Clinical benefits of routine examination and synchronous repair of occult inguinal hernia during laparoscopic peritoneal dialysis catheter insertion: a single-center experience.

PURPOSE: Occult inguinal hernias (IH) predispose peritoneal dialysis (PD) patients to the symptomatic IH formation after starting PD, which may cause complications. We conducted a retrospective study to assess the benefit/risk profile of routine laparoscopic examination for occult IH (RLEOH) with a synchronous repair in patients receiving PD catheter placement. METHODS: 432 patients were enrolled in this study. Patients with an internal hernia sac at all sizes were deemed to have occult IH. We retrospectively reviewed data including demographic characteristics and operative details. We also measured incidence rates of symptomatic IH, metachronous IH repair, and catheter survival over a follow-up period after starting PD. RESULTS: These patients were classified into the RLEOH group (n = 365) and the non-RLEOH group (n = 67). The RLEOH group was subdivided into occult IH with a synchronous repair (n = 17; the subgroup A), no occult IH (n = 339; the subgroup B), and occult IH without a synchronous repair (n = 9; the subgroup C). The incidence rates of symptomatic IH developed after staring PD in subgroups A, B, and C were 0, 5.6, and 22.2%, respectively, whereas that in the non-RLEOH group was 13.4%. The RLEOH group had a reduced hazard ratio for metachronous IH repair compared with the non-RLEOH group (HR = 0.426; 95% CI 0.195-0.930, p = 0.032). None of our patients suffered from herniorrhaphy-related complications. CONCLUSION: RLEOH with a synchronous repair during PD catheter insertion confers clinical benefits in reducing the risk of developing IH after starting PD and the need for a metachronous repair. This is a safe and reasonable approach.

Candida parapsilosis peritonitis complicated with infected pancreatic pseudocysts in a peritoneal dialysis patient: a challenge for nephrologists.

In continuous ambulatory peritoneal dialysis (CAPD)-related cases of fungal peritonitis, Candida parapsilosis (C. parapsilosis) has become as common as Candida albicans (C. albicans) in fungal isolates. This report describes a 74-year-old male CAPD patient who received bypass surgery for coronary artery disease, followed by an episode of bacterial peritonitis. The peritonitis was successfully treated with intraperitoneal antibiotics. However, C. parapsilosis peritonitis with concomitant pancreatitis and infected pseudocysts occurred one month later. Despite surgical drainage and intravenous administration of fluconazole, fungal peritonitis persisted. Finally, he died of nosocomial pneumonia. This case demonstrates the poor outcome of C. parapsilosis peritonitis, suggesting a more aggressive treatment in peritoneal dialysis patients.

Spleen-preserving versus spleen-sacrificing distal pancreatectomy in adults with blunt major pancreatic injury.

BACKGROUND: The aim of this study was to analyse outcomes of spleen-preserving (SPDP) and spleen-sacrificing (SSDP) distal pancreatectomy in adults with severe blunt pancreatic injuries. METHODS: This was an observational study of adult patients who underwent distal pancreatectomy for grade III or IV blunt pancreatic injury between 1991 and 2015. Outcomes of SPDP and SSDP were compared. RESULTS: Fifty-one patients were included, of whom 23 underwent SPDP and 28 SSDP. The median Injury Severity Score (ISS) was 13·0 (i.q.r. 9·0-18·0). No significant differences were observed between the groups regarding sex, trauma mechanism, shock at triage, laboratory data, location, ISS, associated injury, length of stay, mortality or morbidity. Age (27·0 versus 36·5 years; P = 0·012) and time interval from injury to distal pancreatectomy (15·0 versus 44·0 h; P = 0·022) differed significantly between SPDP and SSDP groups respectively. The mortality rate was 4 per cent (1 of 23) versus 11 per cent (3 of 28) respectively (P = 0·617). Nine patients (39 per cent) developed abdominal morbidity after SPDP, compared with 17 (61 per cent) after SSPD (P = 0·125). In the SPDP group, eight patients had grade B postoperative pancreatic fistula (POPF), two of whom required further intervention. In the SSDP group, six of ten patients with grade B POPF required CT-guided drainage, and a further five patients required reoperation for other causes. There were more reinterventions after SSDP: 11 of 28 (39 per cent) versus 3 of 23 (13 per cent) in the SPDP group (P = 0·037). CONCLUSION: SPDP was performed more often in younger patients and at a shorter interval after severe blunt pancreatic injury. SPDP was associated with fewer reinterventions.

