CDH1 polymorphisms and haplotypes in sporadic diffuse and intestinal gastric cancer: a case-control study based on direct sequencing analysis.

BACKGROUND: Findings related to the influence of the -160C → A promoter polymorphism and haplotypes of the E-cadherin (CDH1) gene have not been consistent in previous studies regarding the risk for sporadic gastric cancer. Investigators in most previous studies detected those genotypes using restriction fragment length polymorphism analysis. Therefore, we conducted a case-control study to investigate the association of the CDH1 - 160C → A promoter polymorphism and haplotypes for cancer risk related to sporadic diffuse and intestinal gastric cancer by direct sequencing analysis. METHODS: We included 107 diffuse gastric cancer cases, 60 intestinal gastric cancer cases and 134 controls. The genotypic polymorphisms in the -160 promoter region, exons and intron-exon boundaries of CDH1 were detected by direct sequencing analysis. Genotype frequencies were compared. The CDH1 - 160C → A promoter polymorphism and four polymorphisms (48 + 6 T → C, 2076C → T, 2253C → T and 1937-13 T → C) were included in the haplotype analyses, which were estimated using the expectation-maximization algorithm. RESULTS: Compared to controls, the frequency of the -160A allele was significantly higher in diffuse gastric cancer cases (P = 0.005), but it was not significantly different in intestinal gastric cancer cases (P = 0.119). Two sets of three-marker haplotypes (-160C → A, 48 + 6 T → C, 2076C → T and -160C → A, 1937-13 T → C, 2253C → T) were associated with the risk of diffuse gastric cancer (P = 0.011 and P = 0.042, respectively). CONCLUSION: Based on direct sequencing analysis, our findings suggest that the CDH1 - 160C → A promoter polymorphism and haplotypes play significant roles in cancer risk for sporadic diffuse gastric cancer, but not for intestinal gastric cancer, in a Taiwanese population.

[Ultraviolet-visible spectrometry analysis of insoluble xanthate heavy metal complexes].

A ultraviolet-visible spectrometry method of determining insoluble xanthate heavy metal complexes in flotation wastewater was the first time to be put forward. In this work, the changes of ultraviolet-visible spectra of xanthate solution after the addition of various heavy metal ions were investigated firstly. It was found that Pb2+ and Cu2+ can form insoluble complexes with xanthate, while Fe2+, Zn2+ and Mn2+ have little effect on the ultraviolet absorption of xanthate solution. Then the removal efficiencies of filter membrane with different pore sizes were compared, and the 0.22 µm membrane was found to be effective to separate copper xanthate or lead xanthate from the filtrate. Furthermore, the results of the study on the reaction of sodium sulfide and insoluble xanthate heavy metal complexes showed that S(2-) can release the xanthate ion quantitatively from insoluble complexes to solution. Based on the above research, it was concluded that the amount of insoluble xanthate heavy metal complexes in water samples can be obtained through the increase of free xanthate in the filtrate after the addition of sodium sulfide. Finally, the feasibility of this method was verified by the application to the analysis of flotation wastewater from three ore-dressing plants in the Thirty-six Coves in Chenzhou.

Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations.

BACKGROUND: We investigated the analgesic efficacy of bilateral superficial cervical plexus block in patients undergoing thyroidectomy and to determine whether it reduces the adverse effects of general anesthesia. METHODS: We prospectively recruited 162 patients who underwent elective thyroid operations from March 2006 to October 2007. They were randomly assigned to receive a bilateral superficial cervical block (12 ml per side) with isotonic saline (group A; n = 56), bupivacaine 0.5% (group B; n = 52), or levobupivacaine 0.5% (group C; n = 54) after induction of general anesthesia. The analgesic efficacy of the block was assessed with: intraoperative anesthetics (desflurane), numbers of patients needing postoperative analgesics, the time to the first analgesics required, and pain intensity by visual analog scale (VAS). Postoperative nausea and vomiting (PONV) for 24 h were also assessed by the "PONV grade." We also compared hospital stay, operative time, and discomfort in swallowing. RESULTS: There were no significant differences in patient characteristics. Each average end-tidal desflurane concentration was 5.8, 3.9, and 3.8% in groups A, B, and C, respectively (p < 0.001). Fewer patients in groups B and C required analgesics (A: B: C = 33:8:7; p < 0.001), and it took longer before the first analgesic dose was needed postoperatively (group A: B: C = 82.1:360.8:410.1 min; p < 0.001). Postoperative pain VAS were lower in groups B and C for the first 24 h postoperatively (p < 0.001). Incidences of overall and severe PONV were lower, however, there were not sufficient numbers of patients to detect differences in PONV among the three groups. Hospital stay was shorter in group B and group C (p = 0.011). There was no significant difference in operative time and postoperative swallowing pain among the three groups. CONCLUSIONS: Bilateral superficial cervical plexus block reduces general anesthetics required during thyroidectomy. It also significantly lowers the severity of postoperative pain during the first 24 h and shortens the hospital stay.

