A novel model for simultaneous study of neointestinal regeneration and intestinal adaptation.

The use of autologous grafts, fabricated from tissue-engineered neointestine, to enhance insufficient compensation of intestinal adaptation for severe short bowel syndrome is a compelling idea. Unfortunately, current approaches and knowledge for neointestinal regeneration, unlike intestinal adaptation, are still unsatisfactory. Thus, we have designed a novel model of intestinal adaptation with simultaneous neointestinal regeneration and evaluated its feasibility for future basic research and clinical application. Fifty male Sprague-Dawley rats weighing 250-350 g underwent this procedure and sacrificed at 4, 8, and 12 weeks postoperatively. Spatiotemporal analyses were carried out by gross, histology, and DNA/protein quantification. Three rats died of operative complications. In early experiments, the use of hard silicone stent as tissue scaffold in 11 rats was unsatisfactory for neointestinal regeneration. In later experiments, when a soft silastic tube was used, the success rate increased up to 90.9%. Further analyses revealed that no neointestine developed without donor intestine; regenerated lengths of mucosa and muscle were positively related to time postsurgery but independent of donor length with 0.5 or 1 cm. Other parameters of neointestinal regeneration or intestinal adaptation showed no relationship to both time postsurgery and donor length. In conclusion, this is a potentially important model for investigators searching for solutions to short bowel syndrome.

Autocrine CCL2 promotes cell migration and invasion via PKC activation and tyrosine phosphorylation of paxillin in bladder cancer cells.

The amount of monocyte chemoattractant protein-1 (MCP-1/CCL2) produced by a transitional cell carcinoma is directly correlated with high recurrence and poor prognosis in bladder cancer. However, the mechanisms underlying the effects of CCL2 on tumor progression remain unexplored. To investigate the role played by CCL2, we examined cell migration in various bladder cancer cell lines. We found that high-grade cancer cells expressing high levels of CCL2 showed more migration activity than low-grade bladder cancer cells expressing low levels of the chemokine. Although the activation of CCL2/CCR2 signals did not appreciably affect cell growth, it mediated cell migration and invasion via the activation of protein kinase C and phosphorylation of tyrosine in paxillin. Blocking CCL2 and CCR2 with small hairpin RNA (shCCL2) or a specific inhibitor reduced CCL2/CCR2-mediated cell migration. The antagonist of CCR2 promoted the survival of mice bearing MBT2 bladder cancer cells, and CCL2-depleted cells showed low tumorigenicity compared with shGFP cells. In addition to observing high-levels of CCL2 in high-grade human bladder cancer cells, we showed that the CCL2/CCR2 signaling pathway mediated migratory and invasive activity, whereas blocking the pathway decreased migration and invasion. In conclusion, high levels of CCL2 expressed in bladder cancer mediates tumor invasion and is involved with advanced tumorigenesis. Our findings suggest that this CCL2/CCR2 pathway is a potential candidate for the attenuation of bladder cancer metastases.

Prospective randomized study for comparison of open surgery with laparoscopic-assisted placement of Tenckhoff peritoneal dialysis catheter--a single center experience and literature review.

BACKGROUND: The ideal method for catheter placement in patients undergoing peritoneal dialysis remains debatable. This prospective study intends to clarify whether laparoscopic assisted percutaneous puncture is superior to open surgery. MATERIALS AND METHODS: From 2002 to 2006, 77 patients receiving first catheter placement were enrolled and randomized to either an open group of 40 patients or a laparoscopic group of 37 patients. Patient characteristics, operation-related data, procedural complications, and clinical outcome were compared by using the statistical software SPSS ver. 11.5 (SPSS, Chicago, IL). RESULTS: Laparoscopy had a longer operative time (68.32+/-31.90 versus 46.68+/-15.99 min; P<0.001), shorter wound length (1.69+/-0.46 versus 2.34+/-0.84 cm; P<0.001), and higher costs (P<0.001) compared with open surgery. Laparoscopy tended to have a higher incidence of pericannular bleeding (21.6% versus 7.5%) and a lower rate of early catheter migration (2.7% versus 15.0%), but its early/late/overall complication rate did not statistically differ. No surgical mortality occurred. Rate and cause of overall mortality or catheter dropout did not statistically differ. Catheter longevity was equivalent in both groups. CONCLUSIONS: Laparoscopic assisted percutaneous puncture exhibited no superiority to open surgery. As a matter of fact, open surgery's shorter operative time and reduced equipment requirement can increase cost-effectiveness. Therefore, conventional open surgery is recommended for most patients with primary catheter placement.

