Prognosis and clinicopathologic features in patients with gastric stump cancer after curative surgery.

Background: Gastric stump ("remnant") cancer is the development of a malignancy related to previous gastric surgery. Prognosis in gastric stump cancer, compared with that in primary gastric cancer, is still controversial. Methods: From January 1988 to December 2012 at a single medical centre in Taiwan, 105 patients with gastric stump cancer, including 85 with previous peptic ulcer disease and 20 with previous gastric cancer, were analyzed for clinicopathologic characteristics and overall survival (os). Results: The 5-year os rates for patients with gastric stump cancer and with primary gastric cancer were 51.2% and 54.5% respectively (p = 0.035). Analysis of clinicopathologic characteristics indicated that, compared with patients having primary gastric cancer, those with gastric stump cancer had more lymph node metastasis (p < 0.001) and had been diagnosed at a more advanced stage (p = 0.047). Multivariate analysis with os as an endpoint showed that age [p = 0.015; hazard ratio (hr): 2.300; 95% confidence interval (ci): 1.173 to 4.509], tumour size (p = 0.037; hr: 1.700; 95% ci: 1.031 to 2.801), stromal reaction (p = 0.021; hr: 1.802; 95% ci: 1.094 to 2.969), and pathologic N category (p = 0.001; hr: 1.449; 95% ci: 1.161 to 1.807) were independent predictors in gastric stump cancer. The os rates for patients with gastric stump cancer who previously had gastric cancer or peptic ulcer disease were 72.9% and 50.0% respectively (p = 0.019). The Borrmann classification was more superficial (p = 0.005), lymph node metastases were fewer (p = 0.004), and staging was less advanced (p = 0.025) in patients with gastric stump cancer who previously had gastric cancer than in their counterparts who previously had peptic ulcer disease. Conclusions: Survival is poorer in patients with gastric stump cancer who previously had peptic ulcer disease than in those who previously had primary gastric cancer. Patients with gastric stump cancer who previously had gastric cancer and could receive curative gastrectomy tended to have a better prognosis because of a more superficial Borrmann classification. Regular follow-up in patients who have undergone gastric surgery is recommended for the early detection of gastric stump cancer.

Validation of a nomogram to predict the risk of cancer in patients with intraductal papillary mucinous neoplasm and main duct dilatation of 10 mm or less.

BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is premalignant pancreatic lesion. International guidelines offer limited predictors of individual risk. A nomogram to predict individual IPMN malignancy risk was released, with good diagnostic performance based on a large cohort of Asian patients with IPMN. The present study validated a nomogram to predict malignancy risk and invasiveness of IPMN using both Eastern and Western cohorts. METHODS: Clinicopathological and radiological data from patients who underwent pancreatic resection for IPMN at four centres each in Eastern and Western countries were collected. After excluding patients with missing data for at least one malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum carcinoembryonic antigen and carbohydrate antigen (CA) 19-9 levels, and age). RESULTS: In total, data from 393 patients who fit the criteria were analysed, of whom 265 were from Eastern and 128 from Western institutions. Although mean age, sex, log value of serum CA19-9 level, tumour location, main duct diameter, cyst size and presence of mural nodule differed between the Korean/Japanese, Eastern and Western cohorts, rates of malignancy and invasive cancer did not differ significantly. Areas under the receiver operating characteristic (ROC) curve values for the nomogram predicting malignancy were 0·745 for Eastern, 0·856 for Western and 0·776 for combined cohorts; respective values for the nomogram predicting invasiveness were 0·736, 0·891 and 0·788. CONCLUSIONS: External validation of the nomogram showed good performance in predicting cancer in both Eastern and Western patients with IPMN lesions.

