that the prostanoid imbalance could be considered as an early specific response of the pancreas to the inflammatory events characteristic of induced AP while the altered levels of the lipoxygenase products (LTB4 and 15-HETE) would be more of a nonspecific organ response associated to the high cellular infiltration rate and necrosis observed in the late phases of acute pancreatitis.

Changes of systemic prostacyclin and thromboxane A2 in sodium taurocholate- and cerulein-induced acute pancreatitis in rats

Systemic prostacyclin and thromboxane A2 production in rat experimental acute pancreatitis has been evaluated by measuring the urinary excretion of the 2,3-dinor 6-keto prostaglandin F1 alpha and 2,3-dinor thromboxane B2, respectively. Acute pancreatitis was induced by intraductal administration of 4.5% sodium taurocholate (0.1 ml/100 mg body weight) and intravenous cerulein perfusion (5 micrograms/kg/hr) for 6 hr, respectively. Urinary excretion of 2,3-dinor 6-keto prostaglandin F1 alpha and 2,3-dinor thromboxane B2 were much more important in sodium taurocholate- than in cerulein-induced acute pancreatitis. These data confirm an altered prostacyclin and thromboxane metabolism occurring in experimental acute pancreatitis. Phospholipase A2 activity and the effect of gabexate mesilate on the arachidonate metabolism were also evaluated.

Hemosuccus pancreaticus from a pseudoaneurysm of the hepatic artery proper in a patient with a pancreatic pseudocyst

Pseudoaneurysms of the visceral arteries due to pancreatitis, with subsequent rupture and hemorrhage into the pancreatic duct are unusual. To date, three cases of pseudoaneurysm of the hepatic artery with hemosuccus pancreaticus have been reported in the literature. We describe a case of a pseudoaneurysm of the hepatic artery proper, which ruptured into a pancreatic pseudocyst communicating with the pancreatic duct, and which was the cause of upper gastrointestinal bleeding. This case was successfully managed by resection of both the pseudoaneurysm and the pancreatic pseudocyst.

Prospective analysis of pancreatic grafts with duplex-Doppler ultrasound: value of resistive index in the diagnosis of rejection

The diagnosis of rejection and its differentiation from other causes of pancreatic graft dysfunction remain the basic problem in pancreas transplantation. A previous study with pulsed Doppler (PD) done at our institution demonstrated an increase of the resistive index (RI) during pancreatic graft rejection episodes. The aim of the study was to determine prospectively the utility of duplex-Doppler (DD) ultrasound (US) in identifying the cause of pancreatic graft dysfunction. The major clinical categories were graft rejection and graft pancreatitis.

Experimental and clinical experience with urine amylase monitoring for early diagnosis of rejection in pancreas transplantation

Pancreas allograft rejection in dogs with pancreaticocystostomy can be predicted in advance of hyperglycemia by monitoring the urinary amylase (UA) concentration (U/L): In initial experiments, UA values declined to less than 1000 1.3 +/- 0.2 days before hyperglycemia in nonimmunosuppressed dogs, 3.3 +/- 1.0 days in dogs treated with cyclosporine (CsA), and 9.3 +/- 0.7 days in dogs treated with CsA, azathioprine (Aza), and prednisone (triple therapy). Autotransplanted control dogs maintained high urine amylase concentrations indefinitely (mean 125,544 +/- 36,931). In a subsequent experiment, in 19 dogs with bladder-drained pancreas allografts on CsA only for prophylactic immunosuppression, a five-day course of antirejection treatment with Aza (5.0 mg/kg) and antilymphocyte globulin ALG (1 mg/kg) was started in group A (n = 10) when a raise in serum glucose was detected, and in group B (n = 9) when a drop of UA below 1000 was observed. The functional allograft survival rate was 9.2 +/- 0.5 days in group A (treatment started after hyperglycemia) and 29.0 +/- 5.7 days in group B (treatment started after drop in UA) (P = .002). The UA dropped in all dogs before hyperglycemia, at a mean of 2.7 days in group A and 20.8 days in group B. Clinically, 8 patients received a whole cadaver pancreas transplant with urinary drainage of the exocrine secretions. All were followed with UA monitoring. Three recipients lost the grafts for technical reasons. Three recipients lost the grafts for technical reasons. One had a primary non-function and UA was below 1000 U/24 hr; two developed abscesses and the grafts were removed while functioning with high UA values. Five grafts are currently functioning; 3 recipients had no rejection episodes and their UA values ranged from 30,000 to 100,000 U/24 hr during their entire postoperative course. The other two had rejection episodes. In both cases UA decreased to baseline levels 1 and 4 days in advance of the hyperglycemia. After antirejection treatment UA rose again to high values and plasma glucose levels declined. Both patients are currently insulin-independent, with UA values ranging from 10,000 to 200,000 U/24 hr. Both experimentally and clinically UA is an early predictor of pancreas allograft rejection. The institution of early treatment of rejection episodes in dogs, based on UA, significantly improved allograft survival. Urine amylase monitoring in pancreas transplant recipients could lead to an early treatment of rejection and improve graft survival.