Experience with reversed L-shaped incision for right hemicolectomy combined with liver resection.

BACKGROUND: Various types of incisions have been applied in simultaneous resections of colorectal cancer and synchronous liver metastases. We describe our experience with the reversed L-shaped incision for simultaneous right hemicolectomy and liver resection. METHODS: We applied the reversed L-shaped incision in nine patients who underwent simultaneous right hemicolectomy and right liver resection or left hepatectomy. A reversed L-shaped incision of the abdomen was consisted of midline and transverse incisions with the junction of the umbilicus. The operative field was kept open using Kent retractors. First, right colon mobilization was performed easily and right hemicolectomy was performed. Subsequently, liver mobilization with identification of hepatic vessels was achieved and right liver resection or left hepatectomy was performed. RESULTS: The reversed L-shaped incision successfully provided a good and rapid exposure in nine patients. There were no complications, such as wound infection, lung atelectasis/pneumonia, or incisional hernia, in patients with the reversed L-shaped incision. CONCLUSIONS: Our preliminary experience demonstrated that the reversed L-shaped incision might be a good choice in a subset of patients with simultaneous right hemicolectomy and right liver resection or left hepatectomy. However, a large, prospective, controlled study comparing different incision types in the same procedure with variables, such as operating time, postoperative pain scores, patient's satisfaction, and postoperative complication, is needed to support the benefit of the reversed L-shaped incision.

Transection of the esophagus is optional in the Modified Sugiura procedure.

BACKGROUND/AIMS: Esophageal transection in the Modified Sugiura procedure is advocated by some authors, but considered unnecessary by others. We compared the effectiveness of the Modified Sugiura procedure to our simplified Sugiura procedure that omits esophageal transection for the emergency treatment of bleeding esophagogastric varices. METHODOLOGY: From January 1999 to September 2004 we treated 51 patients with cirrhosis of the liver and bleeding esophagogastric varices. All patients had failed management with emergency endoscopy treatment or balloon tamponade with vasopressin infusion. The patients were randomly divided into two groups and underwent the Modified Sugiura procedure with or without esophageal transections. RESULTS: There were no significant differences in age, gender, cause of cirrhosis, or Child-Pugh classification between the two groups. The preoperative hemoglobin levels, preoperative and intraoperative transfusion volume, mortality, morbidity, and days of hospitalization showed no significant differences between the groups. The operative time was shorter with the simplified Sugiura procedure. The 1-3 year survival rates and the rebleeding rates did not differ significantly between the two groups. CONCLUSION: Both treatments are effective emergency procedures for bleeding esophagogastric varices. Our simplified Sugiura procedure is an effective treatment for bleeding esophagogastric varices and requires a shorter operating time than the Modified Sugiura procedure.

Therapeutic strategies for pancreatic pseudocysts: experience in Taiwan.

BACKGROUND/AIMS: A retrospective study of Chinese patients with pancreatic pseudocysts to compare the results between non-conservative and conservative treatments, and the use of serial serum amylase and imaging in monitoring treatment success. METHODOLOGY: One hundred and sixty-two pseudocyst patients, treated between 1974 and 2003, were divided into two groups, conservative treatment and interventions (percutaneous needle drainage, internal drainage, or resection), and treatment results for these groups compared. RESULTS: Ninety-one cases (56%) showed spontaneous pseudocyst resolution (mean duration to resolution, 33.4 days). Pseudocyst size was less than 5cm in 86 of these cases (94.5%). Excellent symptomatic responses after aggressive treatment were noted in 68 of 71 patients (93.1%) with pseudocysts larger than 5 cm. All percutaneous tube drainage patients had pseudocyst resolution when the pseudocyst size was less than 5 cm. Hyperamylasemia was noted in 114 cases (70.4%) at diagnosis and returned to normal range in those patients whose cysts underwent spontaneous resolution or who had successful operations. CONCLUSIONS: Pancreatic pseudocysts smaller than 5 cm should have conservative treatment or percutaneous needle drainage. Larger pseudocysts should be treated aggressively. Serum amylase and ultrasound examinations are important to evaluate the occurrence of spontaneous resolution or the need for surgical intervention.