Altered expression and distribution of heparan sulfate proteoglycans in human gliomas.

The expression of heparan sulfate proteoglycans (HSPGs) by human glioma cells was examined by biochemical and immunological methods in vitro and in vivo. Chondroitin sulfate was shown to represent the major [3H]glucosamine-labeled glycosaminoglycan synthesized by cultured normal brain cells. However, high-grade glioma-derived cells were shown to express significantly increased quantities of hyaluronic acid and heparan sulfate and approximately equal amounts of chondroitin sulfate compared with normal glial cells. To investigate further the differential expression of HSPGs, proteoglycans were isolated from glioma cells and were used as an immunogen to generate monoclonal antibodies (MAbs). One of these MAbs, 39H (an IgM), was shown to bind more to high-grade glioma-derived cells then to low-grade glioma or normal brain cells in vitro. MAb 39H was also observed to bind to isolated HSPGs but not to heparan sulfate glycosaminoglycan chains or trypsin-treated cells. Immunofluorescence staining of the cultured high-grade glioma cells revealed an intense diffuse cell surface staining pattern over the entire cell and also isolated footpads. In contrast, the low-grade tumor or normal glial cells showed a distinctive punctated staining. A similar differential staining of MAb 39H was most prominent between tissue sections of glioblastoma multiforme and anaplastic astrocytomas versus low-grade astrocytomas and normal brain. The low grade gliomas exhibited a weak punctated staining, whereas the high-grade gliomas showed significantly more intense staining, particularly along the apical regions of the cells. These results suggest that altered expression of HSPGs may be related to the malignant transformation or growth potential of glial-derived cells.

Central nervous system toxicity with high-dose Ara-C.

We evaluated the CNS complications in 118 adults with acute leukemia who received IV high-dose Ara-C therapy. Fourteen (12%) had cerebellar signs, encephalopathy, seizures, or leukoencephalopathy. Symptoms usually occurred within 24 hours after the last treatment. Patients receiving a cumulative dose in excess of 24 g/m2 had more severe or irreversible symptoms. After lower cumulative doses, symptoms often resolved even though treatment was continued. The incidence of CNS complications of high-dose Ara-C is acceptable and is potentially reversible if appropriate precautions are taken.

Brain SPECT with dipyridamole stress to evaluate cerebral blood flow reserve in carotid artery disease.

UNLABELLED: This is a preliminary study of SPECT brain scan using dipyridamole as a stress agent to assess cerebral blood flow reserve in six patients with severe carotid artery disease. METHODS: We performed SPECT scanning of the brain, with and without dipyridamole stress. Dipyridamole (0.57 mg/kg) was given intravenously 3 min before infusion of 99mTc-HMPAO. Patients were studied 30 min later using a rotating head gamma camera. The scans were analyzed qualitatively and semiquantitatively. An acetazolamide stress SPECT image was also obtained in two patients. RESULTS: All patients had at least 80% stenosis in one internal carotid artery, three of them also had contralateral carotid stenosis. The dipyridamole SPECT showed an increased region of hypoperfusion in the hemisphere ipsilateral to the severe carotid disease in four patients. That suggests poor perfusion reserve and the potential risk of regional ischemia. In four of six patients, side-to-side asymmetry increased from the baseline condition after injection of dipyridamole. The asymmetry index increased more after dipyridamole than after acetazolamide injection in two patients. CONCLUSION: This study suggests that dipyridamole stress SPECT is useful in assessing cerebral blood flow reserve. It demonstrates the region of poor vascular reserve in patients with severe carotid artery disease. Dipyridamole SPECT scans show more extensive hypoperfusion than acetazolamide in the two cases.

YC-1 potentiates nitric oxide-induced relaxation in guinea-pig trachea.