A simple novel model to predict hospital mortality, surgical site infection, and pneumonia in elderly patients undergoing operation.

BACKGROUND/AIMS: Predicting models of operative morbidity and mortality in the geriatric population are important in the prevention of adverse surgical outcomes. METHODS: A retrospective review of medical records was performed for patients over 80 years of age who underwent gastrointestinal surgery from 1998 to 2008. RESULTS: 215 patients were identified with a mean age of 83.7 years. Overall morbidity and mortality rates were 48.8 and 14.4%, respectively. Multivariate logistic regression analysis revealed that serum albumin levels [odds ratio (OR) = 0.367, p = 0.0267], postoperative pneumonia (OR = 3.471, p = 0.0101), hollow organ perforation or anastomosis combined with leakage (OR = 7.600, p = 0.0126), and preoperative systemic inflammatory response syndrome (OR = 3.186, p = 0.0323) were significant predictors of hospital mortality. Moreover, albumin (OR = 0.270, p = 0.0002) and physical disability (OR = 3.802, p = 0.0009) were significant predictors of postoperative pneumonia, and albumin (OR = 0.491, p = 0.0212) and enterotomy (OR = 3.335, p = 0.0208) were significant predictors of surgical site infections. CONCLUSION: This study provides novel predicting models to identify the elderly surgical patients at high risk, who should receive more intensive preventive and perioperative care.

Identifying the Growth Factors for Improving Neointestinal Regeneration in Rats through Transcriptome Analysis Using RNA-Seq Data.

Using our novel surgical model of simultaneous intestinal adaptation "A" and neointestinal regeneration "N" conditions in individual rats to determine feasibility for research and clinical application, we further utilized next generation RNA sequencing (RNA-Seq) here in normal control tissue and both conditions ("A" and "N") across time to decipher transcriptome changes in neoregeneration and adaptation of intestinal tissue at weeks 1, 4, and 12. We also performed bioinformatics analyses to identify key growth factors for improving intestinal adaptation and neointestinal regeneration. Our analyses indicate several interesting phenomena. First, Gene Ontology and pathway analyses indicate that cell cycle and DNA replication processes are enhanced in week 1 "A"; however, in week 1 "N", many immune-related processes are involved. Second, we found some growth factors upregulated or downregulated especially in week 1 "N" versus "A". Third, based on each condition and time point versus normal control tissue, we found in week 1 "N" BMP2, BMP3, and NTF3 are significantly and specifically downregulated, indicating that the regenerative process may be inhibited in the absence of these growth factors. This study reveals complex growth factor regulation in small neointestinal regeneration and intestinal adaptation and provides potential applications in tissue engineering by introducing key growth factors identified here into the injury site.

Ileal angiomyolipoma as an unusual cause of small-intestinal intussusception.

Angiomyolipomas are benign mesenchymal tumors, but those that arise from the small intestine are exceedingly rare. We report on a 48-year-old woman who had an ileal angiomyolipoma, who presented clinically with vague abdominal pain and bloody stool. Small-bowel intussusception was shown on an abdominal computed tomography (CT) scan. We discuss the clinical manifestations and clinicopathological and immunohistochemical findings of this benign tumor which appeared in this rare location.

Candida peritonitis due to peptic ulcer perforation: incidence rate, risk factors, prognosis and susceptibility to fluconazole and amphotericin B.

Sixty-two cases of peritonitis due to peptic ulcer perforation were diagnosed between January 2000 and December 2000. Of these 62 cases, 23 isolates of Candida in 23 cases (CP) were cultured from peritoneal fluid. Cultures of peritoneal fluid of 10 (BP) of the remaining 39 cases was positive for bacteria only. Cultures of peritoneal fluid of the remaining 29 cases was negative. Comparison of CP, BP and culture-negative cases did not reveal any significant risk factor. Of the 23 Candida isolates, the Candida species and 48-h MICs of fluconazole and amphotericin B (mean, range ug/ml) were C. albicans 18 (0.688, 0.125-1.0; 0.297, 0.031-0.5), C. glabrata 3 (0.542, 0.125-1.0; 0.25, 0.125-0.5), C. tropicalis 1 (0.25; 0.5), C. intermedia 1 (1.0; 0.125) respectively. Mortality rates of CP, BP and culture-negative peritonitis due to infection were 5/23(21.7%), 0/10 and 1/29(3.4%) respectively. Without effective antifungal therapy, the mortality rate of CP was not low.