Knot formation in the feeding jejunostomy tube: a case report and review of the literature.

Jejunostomy feeding tubes provide surgeons with an excellent method for providing nutritional support, but there are several complications associated with a tube jejunostomy, including complications resulting from placement of the tube, mechanical problems related to the location or function and development of focally thickened small-bowel folds. A 76-year old man who presented with multiple medical diseases was admitted to our hospital due to aspiration pneumonia with acute respiratory failure and septic shock. He underwent exploratory laparotomy with feeding jejunostomy using a 14-French nasogastric tube for nutritional support. However, occlusion of the feeding tube was found 30 d after operation, and a rare complication of knot formation in the tube occurred after a new tube was replaced. On the following day, the tube was removed and replaced with a similar tube, which was placed into the jejunum for only 15 cm. The patient's feedings were maintained smoothly for two months. Knot formation in the feeding tube seems to be very rare. To our knowledge, this is the third case in the literature review. Its incidence is probably related to the length of the tube inserted into the lumen.

Mechanisms inactivating the gene for E-cadherin in sporadic gastric carcinomas.

AIM: To study the role of CDH1/E-cadherin (E-cad) gene alteration profiles including mutation, loss of heterozygosity (LOH), promoter polymorphism and hypermethylation in mechanisms of CDH1 inactivation in gastric carcinoma (GC). METHODS: Specimens were collected surgically from 70 patients with GC. Allelotyping PCR and detection of LOH, denaturing high pressure liquid chromatography and DNA sequencing, restriction fragment length polymorphism analysis, methylation specific PCR, and immunohistochemical staining were used. RESULTS: Promoter polymorphism was not a major mechanism of E-cad inactivation. Only one truncating mutation was found in a diffuse type tumor (3%). Both LOH and promoter hypermethylation were major mechanisms of E-cad inactivation, but interestingly, there was a negative association between the fraction of allelic loss (LOH) in tumors and hypermethylation of CDH1. Therefore LOH and hypermethylation were two different tumorigenic pathways involved in GC. CONCLUSION: Given the findings that somatic mutation was extremely low and the relationship between LOH and hypermethylation was inverse, any two combinations of these three factors cannot fulfill the classical two-hit hypothesis of CDH1 inactivation. Thus, other mechanisms operating at the transcriptional level or at the post-translational level might be required to induce E-cadherin inactivation.

Anti-proliferative activity of Bupleurum scrozonerifolium in A549 human lung cancer cells in vitro and in vivo.

Nan-Chai-Hu, the root of Bupleurum scorzonerifolium, is a traditional Chinese herb used in treatment of liver diseases such as hepatitis and cirrhosis. We recently reported that the acetone extract of B. scorzonerifolium (BS-AE) could inhibit proliferation and induce apoptosis in A549 human lung cancer cells. We further examined its anti-proliferative mechanisms and in vivo anticancer effect. Our results showed that BS-AE had the ability to cause cell cycle arrest in G2/M phase, inducing tubulin polymerization, and activating caspase-3 and -9 in A549 cells. BS-AE-induced apoptosis could be blocked by the broad caspase inhibitor z-VAD-fmk in majority. The result of in vivo study showed that BS-AE could suppress growth in A549 subcutaneous xenograft tumors. These results indicate that BS-AE exerts antiproliferative effects on A549 cells in vitro and in vivo, and prompted us to further evaluate and elucidate the chemical composition profile of BS-AE.

Small-bowel perforation caused by fish bone.

A diagnosis of small-bowel perforation, caused by a sharp or pointed foreign body, is rarely made preoperatively because the clinical symptoms are usually nonspecific and can mimic other surgical conditions, such as appendicitis and diverticulitis. We report the case of a 62-year-old woman who experienced severe pain in the right iliac fossa and fever for about five days before arrival at our hospital. The presumptive diagnosis was acute purulent appendicitis and an emergency appendectomy was planned. Swelling and erythema were noted in a segment of the small bowel in the lower right abdomen. A tiny pointed object was found penetrating the inflamed portion of the bowel, which proved to be a sharp fish bone (gray snapper). The bone was removed, followed by segmental resection of the terminal ileum and ascending colon. The postoperative course was uneventful.

Effect of water-soluble contrast in colorectal surgery: a prospective randomized trial.