1. The effects of YC-1 (3-(5'-hydroxymethyl-2'-furyl)-1-benzylindazole) on tension, levels of cyclic GMP and cyclic AMP were investigated in guinea-pig trachea. We especially studied the combined effect of YC-1 with exogenous or endogenous nitric oxide on these parameters. 2. YC-1 at the concentration 3 or 10 microM, which caused only minor effect by itself, elicited concentration-dependent potentiation of sodium nitroprusside (SNP)-induced tracheal relaxation. This relaxation of YC-1 with SNP was reversed by ODQ. 3. Relaxant responses to electric field stimulation (EFS) in the presence of indomethacin, atropine, guanethidine, alpha-chymotrypsin and histamine were also markedly increased by YC-1 (10 microM). In the presence of L-NAME or ODQ, the relaxant effects to EFS were attenuated and the following addition of YC-1 did not further enhance relaxation. 4. YC-1 (10 microM) or SNP (0.3 microM) alone did not induce significant elevation of cyclic GMP levels in the presence of IBMX, whereas simultaneous application of both compounds markedly elevated the cyclic GMP accumulation. In contrast, the cyclic AMP levels were not altered even at the combination of YC-1 and SNP. Additionally, YC-1 also affected cyclic GMP metabolism, since it inhibited the activity of phosphodiesterase type V in human platelets. 5. YC-1 (30 microM) did not scavenge superoxide anion and had no effect on the removal of superoxide anion by superoxide dismutase in a xanthine/xanthine oxidase system. 6. In conclusion, these results indicate that although YC-1 elicits negligible relaxation of guinea-pig trachea by itself, it can potentiate the relaxant responses of exogenous or endogenous NO. This synergistic response of YC-1 is via the elevation of cyclic GMP contents.

Comparison of two soluble guanylyl cyclase inhibitors, methylene blue and ODQ, on sodium nitroprusside-induced relaxation in guinea-pig trachea.

To clarify further the role of cyclic GMP in mediating the relaxant response in guinea-pig trachea induced by sodium nitroprusside (SNP), the effects of soluble guanylyl cyclase inhibitors, methylene blue and 1H-[1,2,4]oxadiazolo[4,3,-a]quinoxalin-1-one (ODQ) on SNP-induced muscle relaxation and cyclic GMP accumulation were determined. SNP (0.3-100 microM) evoked a concentration-dependent relaxation of guinea-pig isolated tracheas precontracted with 0.3 microM carbachol. Preincubation of the preparations with methylene blue (10, 30 and 100 microM) resulted in a slight but concentration-dependent prevention of the relaxant response to SNP. In contrast, the relaxation to SNP was extensively prevented by 3 microM ODQ and almost abolished by 10 microM ODQ. SNP (30 microM) induced a significant elevation of cyclic GMP accumulation (from 1.34+/-0.14 to 5.39+/-0.28 pmol mg(-1) protein, n= 5; P<0.001), which was partially attenuated by 100 microM methylene blue (3.11+/-0.51 pmol mg(-1) protein, n=5; P<0.05), whereas completely abolished by 10 microM ODQ (1.31+/-0.28 pmol mg(-1) protein, n = 5; P<0.001). Methylene blue, but not ODQ and Nomega-nitro-L-arginine methyl ester (L-NAME), caused a concentration-dependent contraction in the tracheal preparation. The tension produced by 100 microM methylene blue was 41.8+/-4.3% (0.3 microM carbachol as 100%; n = 12). Moreover, the non-selective muscarinic receptor antagonist atropine and the M3-selective antagonist 4-diphenylacetoxy-N-methylpiperidine methiodine greatly inhibited the contractile effect evoked by methylene blue (100 microM). In conclusion, this study provides substantial evidence that SNP-induced muscle relaxation in guinea-pig trachea is completely via a cyclic GMP-dependent mechanism. Furthermore, ODQ, but not methylene blue, will likely become an important tool in differentiating between cyclic GMP-dependent and -independent effects of nitric oxide.

YD-3, a novel inhibitor of protease-induced platelet activation.