ANTECEDENTES: La neoplasia mucinosa papilar intraductal (intraductal papillary mucinous neoplasm, IPMN) es una lesión pancreática premaligna. Las guías internacionales incluyen un número limitado de factores predictivos de riesgo individual. Para predecir el riesgo individual de malignidad del IPMN se ha propuesto un nomograma con un buen rendimiento diagnóstico, basado en una gran cohorte de pacientes asiáticos con IPMN. Este estudio validó el nomograma para predecir el riesgo de cáncer y de invasión de la IPMN utilizando cohortes tanto orientales como occidentales. MÉTODOS: Se recogieron datos clínico-patológicos y radiológicos de pacientes en los que se realizó una resección de páncreas por IPMN en 4 centros en países orientales y en 4 centros de países occidentales. Se excluyeron los pacientes en los que en el nomograma faltaba ≥ 1 factor(es) predictivo(s) de malignidad (diámetro del conducto pancreático principal, tamaño del quiste, presencia de nódulo mural, niveles séricos de CEA y CA19-9, y edad). RESULTADOS: En total, se analizaron datos de 393 pacientes que cumplían con los criterios de inclusión, de los cuales 265 eran de centros orientales y 128 de centros occidentales. Aunque la edad media, el sexo, el valor logarítmico del nivel sérico de CA19-9, la localización del tumor, el diámetro del conducto principal, el tamaño del quiste y la presencia de un nódulo mural difirieron entre las cohortes de Corea/Japón y las cohortes oriental y occidental, las tasas de malignidad y de cáncer invasivo no fueron significativamente diferentes. Las áreas bajo la curva operativa del receptor (area under the receiver operating curve, AUC) que mostró el nomograma para predecir la malignidad fueron: cohorte oriental: 0,745; cohorte occidental: 0,856 y cohortes combinadas: 0,776; y para predecir la invasión tumoral fueron: cohorte oriental: 0,736; cohorte occidental: 0,891, y cohortes combinadas: 0,788. CONCLUSIÓN: La validación externa del nomograma mostró un buen rendimiento en la predicción de cáncer, tanto en pacientes orientales como occidentales con lesiones IPMN.

Using human plasma supplemented medium to cultivate human bone marrow-derived mesenchymal stem cell and evaluation of its multiple-lineage potential.

The objective of this study was to evaluate the proliferation and the multiple-lineage differentiation capacity when bone marrow mesenchymal stem cells (BMSCs) were cultured short-term in autologous serum/plasma instead of fetal calf serum (FCS). The BMSCs from 12 donors were cultivated individually in 10% autogenic plasma or serum, with or without bFGF and EGF growth factors. Cell proliferation was examined by a Tetrazolium assay (MTT) after passages 1, 3, and 5. A medium supplemented with 10% human plasma or serum was sufficient to propagate BMSCs. However, no significant proliferation was shown when bFGF and EGF (20 ng/mL each) were added into the medium with autologous serum/plasma. We examined, inductions of adipogenesis, osteogenesis, and chondrocytogenesis, as capacities of multiple-lineage differentiation of cultivated BMSCs (passages 8). Differentiation was investigated by both RT-PCR and immunohistochemistry staining (IHC). Qualitative evidence demonstrated the differentiation capacity was preserved in cultivated BMSCs with autologous serum/plasma.

Randomized trial of gastrojejunostomy with duodenal partition versus antrectomy in unresectable periampullary cancer.

BACKGROUND: A newly-designed gastrojejunostomy with duodenal partition was hypothesized to be a relatively easier and safer gastric bypass procedure in interrupting the "food reentry", as compared with antrectomy, for patients with unresectable periampullary cancer. METHODS: Thirty patients with unresectable periampullary malignancy were randomized to receive gastrojejunostomy with either duodenal partition or antrectomy, in addition to biliary bypass, to compare surgical risk and efficacy of the gastric bypass between these two groups. RESULTS: Gastrojejunotomy with either duodenal partition or antrectomy could significantly shorten the gastric emptying time 6 weeks after operation. There was no significant difference between these two groups in gastric outlet obstruction (GOO) symptoms, gastric emptying time, and time for resuming oral diet intake after operation. The median operation time was shorter in the duodenal partition group (180 min) than in the antrectomy group (240 min), p < 0.01. The median blood loss was less in the duodenal partition group (250 ml) than in the antrectomy group (400 ml), (p = 0.01). Complications occurred in 3 (20%) patients with duodenal partition and in 7 (47%) patients with antrectomy, (p = 0.25). One duodenal stump leakage occurred in antrectomy group. Surgical mortality occurred in 2 patients with antrectomy. CONCLUSIONS: Duodenal partition, with shorter operation time and less blood loss, had similar efficacy with antrectomy in correction of GOO. Therefore, duodenal partition could be a relatively easier and safer alternative to antrectomy in interrupting the "food reentry" in gastrojejunostomy for patients with unresectable periampullary cancer.