A procalcitonin-based algorithm to guide antibiotic therapy in secondary peritonitis following emergency surgery: a prospective study with propensity score matching analysis.

BACKGROUND: Procalcitonin (PCT)-based algorithms have been used to guide antibiotic therapy in several clinical settings. However, evidence supporting PCT-based algorithms for secondary peritonitis after emergency surgery is scanty. In this study, we aimed to investigate whether a PCT-based algorithm could safely reduce antibiotic exposure in this population. METHODS/PRINCIPAL FINDINGS: From April 2012 to March 2013, patients that had secondary peritonitis diagnosed at the emergency department and underwent emergency surgery were screened for eligibility. PCT levels were obtained pre-operatively, on post-operative days 1, 3, 5, and 7, and on subsequent days if needed. Antibiotics were discontinued if PCT was <1.0 ng/mL or decreased by 80% versus day 1, with resolution of clinical signs. Primary endpoints were time to discontinuation of intravenous antibiotics for the first episode and adverse events. Historical controls were retrieved for propensity score matching. After matching, 30 patients in the PCT group and 60 in the control were included for analysis. The median duration of antibiotic exposure in PCT group was 3.4 days (interquartile range [IQR] 2.2 days), while 6.1 days (IQR 3.2 days) in control (p < 0.001). The PCT algorithm significantly improves time to antibiotic discontinuation (p < 0.001, log-rank test). The rates of adverse events were comparable between 2 groups. Multivariate-adjusted extended Cox model demonstrated that the PCT-based algorithm was significantly associated with a 87% reduction in hazard of antibiotic exposure within 7 days (hazard ratio [HR] 0.13, 95% CI 0.07-0.21, p < 0.001), and a 68% reduction in hazard after 7 days (adjusted HR 0.32, 95% CI 0.11-0.99, p  =  0.047). Advanced age, coexisting pulmonary diseases, and higher severity of illness were significantly associated with longer durations of antibiotic use. CONCLUSIONS/SIGNIFICANCE: The PCT-based algorithm safely reduces antibiotic exposure in this study. Further randomized trials are needed to confirm our findings and incorporate cost-effectiveness analysis. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000601831.

Tubular scaffolds of gelatin and poly(ε-caprolactone)-block-poly(γ-glutamic acid) blending hydrogel for the proliferation of the primary intestinal smooth muscle cells of rats.

The proper regeneration of intestinal muscle for functional peristalsis is the most challenging aspect of current small intestine tissue engineering. This study aimed to fabricate a hydrogel scaffold for the proliferation of intestinal smooth muscle cells (ISMCs). Tubular porous scaffolds of 10-20 wt% gelatin and 0.05-0.1 wt% poly(ε-caprolactone)-block-poly(γ-glutamic acid) blending hydrogel were cross-linked by carbodiimide and succinimide in an annular space of a glass mold. The scaffolds with higher gelatin contents degraded slower in the phosphate buffer solution. In rheological measurements, the hydrated scaffolds were elastic (all tangent delta <0.45); they responded differentially to frequency, indicating a complete viscoelastic property that is beneficial for soft tissue regeneration. Isolated rat ISMCs, with the characteristic biomarkers α-SMA, calponin and myh11, were loaded into the scaffolds by using either static or centrifugal methods. The average cell density inside the scaffolds increased in a time-dependent manner in most scaffolds of both seeding groups, although at early time points (seven days) the centrifugal seeding method trapped cells more efficiently and yielded a higher cell density than the static seeding method. The static seeding method increased the cell density from 7.5-fold to 16.3-fold after 28 days, whereas the centrifugal procedure produced a maximum increase of only 2.4-fold in the same period. In vitro degradation data showed that 50-80% of the scaffold was degraded by the 14th day. However, the self-secreted extracellular matrix maintained the integrity of the scaffolds for cell proliferation and spreading for up to 28 days. Confocal microscopic images revealed cell-cell contacts with the formation of a 3D network, demonstrating that the fabricated scaffolds were highly biocompatible. Therefore, these polymeric biomaterials hold great promise for in vivo applications of intestinal tissue engineering.