1. In the present study, the antiplatelet effects and mechanisms of a new synthetic compound YD-3 [1-benzyl-3(ethoxycarbonylphenyl)-indazole] were examined. 2. YD-3 inhibited the aggregation of washed rabbit platelets caused by thrombin (IC(50)=28.3 microM), but had no or little inhibitory effect on that induced by arachidonic acid, collagen, platelet-activating factor (PAF) or U46619. YD-3 also suppressed generation of inositol phosphates caused by thrombin. On the other hand, thrombin-induced fibrin formation was not affected by YD-3, indicating YD-3 does not inhibit the proteolytic activity of thrombin. 3. In washed human platelets, however, YD-3 had only mild inhibitory effect on the low concentration (0.05 u ml(-1)) of thrombin-induced human platelet aggregation, and did not affect that induced by higher concentrations (> or =0.1 u ml(-1)) of thrombin or SFLLRN, the protease-activated receptor 1 (PAR1) agonist peptide. By contrast, YD-3 inhibited both human and rabbit platelet aggregation elicited by trypsin with IC(50) values of 38.1 microM and 5.7 microM, respectively. 4. YD-3, at 100 microM, had no effect on ristocetin-induced glycoprotein Ib (GPIb)-dependent aggregation of human platelets. In addition, platelets treated with chymotrypsin, which cleaves GPIb, enhanced rather than attenuated the inhibition of YD-3 on thrombin-induced human platelet aggregation. These data indicate that GPIb plays no role in the antiplatelet effect of YD-3. 5. In SFLLRN-desensitized human platelets, high concentration of thrombin (1 u ml(-1)) could still elicit intracellular Ca(2+) mobilization, and the rise of [Ca(2+)](i) was prevented by either leupeptin or YD-3. 6. Our results suggest that YD-3 inhibits a non-PAR1 thrombin receptor which mediates the major effect of thrombin in rabbit platelets, but in human platelets, this receptor function becomes significant only when the function of PAR1 has been blocked or attenuated.

Vaninolol: a new selective beta 1-adrenoceptor antagonist derived from vanillin.

The beta-adrenoceptor blocking properties of vaninolol ((+/-)4-[4'-(2-hydroxy-3-tert-butyl-aminopropoxy)-3'-methoxyphenyl]- 3-buten-2-one), derived from vanillin, were first investigated under in vivo and in vitro conditions. Vaninolol (0.1, 0.5, 1.0 mg/kg, i.v.), as well as propranolol, produced a dose-dependent bradycardia response and a sustained pressor action in urethane-anesthetized normotensive rats. Vaninolol inhibited the tachycardia effects induced by (-)isoproterenol, but had no blocking effect on the arterial pressor responses induced by phenylephrine. These findings suggested that vaninolol possessed beta-adrenergic blocking activity, but was without alpha-adrenergic blocking activity. In isolated guinea-pig tissues, vaninolol antagonized (-)isoproterenol-induced positive inotropic and chronotropic effects of the atria and tracheal relaxation responses in a concentration-dependent manner. The parallel shift to the right of the concentration-response curve of (-)isoproterenol suggested that vaninolol was a beta-adrenoceptor competitive antagonist. The effect of vaninolol was more potent on the atria than on tracheal tissues, indicating it had some beta 1-adrenoceptor selectivity. On the other hand, the order of the hydrophilicity was atenolol >> vaninolol > propranolol. In addition, vaninolol had a mild direct cardiac depression at high concentrations and was without intrinsic sympathomimetic activity (ISA). Furthermore, binding characteristics of vaninolol and other beta-adrenoceptor antagonists were evaluated in [3H]dihydroalprenolol binding to guinea-pig ventricular membranes. The order of potency of beta-adrenoceptor antagonists in competing for the binding sites was (-)propranolol >> vaninolol > or = atenolol. In conclusion, vaninolol was found to be a selective beta 1-adrenoceptor antagonist with relatively low lipophilicity in comparison with propranolol, devoid of ISA, and had a mild myocardial depressant effect.

Changes in inositol 1,4,5-triphosphate binding in microsomal fractions from the rat liver during sepsis.

Inositol 1,4,5-triphosphate has been proposed as a second messenger for calcium mobilization. The addition of inositol 1,4,5-triphosphate at a low concentration has been shown to cause calcium release from intracellular microsomal stores in rat hepatocytes. The effects of sepsis on the inositol 1,4,5-triphosphate binding from microsomal fractions of rat liver were investigated. Sepsis was induced by cecal ligation and puncture (CLP). Control rats were sham operated. Three microsomal fractions (rough, intermediate, and smooth I) were isolated from the rat liver. The study of inositol 1,4,5-triphosphate receptor binding was performed with tritium-labeled inositol 1,4,5-triphosphate. Our results showed that the Bmax of inositol 1,4,5-triphosphate binding in early septic, late septic, and control groups was 14.9 +/- .9 fmol/mg, 9.8 +/- 1.0 fmol/mg, and 17.2 +/- 1.3 fmol/mg, respectively. The binding activity was unaffected during early sepsis but was significantly depressed by 40-50% (p < .05, vs. control) during late sepsis (18 h after CLP) in all three subfractions of endoplasmic reticulum. Because the inositol 1,4,5-triphosphate binding plays an important role in the regulation of intra-cellular calcium homeostasis in hepatocytes, an impairment of the calcium release due to depressed inositol 1,4,5-triphosphate binding in the endoplasmic reticulum may have a pathophysiological significance in contributing to altered hepatic metabolism during septic shock.