Reappraisal of surgical risk and prognosis for periampullary lesions after pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy remains a high-risk and formidable challenge to many surgeons. This study reappraised the surgical risk and prognosis for periampullary lesions in patients undergoing pancreaticoduodenectomy before and after 1990. METHODS: Data on 308 patients with periampullary lesions undergoing pancreaticoduodenectomy were analyzed. The surgical risk was assessed by a variety of factors. Prognoses for periampullary cancers were determined and compared. RESULTS: The overall surgical mortality, morbidity and pancreatic leakage were 12.7%, 47.7% and 14.9% respectively. Surgical morbidity (43.5% vs. 51.6%) and pancreatic leakage (12.9% vs. 16.8%) did not change significantly before 1990 and after 1990. Surgical mortality significantly decreased from 17.1% before 1990 to 8.7% after 1990 (p = 0.043). Surgeons having more experience in performing pancreaticoduodenectomy (count > 20) made significantly lowest rates of surgical mortality, pancreatic leakage and bile leakage, as compared with those having performed this surgery with medium count (10-20) or low count (< 10). Statistically, pancreatic leakage was highly associated with operative mortality, (p < 0.001). As analysed by multivariate logistic regression, the most independent risk factor of surgical mortality after pancreaticoduodenectomy was pancreatic leakage (odds ratio = 12.1), followed by date of operation (odds ratio = 2.5). The 5-year survival rate for overall periampullary cancers was 23.0%, with the highest in ampulla of Vater cancer (32.7%), followed by duodenal cancer (18.0%), distal common bile duct cancer (12.3%) and pancreatic head cancer (5.5%) (p < 0.001). CONCLUSIONS: Surgical morbidity following pancreaticoduodenectomy remains high and unchanged while surgical mortality has significantly reduced. Pancreatic leakage is the most independent risk factor of surgical mortality. Patients with periampullary lesions appear to benefit from the experience of surgeons. The overall 5-year survival is most favorable for ampulla of Vater cancer and worst for pancreatic head cancer.

Diverticular disease of the small bowel.

BACKGROUND/AIMS: The clinical picture of small bowel diverticula has not been well-clarified because of its infrequent incidence and limited case number in most published reports. We evaluated a large series of small bowel diverticula and further compared the clinical picture of the diverticula at different parts of small bowel. METHODOLOGY: The medical records of 88 patients with diverticular disease of the small bowel were reviewed from 1979-1997. This study included all diverticula from duodenum to ileum. RESULTS: The most common small bowel diverticulum was duodenal diverticulum (45%), followed by Meckel's diverticulum (23%). The most common clinical presentation was abdominal pain (48.9%), followed by gastrointestinal bleeding (29.5%). However, among the Meckel's diverticula, gastrointestinal bleeding (60%) was the most common presentation. The accurate diagnostic rate for diverticula, overall, was 25.0%. Thirty-nine (44.3%) of the diverticula were found incidentally. Twenty-three cases (26.1%) were diagnosed by gastrointestinal barium study. Thirty-eight (42.1%) diverticula were left alone without any sequela, and the remaining 55 (56.8%) diverticula needed either bowel resection (30.7%) or diverticulectomy (26.1%). All of the Meckel's diverticula were treated by surgery. Postoperative complication occurred in 9 (10.3%) patients. Hospital mortality rate was 3.4%. CONCLUSIONS: Duodenal diverticulum was the most common small bowel diverticulum. Abdominal pain and gastrointestinal bleeding were the most common clinical presentations. The small bowel diverticula, except for Meckel's diverticulum, did not need to be treated if there were no significant symptoms.

Non-functioning islet cell tumors of the pancreas--a multicentric clinical study in Taiwan.

