Laparoscopic adrenalectomy by general surgeons familiar with laparoscopic surgical skills: experiences of a single center.

INTRODUCTION: Laparoscopic adrenalectomy (LA) is still considered an advanced procedure requiring a high level of skills with potentially lethal pitfalls. We report our clinical outcomes of 50 cases of LA, and discuss whether a general surgeon is suitable to perform LA, and the effect of mentor-initiated training on improving outcomes. METHODS: Patients' age and sex, size of tumor, preoperative diagnosis, procedure details, intra- and postoperative complications, operation time, final histological diagnosis, and length of stay of 50 consecutive cases of LA were collected through a review of hospital charts. These cases were divided into two equal consecutive groups. The first 25 cases were named Group A, and the latter 25 cases were named Group B, and two groups were compared. RESULTS: Median operation time in Group B (110 min) was significantly shorter than that in Group A (125 min) (P=0.021). Mean postoperative hospital stay in Group B (7.0 ± 2.8 days) was significantly shorter than that in Group A (10.9 ± 8.8 days) (P=0.019). Only one case (Group B) of 50 LA (2%) required a conversion to open adrenalectomy because of failure to control bleeding during dissection. CONCLUSION: Under mentor-initiated training, general surgeons with experience of more than 50 cases of laparoscopic cholecystectomies can attain favorable clinical outcomes in LA.

Natural history of a patient with malignant nonfunctioning islet cell tumor associated with unresectable multiple liver metastases.

Islet cell tumors of the pancreas are uncommon. Approximately 15% of islet cell tumors are nonfunctioning and have a higher malignancy rate than their functioning counterparts. Though, because of the rarity of malignant nonfunctioning islet cell tumors, the natural history of a patient with this tumor has not been clearly defined. We describe a young patient with unresectable malignant nonfunctioning islet cell tumor associated with multiple liver metastases. He was treated with palliative therapies to improve his quality of life, but did not undergo surgical removal of tumors or systemic chemotherapy. He survived for 46 months since laparotomy for histological diagnosis. Our findings may represent the natural history of patients with unresectable malignant nonfunctioning islet cell tumor, and suggest that palliative therapy may contribute not only to the improvement of a patients' quality of life but also the prolongation of survival.

Changes in immune-endocrine response after surgery.

The authors evaluated the relationship between hormonal and cytokine responses after surgery. Patients who underwent thoracic oesophagectomy (O group; n = 7), pulmonary lobectomy (P group; n = 5), modified mastectomy (M group; n = 5) and laparoscopic cholecystectomy (LC group; n = 7), were randomly selected. Circulating neutrophil and lymphocyte numbers were assayed. Changes in the concentration of the hormones [adrenocorticotrophic hormone (ACTH), cortisol, and antidiuretic hormone (ADH)] and cytokines [tumour necrosis factor alpha (TNF-alpha), interleukin 1 beta (IL-1 beta), IL-6, and IL-10] were analysed. In O and P groups, neutrophils were still seen on post-operative day (POD) 3, while the leukocyte counts of M and LC groups returned to normal. The number of lymphocytes significantly decreased on POD1 and POD3 only after oesophagectomy. The pattern of hormonal levels was consistent in all groups. While TNF-alpha and IL-1 beta were undetectable in the peripheral blood, the concentration of IL-6 and IL-10 increased in O and P groups, but not in M and LC groups. The degree of lymphocytepenia and neutrophilia correlated well with the extent of surgical trauma.

Hormone-cytokine response. Pneumoperitoneum vs abdominal wall-lifting in laparoscopic cholecystectomy.

BACKGROUND: Changes in blood hormone and cytokine were investigated in patients who underwent laparoscopic cholecystectomy via insufflation (CO2 group) vs those who had abdominal wall-lifting (Air group). METHODS: Seventeen female patients with cholecystolithiasis were randomly divided into two groups. Peripheral blood samples were obtained during perioperative period, and plasma hormone levels (ACTH, cortisol) and serum cytokine levels (TNFalpha, IL-1beta, IL-6, IL-10) were measured. RESULTS: The number of circulating lymphocytes significantly decreased at 1 h after surgery in both groups, but the decrease in the CO2 group was significantly smaller than that in the Air group. There was no significant difference in hormone elevation between groups. Serum concentrations of IL-6 and IL-10 in the Air group were significantly higher than in the CO2 group. CONCLUSIONS: CO2 insufflation may reduce cytokine production in laparoscopic cholecystectomy.

Study on distribution of pericyte and fluorescent granular perithelial (FGP) cell in the transitional region between arteriole and capillary in rat cerebral cortex.