Leukocyte-endothelial adherence correlates with pancreatic nitric oxide production in early cerulein-induced pancreatitis in rats.

The role of nitric oxide (NO) in microcirculation during the development of acute pancreatitis was not clear. An in vivo microscopic technique was used for evaluating leukocyte-endothelial adherence in the pancreatic microcirculation after induction (cerulein) of acute pancreatitis. Microdialysis was performed to detect pancreatic nitrate concentration (NO level) by high-performance liquid chromatography. Cerulein caused significantly reduced flow velocity in 1 h (31 %) and increased the number of sticking leukocytes in 2 h; both persisted for at least 3 h. Pancreatic NO level was found to be significantly elevated (2.5-fold) in 1 h and also persisted for 3 h. Both microcirculatory changes and NO elevation were significantly alleviated in cerulein-induced animals pretreated with NO synthase inhibitor (NG-nitro-L-arginine), indicating that elevation of NO could precede and account for a major portion of the observed microcirculatory changes. Furthermore, there was a strong positive correlation between numbers of adherent leukocytes and pancreatic NO level, suggesting that during the development of acute pancreatitis, NO could play an adverse role in microcirculation.

Neutrophil elastase inhibitor (ONO-5046) attenuates reperfusion-induced hepatic microcirculatory derangement, energy depletion and lipid peroxidation in rats.

UNLABELLED: Microcirculatory derangement, energy depletion, and lipid peroxidation are associated with the development of ischemia-reperfusion injury in the liver. This study investigated the effects of a neutrophil elastase inhibitor (ONO-5046) on hepatic ischemia-reperfusion injury. Adult, male Sprague-Dawley rats were divided into four treatment groups: 1) sham-operated control (laparotomy only, no ischemia) and saline injection (1 mL/kg), n = 6; 2) ischemia control (1-h ischemia, 2-h reperfusion) and saline injection (1 mL/kg), n = 6; 3) intravenous injection with ONO-5046 at a dose of 1 mg/kg 5 min before ischemia and immediately after reperfusion plus 1-h ischemia and 2-h reperfusion, n = 6; and 4) intravenous injection with ONO-5046 at a dose of 10 mg/kg 5 min before ischemia and immediately after reperfusion plus 1-h ischemia and 2-h reperfusion, n = 6. A laser-Doppler flowmeter and in vivo microscopy were used to investigate hepatic microcirculation. Tissue malondialdehyde (MDA) and adenosine triphosphate (ATP) levels were determined at the end of the experiment. RESULTS: Compared with ischemia alone, ONO-5046 significantly reduced the extent of microcirculatory and hemodynamic derangement after ischemia-reperfusion. ONO-5046 at both doses significantly attenuated decreases in mean arterial pressure. ONO-5046 lessened adherent leukocyte count and improved flow velocity in the sinusoids and postsinusoidal venules. ONO-5046 at the dose of 10m/kg reduced MDA (1.97 +/- 0.54 micromol/g protein vs. 3.58 +/- 1.21 micromol/g protein in the ischemia and reperfusion group) and increased ATP levels (2.62 +/- 0.19 micromol/g wet wt vs. 0.57 +/- 0.37 pmol/g wet wt in the ischemia and reperfusion group), whereas ONO-5046 at a smaller dose (1 mg/kg) had lesser but significant effects on MDA and ATP alterations. This study demonstrates that treatment with ONO-5046, a neutrophil elastase inhibitor, can ameliorate ischemia-reperfusion injury of the rat liver.

Effects of intravenous fat emulsion on respiratory failure.

The effects of intravenous fat emulsion on ventilated normal, diseased or distressed lungs were studied. Forty-eight patients with different types of respiratory failure were divided into four groups. Group A was composed of the patients with a normal lung condition; group B, patients with infectious pulmonary condition and respiratory failure; group C, patients with COPD and respiratory failure; and, group D was composed of the patients with ARDS due to various causes. Five hundred milliliters of 10 percent fat emulsion was infused within 4 h as partial parenteral nutritional support. We concluded that intravenous fat infusion decreased PaO2/FIO2 and increased P(A-a)O2 and intrapulmonary shunt in the patients with ARDS, while it had little effect on the patients with infectious pulmonary disease or COPD. The infusion of fat emulsion had positive effects on the patients with normal lung condition with increased PaO2/FIO2 and decreased P(A-a)O2 and shunt.