BACKGROUND/AIMS: Islet cell tumors of the pancreas are rare. Functioning tumors are characterized by the symptoms induced by the hormones they secrete. The clinical behaviors of non-functioning tumors are quite different. In this retrospective study, we scrutinized 16 patients with non-functioning islet cell tumor in three tertiary university hospitals in Taiwan during a 20-year period. METHODOLOGY: There were 12 women and 4 men with a mean age of 47 years. Body-weight loss, abdominal pain and palpable mass were the most frequent symptoms. RESULTS: The mean size of these tumors was 8.9 cm in diameter. Ten tumors were located at the tail of pancreas, the other 6 located at the head. Except for hyperbilirubinemia in 2 patients, none of the patients with non-functioning islet cell tumor showed abnormalities of laboratory data including serum tumor markers. Preoperative detection of these tumors by imaging modalities was not difficult due to the large size of the tumors. However, differentiation with functioning tumor or ductal cell carcinoma required clinical and imaging correlation. Fourteen tumors were malignant including 8 with regional lymph nodes involvement, 3 with locally microscopic invasion, 2 with hepatic metastasis and 2 with nearby organ invasion. CONCLUSIONS: Even with its malignant behavior, non-functioning islet cell tumor still possessed a good prognosis after adequate surgical removal in comparison with a higher mortality rate of ductal carcinoma of the pancreas.

Splenic abscess--a changing trend in treatment.

Fifteen patients with splenic abscesses were evaluated between 1985 and 1995. The most common predisposing factors were remote infection, diabetes mellitus and heart disease. Common clinical presentations included leucocytosis, fever, left upper quadrant abdominal pain and left pleural effusion. Four patients with splenic abscesses smaller than 4 cm in diameter were treated with antibiotics alone, and 1 in this treatment group died. Among the 10 patients with splenic abscesses larger than 4 cm in diameter receiving percutaneous drainage, 9 (90%) were successfully cured, including 8 with unilocular abscesses and 1 with multilocular abscesses. Two patients underwent splenectomy. In conclusion, percutaneous drainage using ultrasound or computed tomography guidance may be recommended as the treatment of choice for splenic abscess larger than 4 cm in diameter. Antibiotics alone may sometimes be considered for splenic abscesses smaller than 4 cm in diameter. Splenectomy is reserved for those cases where medical treatment has failed.

Prospective study of gastric outlet obstruction in unresectable periampullary adenocarcinoma.

Controversy persists regarding the role of prophylactic gastrojejunostomy in patients with unresectable periampullary adenocarcinoma. In review of the retrospective series, presence of gastric outlet obstruction (GOO) has been claimed to be a bad prognostic sign. This prospective study aimed to clarify the necessity of routine prophylactic gastrojejunostomy in patients with unresectable periampullary adenocarcinoma. The incidence and prognostic significance of GOO were also evaluated. Sixty-six patients with unresectable periampullary adenocarcinoma were enrolled. They were divided into 2 groups to receive either a single biliary bypass or a double bypass (concomitant gastric and biliary bypasses) if they had GOO. The single bypass group was followed up to assess the incidence of GOO and subsequent need of a gastric bypass. Prognostic factors were evaluated by univariate and multivariate analyses. Forty-four (67%) of the overall 66 patients presented with GOO at the time of diagnosis. There was no statistical difference regarding the morbidity and mortality between the 2 groups, except longer (7 days) hospital stay in the double bypass group. Seven (31.8%) of the 22 patients in the single bypass group subsequently developed GOO an average of 6.2 +/- 1.0 months after their initial biliary bypass. By univariate analysis, significant prognostic factors for unresectable periampullary adenocarcinoma were: GOO (p = 0.0379), pancreatic head origin (p = 0. 0146 by univariate analysis), and distant metastasis (p < 0.0001). After multivariate analysis, only pancreatic head origin and distant metastasis remained significant independent factors of poor prognosis. In conclusion, gastrojejunostomy should be performed prophylactically in addition to a biliary bypass in patients with unresectable periampullary adenocarcinoma. The presence of GOO is not an independent factor of poor prognosis, but a reflection of the aggressive biologic behavior of pancreatic head adenocarcinoma.

The role of MIB-1 index in the prognosis of resectable pancreatic head cancer.