AIM: Postoperative gastrointestinal-tract motility is normally delayed. Early feeding after colorectal surgery has been reported recently, but late feeding is common. Gastrografin not only enhances bowel peristalsis, but also decreases bowel-wall edema. Whether contrast medium allows early oral feeding and reduces the duration of hospitalization requires clarification. METHODS: Fifty patients underwent elective colorectal surgery in a regional medical center. Patients were prospectively randomized into a Gastrografin group or control group (n = 25 each). Patients in the Gastrografin group began their feeding schedule with 100 mL of 5% dextrose water with 100 mL of Gastrografin on postoperative d 3 and were advanced to a full liquid diet when the contrast reached the colon in 4 h. Patients in the control group began their feeding schedule with 200 mL of 5% dextrose water on postoperative d 3 and were advanced to a full liquid diet after the passage of flatus and stool. Nasogastric tubes were inserted for persistent postoperative vomiting. Fullness, nausea, vomiting, complications, time of anesthesia, time of operation, time of mobilization, time of oral feeding, and duration of hospital stay were recorded and analyzed with Student's t-test. RESULTS: In the Gastrografin group, one patient had aspiration pneumonia and one patient had anastomotic leakage resulting in sepsis and eventual death. This mortality was excluded from the subsequent statistical analysis. In the control group, two patients had wound infections. There was no significant difference between the two groups at the time of anesthesia, time of operation, or time of mobilization. There were significant differences between the two groups in the time of oral feeding (3.3+/-0.3 d in the Gastrografin group vs 4.8+/-0.4 d in the control group; P = odds ratio--, 95%CI [-0.5 to +0.7 d]) and in the length of hospital stay (7.6+/-1.1 d in the Gastrografin group vs 10.2+/-1.3 d in the control group; P = odds ratio--, 95% CI [-1.2 to +1.4 d]). CONCLUSION: Gastrografin not only allowed early oral feeding but also reduced the duration of hospitalization after elective colorectal surgery.

Intrauterine contraceptive device appendicitis: a case report.

Uterine perforation is one of the serious complications associated with use of the intrauterine contraceptive device (IUD). Uterine perforation by IUD can involve several neighboring organs. A case of acute appendicitis was caused by a Multiload Cu 375 IUD inserted previously. This is a rare complication and only fourteen previous cases were recorded in the literature.

Diverticulosis of the jejunum with intestinal obstruction: A case report.

A diagnosis of intestinal diverticulosis is difficult to make pre-operatively because the clinical symptoms are usually non-specific. We report the case of a 70-year-old man who had suffered from three episodes of intestinal obstruction in 1 year. He experienced dull pain and a sensation of fullness over the whole abdomen. The symptoms did not improve after conservative treatment. The presumptive diagnosis was intestinal obstruction, and an exploratory laparotomy found diverticulosis of the proximal jejunum, with an adhesion band formed from the base of one diverticulum. Strangulation of a segment of the jejunum resulted from the internal herniation caused by the band. The band was removed and the proximal jejunum segmentally resected. His postoperative course was uneventful.

Preventing prolonged post-operative ileus in gastric cancer patients undergoing gastrectomy and intra-peritoneal chemotherapy.

AIM: To assess the efficacy of metoclopramide (Met) for prevention of prolonged post-operative ileus in advanced gastric cancer patients undergoing D2 gastrectomy and intra-peritoneal chemotherapy (IPC). METHODS: Thirty-two advanced gastric cancer patients undergoing D2 gastrectomy and IPC were allocated to two groups. Sixteen patients received Met immediately after operation (group A), and 16 did not (group B). Another 16 patients who underwent D2 gastrectomy without IPC were enrolled as the control group (group C). All patients had received epidural pain control. The primary endpoints were time to first post-operative flatus and time until oral feeding with a soft diet without discomfort. Secondary endpoints were early complications during hospitalization. RESULTS: Gender, the type of resection, operating time, blood loss, tumor status and amount of narcotics were comparable in the three groups. However, the group C patients were older than those in groups A and B (67.5+/-17.7 vs 56.8+/-13.2, 57.5+/-11.7 years, P = 0.048). First bowel flatus occurred after 4.35+/-0.93 d in group A, 4.94+/-1.37 d in group B, and 4.71+/-1.22 d in group C (P>0.05). Oral feeding of a soft diet was tolerated 7.21+/-1.92 d after operation in group A, 10.15+/-2.17 d in group B, and 7.53+/-1.35 d in group C (groups A and C vs group B, P<0.05). There was no significant difference in respect to the first flatus among the three groups. However, the time of tolerating oral intake with soft food in groups A and C patients was significantly shorter than that in group B patients. Levels of C-reactive protein (CRP) were significantly lower in group C and there was a more prominent and prolonged response in CRP level in patients undergoing IPC. The incidence of post-operative complications was similar in the three groups except for prolonged post-operative ileus. There was no increased risk of anastomotic leakage in patients receiving Met. CONCLUSION: The results suggest that a combination of intravenous Met and epidural pain control may be required to achieve a considerable decrease in time to resumption of oral soft diet in advanced gastric cancer patients who underwent gastrectomy and IPC. Furthermore, the administration of Met did not increase anastomotic leakage. Met has a role in the prevention of prolonged post-operative ileus.