Flow cytometric DNA analysis of hepatocellular carcinoma: preliminary report.

Flow cytometric DNA analysis was performed in 50 paraffin-embedded specimens of clinical hepatocellular carcinoma (HCC) after hepatic resections. The DNA distribution pattern was classified in two types, diploid and aneuploid, according to the degree of dispersion on the DNA histogram. The major DNA pattern of HCC in this report proved to be aneuploid (78%), although 22% of tumors revealed a diploid pattern. The serum alpha-fetoprotein level exceeded 40 ng/ml in 86.1% of the aneuploid tumors and in 13.9% of the diploid tumors (p less than 0.05). We found no correlation between DNA distribution and hepatitis B surface antigen positivity, the presence of liver cirrhosis or tumor size. Additionally we noted no significant correlation between the DNA pattern and survival rates in patients with HCC who underwent hepatic resection.

Changes of adenosine triphosphate-dependent calcium uptake in microsomal fractions of rat liver during sepsis.

BACKGROUND: Intracellular calcium concentration is an important regulator of cellular metabolism. Endoplasmic reticulum membranes play an important role in the regulation of cytoplasmic calcium in the mammalian liver. The characterization of the changes of calcium uptake in endoplasmic reticulum may contribute to the potential intracellular mechanisms for cellular dysfunction during sepsis. METHODS: The effects of sepsis on the calcium uptake in rough endoplasmic reticulum of rat liver were studied. Sepsis was induced by means of cecal ligation and puncture (CLP). The control rats underwent sham operation. Microsomal fractions were isolated from the liver with differential centrifugation. RESULTS: The calcium uptake by liver endoplasmic reticulum was decreased by 30% to 35% (p < 0.05) during early sepsis (9 hours after CLP) and by 38% to 43% (p < 0.05) during late sepsis (18 hours after CLP), respectively. The maximum velocity values for adenosine triphosphate (ATP) and for Ca2+ were also decreased by 25% to 37% (p < 0.05) during early sepsis and by 35% to 42% (p < 0.05) during late sepsis. The Michaelis-Menten constant for ATP and Ca2+ transport had no difference among three groups. The magnesium stimulation and vanadate inhibitory activity were also decreased by 17% to 38% (p < 0.05) during early sepsis and by 34% to 50% (p < 0.05) during late sepsis. CONCLUSIONS: These data demonstrate that ATP-dependent calcium uptake in rough endoplasmic reticulum of rat liver was impaired during early and late sepsis. Because the low intracellular calcium concentration plays an important role in the regulation of cellular function, an impairment in the ATP-dependent calcium uptake by endoplasmic reticulum during early and late sepsis may have a pathophysiologic significance in contributing to the development of altered hepatic metabolism during sepsis.

Surgical treatment of hepatolithiasis: long-term results.

BACKGROUND: Hepatolithiasis is a common disease in East Asia and is prevalent in Taiwan. Surgical and nonsurgical procedures for management of hepatolithiasis have been discussed, but long-term follow-up results of surgical treatment of hepatolithiasis are rarely reported. METHODS: We conducted a retrospective study of case records of patients with hepatolithiasis who underwent surgical or nonsurgical percutaneous transhepatic cholangioscopy treatment. Of 614 patients with hepatolithiasis seen between January 1984 and December 1988, 427 underwent follow-up after surgical (380) or percutaneous transhepatic cholangioscopy (47) treatment for 4 to 10 years and constituted the basis of this study. RESULTS: Long-term results of 427 patients with hepatolithiasis after surgical and nonsurgical treatment within 4 to 10 years of follow-up were recurrent stone rate 29.6% (105 of 355), repeated operation 18.7% (80 of 427), secondary biliary cirrhosis 6.8% (29 of 427), late development of cholangiocarcinoma 2.8% (12 of 427), and mortality rate 10.3% (44 of 427). The patients with hepatectomy had a better quality of life (symptom-free) with a lower recurrent stone rate (9.5%), lower mortality rate (2.1%), and lower incidence of secondary biliary cirrhosis (2.1%) and cholangiocarcinoma (0%) than did the nonhepatectomy group (p < 0.01). The patients without residual stones after choledochoscopy had a better quality of life than did the residual stone group (p < 0.01). CONCLUSIONS: Long-term follow-up study of hepatolithiasis after surgical treatment revealed a high recurrent stone rate (29.6%) that required repeated surgery and a high mortality rate (10.3%) resulting from repeated cholangitis, secondary biliary cirrhosis, and late development of cholangiocarcinoma. Patients who received hepatectomy or without residual stones after choledochoscopy had a good prognosis and quality of life.