BACKGROUND/AIMS: Cell kinetics are important indicators of the biological behavior of various human tumors. In this study, we evaluated the prognostic values of the proliferative factors including MIB-1 index, DNA ploidy and S-phase fraction, and further determined the independent prognostic factors in pancreatic head cancer after pancreatoduodenectomy. METHODOLOGY: Patients with pancreatic head cancer undergoing pancreatoduodenectomy were included. Cell proliferative parameters including MIB-1 index, DNA ploidy and S-phase fraction measured by flow cytometry were evaluated and compared with the conventional clinicopathologic factors. RESULTS: There were 21 resectable pancreatic head cancers. By univariate analysis MIB-1 index, cell differentiation and lymphovascular invasion were significant prognostic factors. The 5-year survival rate was 22.2% for overall patients and 29.2% for patients with MIB-1 < or = 11%, while it was 0% for MIB-1 index > 11%, p=0.011. Tumors without lymphovascular invasion had significantly better prognosis than those with lymphovascular invasion (median survival: 38 vs. 10 months, p=0.009). The median survival was significantly longer for well-differentiated cancers than for moderately and poorly differentiated cancers (44 vs. 11 and 9 months, p=0.038). There was no correlation between the MIB-1 index and the other 2 conventional prognostic factors. After multivariate analysis, only the MIB-1 index emerged as the independent prognostic factor. CONCLUSIONS: MIB-1 index played a significant role in the prognosis of the resectable pancreatic head cancer and could potentially complement the conventional factors in predicting the prognosis and determining the optimal treatment strategy. MIB-1 index was also an important independent prognostic factor.

Laparoscopic unroofing of hepatic cysts with intraperitoneal drainage: a report of three cases.

Hepatic cysts are not uncommon and are usually asymptomatic, while large cysts sometimes show clinical manifestations. The management of large symptomatic hepatic cysts includes both percutaneous aspiration and surgical intervention. Aspiration has a high recurrence rate and is not a curative treatment. Recently, laparoscopic unroofing or "fenestration" in selected patients with hepatic cysts has gained popularity, for it shortens hospital stay, involves minimal invasiveness and does not result in a high recurrence rate. We report three cases of symptomatic hepatic cysts successfully treated with laparoscopic surgery.

Poorer prognosis in young patients with gastric cancer?

BACKGROUND/AIMS: Although the relationship between prognosis and age of patients with gastric cancer is controversial, a poorer prognosis in young patients has been suggested by most investigators. To further examine the hypothesis, a retrospective study was undertaken to analyze a large series of patients with gastric cancer in Taiwan. METHODOLOGY: A total of 1,642 consecutive patients diagnosed with gastric cancer and receiving further management at one medical center from 1988 to 1993 were reviewed. The gender, TNM tumor stage, rate of curative resection and survival of the patients were compared in the young age group (< or = 39 years) and the old age group (> 39 years). Survival was estimated with the product-limit method and difference in survival was tested by the log-rank test. Multivariate analysis was done by the Cox proportional hazard model. RESULTS: Among the 1,642 patients, 61 patients were in the young age group and 1,581 patients were in the old age group. There was no significant difference for the 2 groups of patients in the distribution of TNM stage (stage I: 20%; II: 8%; III: 13%; IV: 59% vs. 19%, 11%, 25% and 45% respectively, in the old age group, p = 0.098) and rate of curative resection (38% vs 51% in the old age group, p = 0.059). The overall 5-year survival showed no significant difference between the 2 groups (25% vs. 29% in the old). Subgroup analyses showed that survival after curative resection and survival without curative treatment (including palliative resection and no resection) also had no difference in the 2 groups. Multivariate analysis also showed that age was not an independent factor. CONCLUSIONS: Although most reports suggested a dismal prognosis in young patients with gastric cancer, based on our findings, young patients (< or = 39 years) do not have a worse prognosis than older patients.

Glucagonoma syndrome: a case report.

Glucagonoma is a very rare islet cell tumor of the pancreas. We present a case of pancreatic tail tumor with the typical glucagonoma syndrome of necrolytic migratory erythema (NME), diabetes mellitus (DM), anemia, weight loss and glossitis. After complete resection of the pancreatic tumor, the glucagonoma syndrome subsided. In reviewing 120 cases of glucagonoma in the literature, the average tumor diameter was 3.6 cm. Most (68.1%) of the tumors occurred in the pancreatic tail. Two-thirds of the reported glucagonomas were malignant and 53.5% metastasized to other organs. The curative resection rate was 45.8%. A triad of pancreatic tumor, NME and DM should lead to the diagnosis of glucagonoma.

Factors affecting morbidity, mortality and survival after pancreaticoduodenectomy for carcinoma of the ampulla of Vater.