BACKGROUND: The FGP (fluorescent granular perithelial) cell nominated by M. Mato were distributed around small cerebral vessels and potent in the uptake capacity. They are provided with surface antigens related to macrophage lineage. The aim of this report is to show the regional distribution of pericytes and novel perivascular cells (FGP cell) in relation to the glia limitans and basal lamina. METHODS: The perietal cortex of rat cerebrum were fixed with a mixture containing 2.5% glutaraldehyde and 2% paraformaldehyde with or without 1% tannic acid and 1% osmium tetroxide buffered with 0.1 M phosphate. The specimens were embedded in Epon 812 and cut serially and observed with the light microscope. After selecting the appropriate region of blood vessels in the sections, they were reembedded in Epon 812 and were prepared for electron microscopic observation. RESULTS: Fixatives containing tannic acid gave good results for the discrimination between the glia limitans and the basal lamina at an electron microscopical level. The FGP cells were situated in the interstices between thick basal lamina of blood vessel and thin glia limitans of astrocyte (Virchow Robin space). In the terminal part of cerebral arteriole, the vascular basal lamina abutted against the glia limitans and both laminae were fused. The basal lamina enclosing pericytes was common to endothelium and the basal lamina of capillary was assumed to be the composite of proper basal lamina and glia limitans. Subsequently, the FGP cells surround only arteriole and venule, whereas the pericytes belong to capillaries. At the boundary of arterioles and capillaries, FGP cells coexisted with pericytes and were localized at the external site of pericytes bordering with basal lamina. CONCLUSIONS: Based on these findings, the FGP cells were different from pericytes in their localization and distribution. Some roles of FGP cells in cerebral metabolism are discussed.

[Sex hormone-binding globulin in breast cancer].

Serum level of sex hormone-binding globulin (SHBG) was measured by immunoradiometric assay in fifty two breast cancer patients and twenty nine healthy female volunteers. The results are as follows: 1) Although the serum SHBG concentration showed no significant difference between the breast cancer group and the healthy control group, the serum SHBG concentration in postmenopause was significantly higher in the breast cancer group (63.8 +/- 31.2nmol/ml/ml; mean +/- S.D.) than in the healthy control group (40.1 +/- 15.4nmol/ml). 2) Subsequently in the postmenopausal breast cancer group, the serum SHBG concentration was significantly higher in the estrogen receptor (ER)-negative cancer group (97.8 +/- 12.7nmol/ml) than in the ER-positive cancer group (55.8 +/- 32.1nol/ml). 3) No significant relationships were showed between the serum SHBG concentration and obesity or serum estradiol concentration in postmenopausal patients. 4) The serum SHBG concentration showed significant decrease 3 months after radical operation for breast cancer in postmenopausal patients. These results suggest the possibility of the SHBG synthesis in breast cancer tissue.

[Hepatic hemodynamics after hepatectomy and the effect of administration of glucagon].

The effect of hepatectomy and administration of glucagon on hepatic hemodynamics were studied using mongrel dogs. The results were as follows: 1) Hepatic blood flow in the 70% hepatectomized dogs was significantly less than that in dogs subjected to sham operation or 40% hepatectomy. 2) Bolus injection of glucagon (10 micrograms/kg) increased blood flow in the hepatectomized dogs as well as that in the control dogs. The percentage increment, however, was significantly smaller in the 70% hepatectomized dogs, possibly due to little increase of portal vein blood flow. 3) Portal vein pressure and its resistance were significantly higher in the 70% hepatectomized dogs than in both the 40% hepatectomized dogs and the control dogs. 4) Although pre-sinusoidal resistance showed no significant difference among these three groups, post-sinusoidal resistance increased stepwise in the order of extent of hepatectomy. These results suggest that administration of glucagon after extended major hepatectomy is not so particularly effective in generating adequate hepatic tissue blood flow.

[A resected case of recurrent carcinoma of the right colon ten years after the initial operation].

A 59 year-old female complained of right lower abdominal mass. She underwent radical operation 10 years ago for the right colonic cancer staged Dukes C. She had passed 10 years without any sign or symptom of recurrence. She noticed a egg-sized tumor in the right lower abdomen unexpectedly one month ago when she got a bruise on that region, and then the tumor grew rapidly. Preoperative examinations, including barium enema, abdominal computerized tomography and so on, suggested a extraluminal tumor with infiltration to the colon. Laparotomy revealed that the tumor originated from the right paracolic gutter. The tumor sized 18 X 11 X 8 cm was resected and histological diagnosis was adenocarcinoma with the similar structural pattern to the initial specimen. On the basis of both operations and histological findings, we concluded that free tumor cells might be implanted in the large raw surface of the right dorsolateral abdominal wall, which was created by surgical incision at the initial operation, and subsequently appeared as a local recurrence after 10 years interval.

[Competitive binding assay with dextran-coated charcoal for measurement of sex hormone-binding globulin in breast cancer].

A simplified method for determination of the binding capacity of the sex hormone binding globulin (SHBG-BC) in human serum and its clinical application are described. This method is based on the estimation of the amount of estradiol (E2) bound with SHBG which possessed binding sites with it. After removing the endogenous steroids from the serum-samples by adsorption with dextran coated charcoal, the value of SHBG-BC increased by 18% compared with that of untreated serum. In 48 patients of various ages with breast cancer, the value of SHBG-BC (34.6 +/- 11.1; mean +/- S.D.), expressed as pico mole per 1 ml serum, did not differ significantly from that of 12 healthy control women (29.6 +/- 6.6). However, in postmenopausal women, the value of SHBG-BC in 24 patients with breast cancer (33.4 +/- 12.2) differed from that of 6 controls (26.1 +/- 4.9; p less than 0.05). In addition, estrogen receptors (ER) were measured by using gel-filtration method in cytosols from the tissue of breast cancer. The value of SHBG-BC in 15 ER-positive cases (40.4 +/- 10.1) was significantly higher than that in 13 ER-negative cases (29.3 +/- 8.7; p less than 0.01), but the value of SHBG-BC and ER did not run parallel completely.