Evaluation of the potential therapeutic role of a new generation of vitamin D analog, MART-10, in human pancreatic cancer cells in vitro and in vivo.

Pancreatic cancer is a lethal disease with no known effective chemotherapy and radiotherapy, and most patients are diagnosed in the late stage, making them unsuitable for surgery. Therefore, new therapeutic strategies are urgently needed. 1α,25-dihydroxyvitamin D3 [1α,25(OH)2D3] is known to possess antitumor actions in many cancer cells in vitro and in vivo models. However, its clinical use is hampered by hypercalcemia. In this study, we investigated the effectiveness and safety of a new generation, less calcemic analog of 1α,25(OH)2D3, 19-nor-2α-(3-hydroxypropyl)-1α,25-dihydroxyvitamin D3 (MART-10), in BxPC-3 human pancreatic carcinoma cells in vitro and in vivo. We demonstrate that MART-10 is at least 100-fold more potent than 1α,25(OH)2D3 in inhibiting BxPC-3 cell proliferation in a time- and dose-dependent manner, accompanied by a greater upregulation of cyclin-dependent kinase inhibitors p21 and p27 and a greater downregulation of cyclin D3 and cyclin-dependent kinases 4 and 5, leading to a greater increase in the fraction of cells in G0/G1 phase. No induction of apoptosis and no effect on Cdc25 phosphatases A and C were observed in the presence of either MART-10 or 1α,25(OH)2D3. In a xenograft mouse model, treatment with 0.3 µg/kg body weight of MART-10 twice/week for 3 weeks caused a greater suppression of BxPC-3 tumor growth than the same dose of 1α,25(OH)2D3 without inducing hypercalcemia and weight loss. In conclusion, MART-10 is a promising agent against pancreatic cancer growth. Further clinical trial is warranted.

Doxorubicin-Loaded PEG-PCL-PEG Micelle Using Xenograft Model of Nude Mice: Effect of Multiple Administration of Micelle on the Suppression of Human Breast Cancer.

The triblock copolymer is composed of two identical hydrophilic segments: Monomethoxy poly(ethylene glycol) (mPEG) and one hydrophobic segment poly(ε­caprolactone) (PCL); which is synthesized by coupling of mPEG-PCL-OH and mPEG­COOH in a mild condition using dicyclohexylcarbodiimide and 4-dimethylamino pyridine. The amphiphilic block copolymer can self-assemble into nanoscopic micelles to accommodate doxorubixin (DOX) in the hydrophobic core. The physicochemical properties and in vitro tests, including cytotoxicity of the micelles, have been characterized in our previous study. In this study, DOX was encapsulated into micelles with a drug loading content of 8.5%. Confocal microscopy indicated that DOX was internalized into the cytoplasm via endocystosis. A dose-finding scheme of the polymeric micelle (placebo) showed a safe dose of PEG-PCL-PEG micelles was 71.4 mg/kg in mice. Importantly, the circulation time of DOX-loaded micelles in the plasma significantly increased compared to that of free DOX in rats. A biodistribution study displayed that plasma extravasation of DOX in liver and spleen occurred in the first four hours. Lastly, the tumor growth of human breast cancer cells in nude mice was suppressed by multiple injections (5 mg/kg, three times daily on day 0, 7 and 14) of DOX-loaded micelles as compared to multiple administrations of free DOX.

Multifocal intraductal papillary mucinous neoplasm of the pancreas--a case report.