BACKGROUND/AIMS: The aim of this paper is to reevaluate the factors responsible for hospital morbidity, mortality and post-operative survival following pancreaticoduodenectomy for ampullary cancer. METHODOLOGY: Peri-operative data on 132 patients undergoing pancreaticoduodenectomy for ampullary cancer were correlated with post-operative morbidity, mortality and long-term survival. RESULTS: Three factors were found to correlate well with post-operative morbidity; however, only intraabdominal or wound sepsis was an independently significant variable. Four parameters correlated well with hospital mortality, while multivariate analysis revealed age > 75 y/o, positive blood culture and albumin < or = 3.0 g% to be independently significant in predicting post-operative mortality. Univariate analysis identified seven significant factors: 1) age < or = 75 y/o, 2) hematocrit > 30%, 3) blood urea nitrogen < 20 mg%, 4) earlier TNM staging, 5) smaller tumor size, 6) negative nodal status and 7) well-differentiated tumors, which were associated with longer survival. However, multivariate analysis disclosed nodal status and hematocrit to be the two most significant independent variables. CONCLUSIONS: Although radical resection for ampullary cancer can be performed with a low mortality in recent years, the justification for performing this major operation in a patient over 75 years of age should be reevaluated for prohibitively high mortality (10x) and shorter survival (median 6.0 months). Pre-operative nutritional support and careful surgical technique to prevent post-operative sepsis are mandatory to reduce operative morbidity and mortality. Correction of anemia and adequate lymph node dissection will clarify the patient's survival benefit following this operation.

Comparison of pylorus-preserving and classic pancreaticoduodenectomy.

BACKGROUND: The authors present their recent experience with the treatment of periampullary lesions to compare the surgical technique, safety and prognosis between pylorus-preserving pancreaticoduodenectomy (PPPD) and classic pancreaticoduodenectomy (CPD). METHODS: Prospective data from 100 patients with periampullary lesions treated with either PPPD or CPD between January, 1991, and June, 1997, were evaluated, including demographic data, surgical technique, surgical risk and prognosis. RESULTS: There were 35 patients treated with PPPD and 65 treated with CPD. The operating time was significantly shorter in the PPPD group (9.3 +/- 0.3 hours) than in CPD (10.4 +/- 0.3 hours). The average overall blood loss was 1,275 +/- 71 ml, with no statistical difference between PPPD and CPD groups. The overall complication rate was 56%, with 54% in the PPPD group and 57% in the CPD group (p = 0.755). The overall mortality was 4%, with 0% in the PPPD group and 6.2% in CPD (p = 0.655). There was no statistical difference in survival time for overall periampullary cancers between the PPPD and CPD groups (median = 28.0 vs 26.5 months, p = 0.393). The difference in survival time was still of no significance between the PPPD and CPD groups when the periampullary cancers were further stratified into pancreatic head cancer and nonpancreatic periampullary cancer. CONCLUSIONS: Morbidity and mortality of PPPD did not exceed that of CPD, and the prognosis after PPPD was not compromised in patients with periampullary cancer. PPPD, with a shorter operating time, can be a safe and effective alternative to CPD in the treatment of periampullary lesions.

Diagnostic and prognostic values of CA 19-9 and CEA in periampullary cancers.

BACKGROUND: The roles of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) in periampullary cancers have not been clearly established. Diagnostic and prognostic values of these two tumor markers were clarified in this study. STUDY DESIGN: Preoperative serum levels of CEA and CA 19-9, and clinicopathologic features were retrospectively reviewed in 143 surgical patients with periampullary cancer from 1989 to 1997. RESULTS: There were 86 resectable and 57 unresectable periampullary cancers. CA 19-9 demonstrated significantly higher sensitivity in detecting these cancers than CEA. The cancer with unresectable lesion, total bilirubin >7.3 mg/dL, or tumor size >2 cm tended to associate with higher CA 19-9 level. CEA level was significantly higher in the tumor >2 cm, not in the tumor < or =2 cm. CA 19-9 was a significant prognostic factor in both resectable and unresectable periampullary cancers, but CEA was significant only in the resectable group. Multivariate analysis revealed that independent prognostic factors included CA 19-9, resectability, primary tumor, and stage, and CA 19-9 was the most important one. CONCLUSION: CA 19-9 provided more important diagnostic and prognostic values than CEA in periampullary cancers and was the most important independent prognostic factor for periampullary cancers. This study recommends serum CA 19-9 as an adjunct in detecting periampullary cancers, in evaluating resectability, and in predicting prognosis.