Urinary amylase monitoring for early diagnosis of pancreas allograft rejection in dogs

The diagnosis of pancreas allograft rejection is usually made on the basis of blood glucose concentration, a late indicator of rejection. We performed segmental pancreas transplants in totally pancreatectomized dogs with the exocrine secretions drained into the bladder (ductocystostomy). We directly measured exocrine pancreatic secretions (urinary amylase), in an attempt to find a sensitive indicator for early rejection. Five groups were studied: (I) autografts; (II) autografts immunosuppressed with cyclosporine (CsA), azathioprine and prednisone; (III) allografts without immunosuppression; (IV) allografts immunosuppressed with CsA alone; (V) allografts immunosuppressed with CsA, azathioprine, and prednisone. The control groups (I, II) maintained high urine amylase concentrations indefinitely (mean +/- SE of 125,544 +/- 36,931 u/liter). Rejection, as diagnosed by rise of serum glucose to greater than 150 mg/dl, occurred at a mean (+/- SE) of 9.0 +/- 0.2 days in nonimmunosuppressed recipients of Group III, at 9.3 +/- 0.7 days in cyclosporine-treated dogs of Group IV, and at 28.0 +/- 8.3 days after transplantation in dogs immunosuppressed with triple therapy of Group V. In all allograft recipients, urine amylase declined precipitously (less than 1000 u/liter) before the onset of hyperglycemia, by 1.3 +/- 0.2 days in Group III, 3.3 +/- 1.0 days in Group IV, and 9.4 +/- 2.8 days in Group V. In a further experiment, nine dogs with pancreas allografts received cyclosporine for prophylactic immunosuppression; further antirejection therapy with azathioprine and antilymphocyte globulin was given for 5 days beginning the first day that rejection was diagnosed. In five dogs (Group A) rejection was diagnosed when serum glucose rose to greater than 150 mg/dl.(ABSTRACT TRUNCATED AT 250 WORDS)

Retrosternal goiter and chylothorax: case report

We describe a case of chylothorax associated with a retrosternal goiter. Such an association has not been previously reported. The chylothorax was probably caused by compression of the thoracic duct and brachiocephalic vessels.

Quantitative morphological studies of aging changes in the kidney of the Lewis rat

Spontaneous aging changes in the kidneys of the rat have been previously described. In the Lewis strain, we performed semiquantitative studies of kidney histology and quantitative studies of glomerular basement membrane thickness and mesangial area in animals aged 6-30 months. There is a progressive increase in glomerular basement membrane thickness and mesangial area throughout the life of the rat. Spontaneous glomerulosclerosis in the Lewis rat does not appear to be as extensive as in other strains. The importance of spontaneous glomerulosclerosis in studies of induced kidney disease is emphasized.

Papillary adenocarcinomatous degeneration occurring in a multilocular renal cyst

A multilocular cyst of the kidney in an adult with malignant papillary adenocarcinomatous transformation is described. The histogenesis and prognosis of multilocular cysts are discussed with special reference to their relationship with Wilms' tumour.

Experimental portal hypertension in the rat

Previous attempts to produce sustained portal hypertension in experimental animals by portal venous obstruction have not been successful. Experiments were designed to study the effects of gradual portal venous occlusion plus hepatic lymphatic ligation in the rat. Adult male Lewis rats were divided into three groups: (A) nonoperated or sham-operated; (B) operated, with hepatic lymphatic ligation only; and (C) operated, with placement of a portal vein ameroid constrictor and hepatic lymphatic ligation. There were no differences noted in portal venous pressures (control 9.6 +/- 0.4 cm H2O) and portovenograms between groups A and B throughout the study. In group C there was greater than doubling of portal venous pressure by 1 wk which remained for 2 mo. Portal pressure then fell but remained elevated at greater than 30% above control values for 1 yr. Three systems of collateral circulation developed rapidly in response to this extrahepatic portal venous occlusion: (A) veins directly bridging across the occluding ameroid reestablishing hepatopetal flow which steadily increased; (B) spontaneous portosystemic shunts at the splenorenal area that occur early and then regress; and (C) retroperitoneal, paraesophageal and submucosal esophageal veins that develop late and remain stable. Quantitative assessment of the lumen size of the submucosal esophageal veins revealed a twofold increase in these veins in group B when compared to controls by 4 wk and a fivefold increase in these veins in group C by 8 wk that persisted for 1 yr. This model appears useful for studying the course and effects of extrahepatic portal hypertension and its gradual alteration by the spontaneous development of portosystemic collaterals in the rat. This model may have enough similarities to the extrahepatic portal hypertension seen in children that its use for future studies may be fruitful.