Ruptured hepatoblastoma with massive internal bleeding in an adult.

Hepatoblastoma is the most common primary hepatic tumor of children. However, only a very few cases have been reported in adults. Most studies support treatment with chemotherapy followed by surgical resection. We present the first reported case of adult hepatoblastoma in Taiwan. A 52-year-old female suffered from sudden onset of abdominal pain and general weakness for days. Internal bleeding with hemorrhagic shock was suspected and two massive lesions in both lobes of the liver with hemoperitoneum were noted from imaging studies. Surgical resection of the larger left lobe tumor and radio-frequency ablation of the right smaller one were performed. The histopathology diagnosis was of a hepatoblastoma.

Helicobacter pylori infection in relation to E-cadherin gene promoter polymorphism and hypermethylation in sporadic gastric carcinomas.

AIM: To study Helicobacter pylori (H. pylori) infection in relation to E-cadherin (E-cad) promoter polymorphism and hypermethylation in GCs. METHODS: Specimens were taken from representative cancerous lesions and adjacent non-cancerous epithelia of 67 resected GCs. H. pylori was detected by real-time PCR of the cagA gene from non-neoplastic epithelium. E-cad promoter polymorphism and hypermethylation were determined by restriction fragment length polymorphism analysis and methylation-specific PCR, respectively. Expression of E-cad protein was determined by immunohistochemistry. RESULTS: H. pylori was found in 57% of patients with GC. H. pylori infection was more frequently found in tumors with the -160C/C genotype than those with the -160C/A and -160A/A genotypes (74% vs 47%, P = 0.02). H. pylori infection was associated with E-cad methylation in non-neoplastic epithelium; however, no significant difference in H. pylori was observed between methylated and unmethylated cancerous lesions. CONCLUSION: Patients with the -160C/C genotype might require H. pylori infection to promote the inactivation of CDH1, suggesting that H. pylori infection might affect GC in an initial stage because polymorphism is germ line. Mechanism of hypermethylation of CDH1 promoter in GC is complex, and H. pylori infection might affect it in an initial stage.

Modified saphenous-peritoneal shunt in refractory ascites: new technique.

BACKGROUND: Refractory ascites is a serious complication for patients with decompensated liver cirrhosis. Saphenous-peritoneal shunting is a possible surgical treatment for its relief, but tends to lead to higher groin infections. The purpose of the present paper was to determine whether a modified procedure could resolve the problem and offer potential advantages over a peritoneo-venous shunt. METHODS: Sixteen patients with refractory ascites who received modified saphenous-peritoneal shunts were studied. Clinical data such as bodyweight, abdominal girth, indocyanine green 15-min retention rate (ICG-15), serum bilirubin concentrations, Child-Pugh Score, creatinine clearance (C(Cr)), daily urinary output, urine sodium (U(Na)) and operative complications were recorded before, and 3 months after, surgery. RESULTS: Three months after the operation, the urinary output, nutritional status and Child-Pugh scores had improved, but ICG-15 and total bilirubin output had not changed significantly. The C(Cr), U(Na) bodyweight and abdominal girth tended to decrease, but not significantly. No groin infections were noted following this procedure. CONCLUSIONS: This modified procedure not only improved the nutritional status of cirrhotic patients with refractory ascites but also improved their quality of life. Infections and obstructions decreased in the short term. However, long-term follow up is mandatory. This new technique requires more practice and experience.

Spontaneous splenic rupture associated with hepatosplenic gammadelta T-cell lymphoma.

Spontaneous splenic rupture is an uncommon but life-threatening complication of hematologic malignancies, despite the frequent involvement of the spleen in these diseases. It has been reported in patients with acute and chronic leukemia, Hodgkin's disease, non-Hodgkin's lymphoma, and histiocytic lymphoma. A 50-year-old previously healthy man presented with acute symptoms of spontaneous splenic rupture. Emergency splenectomy with liver biopsy was performed. The clinicopathologic features suggested a hepatosplenic gammadelta T-cell lymphoma (HSgammadeltaTL). Here, we report a rare case of spontaneous splenic rupture associated with HSgammadeltaTL, unspecified in the World Health Organization classification.