Contrast-enhanced dynamic computed tomography does not aggravate the clinical severity of patients with severe acute pancreatitis: reevaluation of the effect of intravenous contrast medium on the severity of acute pancreatitis.

BACKGROUND: Contrast-enhanced abdominal computed tomography (CT) is useful in demonstrating pancreatitis necrosis, but the administration of contrast medium in animal models with acute pancreatitis may worsen the severity. HYPOTHESIS: The use of contrast-enhanced CT in clinical patients with acute pancreatitis may actually aggravate the severity of the disease. DESIGN: A randomized prospective study. SETTING: Chang Gung Memorial Hospital, Taipei, Taiwan. PATIENTS: Twenty patients with severe acute pancreatitis were randomly divided into 2 groups. Those in group A (n = 10) underwent a CT examination with a contrast-enhanced medium, and those in group B (n = 10) underwent a CT examination without a contrast-enhanced medium. MAIN OUTCOME MEASURES: The patients' serum amylase, lipase, C-reactive protein, leukocyte, glutamicoxaloacetic transaminase, creatinine, calcium, and phosphate levels were serially checked before the CT examination and at 2, 4, 6, 8, 12, and 24 hours after the examination was performed. The biochemical data between the 2 groups were compared. The morbidity, length of stay, and mortality were also compared. RESULTS: There were no significant changes in the level of pancreatic enzymes, C-reactive proteins, and leukocytes and in the biochemical data of either group before or after the CT examination. The difference in the previously examined values between the 2 groups was also not significant. There was also no difference in the morbidity, length of hospital stay, and mortality between the 2 groups. CONCLUSION: Contrast-enhanced abdominal CT does not aggravate the severity of clinical patients with severe acute pancreatitis.

Upper gastrointestinal tract ablation for patients with extensive injury after ingestion of strong acid.

OBJECTIVE: Extensive corrosive injury involving the structures beyond the pylorus caused by ingestion of strong acid has a poor prognosis. We reviewed six cases of patients who underwent total upper gastrointestinal tract ablation to see the effect of this extensive procedure for such an injury. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Six patients who ingested more than 250 mL of 20N hydrochloric acid were treated in the Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China, from 1986 to 1992. RESULTS: Three patients with preoperative metabolic acidosis and renal failure died of multiple organ failure within the first postoperative month. The other three patients survived the acute stage. While being readied for a late reconstructive procedure, sepsis developed in one patient due to cholecystostomy leakage about 1 year postoperatively. Another patient died of respiratory failure after development of aspiration pneumonia due to poor drainage of a spit fistula, after surviving for 6 months. Only one patient had a good recovery following a full reconstruction procedure and restoration of the continuity of the gastrointestinal tract. CONCLUSIONS: Three of six patients died in the hospital. The risk factors were preoperative metabolic acidosis, renal failure, and an upper jejunal resection greater than 100 cm in length. Early and aggressive approaches to resect all the necrotic tissue certainly provide good chances to survive the acute stage and later reconstruction.

Resection of hepatocellular carcinoma after transcatheter arterial embolization. Reevaluation of the advantages and disadvantages of preoperative embolization.

Hepatocellular carcinomas (HCCs) were resected in eight patients who had preoperative transcatheter arterial embolization (TAE) and in 25 patients without preoperative TAE. Three patients in the former group had ruptured HCCs before operation. Two of the former group and three of the latter group were found to have recurrences after a follow-up of 1 1/2 years. Although preoperative TAE resulted in significantly increased tumor necrosis, it increased the risk of gangrenous change of the gallbladder, induced adhesion of the hepatoduodenal ligament, and was not effective in reducing operative blood loss or operative time if the vessel selected for TAE was inadequate. Pathologic examination revealed tumor emboli still existing in the intrahepatic veins. Daughter nodules and capsular invasion by tumor cells were not affected by TAE. Transcatheter arterial embolization seems to be effective in controlling bleeding from ruptured HCC prior to staged resection of the tumor.