Prognostic value of MIB-1 index and DNA ploidy in resectable ampulla of Vater carcinoma.

OBJECTIVE: To evaluate the prognostic value of the proliferative factors, MIB-1 index, DNA ploidy, and S-phase fraction, and further to determine the independent prognostic factors in ampulla of Vater carcinoma after pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Cell kinetics are important indicators of the biologic behavior of various human tumors, but only a few authors have reported the application of cell proliferative factors in ampulla of Vater carcinoma. METHODS: Patients undergoing pancreaticoduodenectomy for ampulla of Vater carcinoma were included. Proliferative factors, MIB-1 index, and DNA contents, measured by flow cytometry, were evaluated and compared with the conventional clinicopathologic factors. RESULTS: Ninety resectable ampulla of Vater carcinomas were included. By univariate analysis, MIB-1 index, DNA ploidy, S-phase fraction, stage, and lymph node status were significant prognostic factors. The 5-year survival rate was 40.7% for tumors with MIB-1 index < or =15% and 0% for those with MIB-1 index >15%. Diploid tumors had a significantly better prognosis than aneuploid. Outcomes of stage I and II tumors were more favorable than those of stage III and IV. After multivariate analysis, MIB-1 index, DNA ploidy, and stage remained as the independent prognostic factors. Among the three independent prognostic factors, MIB-1 index was the most powerful. CONCLUSIONS: Both MIB-1 index and DNA ploidy provide important prognostic value and potentially complement the conventional prognostic factors in resectable ampulla of Vater carcinoma. MIB-1 index is the most powerful independent prognostic factor.

PAF and CD18 mediate neutrophil infiltration in upper gastrointestinal tract during intra-abdominal sepsis.

Neutrophil infiltration is a critical event in the development of multiple organ failure during sepsis. We hypothesized that platelet-activating factor (PAF) release contributes to neutrophil infiltration in the gastrointestinal tract during sepsis. In the first experiments we administered exogenous PAF (1.56, 6.25, 25, and 100 ng . kg-1 . min-1 for 30 min) to urethan-anesthetized Sprague-Dawley rats. PAF was administered alone or in combination with either the PAF antagonist WEB-2086 (250 microg . kg-1 . min-1), a monoclonal antibody (MAb) to CD18, or a MAb to intercellular adhesion molecule 1 (ICAM-1). In separate groups of rats, cecal ligation and incision (CLI) was performed to create intra-abdominal sepsis, which we hypothesized would stimulate the release of endogenous PAF. CLI was performed in rats given either saline, WEB-2086, anti-CD18, or anti-ICAM-1 MAb. After these experiments, tissue myeloperoxidase (MPO) levels were determined as a marker of neutrophil infiltration. Both exogenous PAF and CLI induced significant increases in MPO activity in the stomach and duodenum. These increases were significantly attenuated by WEB-2086, anti-CD18 MAb, and anti-ICAM-1 MAb in both PAF- and CLI-treated rats. These results suggest that both the inflammatory mediator PAF and the CD18 integrins play a major role in neutrophil infiltration in the upper gastrointestinal tract during sepsis.

Hepatolithiasis associated with cholangiocarcinoma.

BACKGROUND: Intrahepatic stone is common in East Asia. Hepatolithiasis is a risk factor for cholangiocarcinoma but it is difficult to make an accurate diagnosis before operation. The effect of intrahepatic stone on diagnosis, treatment and survival in patients with coexistent cholangiocarcinoma was investigated. METHODS: Between 1981 and 1994, 33 patients with hepatolithiasis and associated cholangiocarcinoma were identified and compared respectively to 18 patients with intrahepatic cholangiocarcinoma alone. RESULTS: Patients with intrahepatic stones had a significantly longer duration of symptoms, a higher frequency of previous biliary surgery but a lower rate of preoperative diagnosis. Surgical resection was the treatment of choice and was performed in 18 of 33 patients with cholangiocarcinoma and stones and in nine of 18 with intrahepatic cholangiocarcinoma alone. Significantly inferior 5-year survival rates were found in patients with hepatolithiasis: two of 32 versus four of 14 for all cases and two of 17 versus four of nine for resectable cases (P < 0.05). CONCLUSION: These survival differences may be attributed to delayed diagnosis, lower diagnostic rate and relatively fewer curative resections in the patients with stone-containing cholangiocarcinoma.