Cystic neoplasms of the pancreas are relatively rare, comprising 10 percent of pancreatic cysts and only 1 percent of pancreatic cancers. Cystic neoplasms include mucinous cystic neoplasms, serous cystadenomas, papillary cystic tumors, cystic islet cell tumors and intraductal papillary mucinous neoplasms of the pancreas (IPMNs). IPMN was first described in 1982. It has been most commonly described in 60 to 70 years old males, and represents a relatively "new" but increasingly recognized disease. The improvement and widespread use of modern imaging equipments and heightened awareness of physicians contribute to the increasing incidence of IPMN. The majority of IPMNs are located in the pancreatic head (75%) while the rest involves the body/tail regions. Multifocal IPMNs have been hypothesized, but the true presence of multifocality is unknown. Here we present a 72-year-old male diagnosed with IPMN (carcinoma in situ) in the pancreatic head and a branch duct type IPMN (duct atypia) in the pancreatic body and tail. The patient underwent a Whipple intervention and a distal pancreatectomy. A three-year disease-free survival has been observed so far.

Primary testicular actinomycosis mimicking metastatic tumor.

We report a rare case of right primary testicular actinomycosis presenting as multiple testicular lesions mimicking a metastatic tumor in a 71-year-old patient with gastric adenocarcinoma. Preoperative diagnosis is difficult. The enlarged and inflamed testis was removed by orchiectomy and testicular actinomycosis was diagnosed after pathological examination. The patient had not received any further antibiotic prescription and there was no recurrent or other site involvement after orchiectomy. We illustrate this case, though it is rare, to alert pathologists and clinicians to the possible occurrence of primary testicular actinomycosis mimicking metastatic lesions in a cancer patient. To diagnose, extensive sampling of the tissue specimens may be needed. We also reviewed the published literature and found that the treatment of choice for testicular actinomycosis was orchiectomy. The usage of penicillin after orchiectomy does not seem to affect the outcomes of the disease.

Clinicopathological features, surgical management, and disease outcome of perforated gastric cancer.

BACKGROUND AND OBJECTIVES: Perforated gastric cancer is rare and generally not diagnosed preoperatively or intraoperatively, if a frozen section is unavailable. Therefore, the elucidation of its clinicopathological features and disease outcomes will help surgeons manage perforated gastric cancer. PATIENTS AND METHODS: The clinicopathological features, surgical management, and disease outcomes of 13 patients with perforated gastric cancer from March 1989 to May 2003 were retrospectively analyzed. Disease outcomes were analyzed in-depth based on tumor stage, depth of tumor invasion, operative curability, and three treatment groups. RESULTS: All 13 patients (median age of 72 years) received emergent laparotomy. Malignant gastric perforation was diagnosed intraoperatively in eight (61.5%) patients. Four patients whose frozen sections exhibited perforated gastric cancer underwent radical surgery with curative intent and were assigned to Group 1. Another four patients with overt distal metastases underwent palliative surgery and were assigned to Group 2. The remaining five patients were misdiagnosed as having benign gastric perforation and underwent local surgery; these patients were assigned to Group 3. All patients received follow-up for a median of 26 months. The survival rates for Stage I disease (P = 0.0342), T1/T2 tumors (P = 0.0342), and curative resection (P = 0.0012) significantly exceeded those of Stage III/IV, T3/T4 tumors, and non-curative resection. Additionally, the survival rates of Group 1 (P = 0.0067) and Group 3 (P = 0.0067) significantly exceeded those of Group 2. Stepwise logistic regression analysis revealed no significant predictor of prognosis. CONCLUSIONS: In resectable cases, one-stage radical gastrectomy with possible extensive lymphadenectomy should be encouraged if conditions allow. In cases of misdiagnosis, non-radical local surgery with curative resection is sufficient to treat early-stage cancer.

Squamous cell carcinoma arising in an epidermal inclusion cyst.

An epidermal inclusion cyst is a widespread benign intradermal lesion and may occur anywhere in the body. Normally, it appears as a non-tender, soft mass of variable size. Dissection usually reveals grayish-white or whitish gelatinous materials and a smooth inner surface. The overlying skin almost always shows unremarkable changes. On occasion, the cyst may rupture and induce an inflammatory reaction. It rarely turns malignant or displays a firmer mass. This study reports on a rare case of squamous cell carcinoma arising from the lining cells of an epidermal inclusion cyst, which was located in the left axillary region of a 68-year-old male patient. Clinically, it is difficult to differentiate between a benign and malignant cystic lesion. Histological examination normally yields the diagnosis. Once a diagnosis is confirmed, the tumor should be widely excised with a free margin. The outcome is always excellent. We therefore emphasize that all resected skin cystic specimens should undergo further microscopic examination to avoid any unnecessary misdiagnosis.