Being-Whey Wang

Risk factors of mortality in perforated peptic ulcer

OBJECTIVE To assess the risk factors that influence mortality from perforated peptic ulcer. DESIGN Retrospective study. SETTING General hospital, Taiwan. SUBJECTS 179 patients who had their perforated peptic ulcers operated on and who had minimum follow-up of one year. MAIN OUTCOME MEASURES Mortality. RESULTS The overall mortality was 15% (26/179). Of the 26 patients who died, the cause of death was uncontrolled systemic infection in 21 (81%), hypovolaemic shock in 2, and fatal arrhythmia and heart failure in 1 each. 15 of the patients who died of sepsis did not have fulminant abdominal sepsis. Most deaths occurred early after operation, (range 1-96 days). Old age, preoperative shock, and type of operation seemed to be related to these deaths on univariate analysis, but multivariate analysis showed that coexisting medical illness, delayed treatment, and low albumin concentration were independent risk factors for mortality. CONCLUSIONS To improve the result of treatment of perforated peptic ulcer, the diagnosis and treatment should not be delayed, the associated medical illnesses should be treated, and nutritional support should be given.

Is Hepatectomy Beneficial in the Treatment of Multinodular Hepatocellular Carcinoma

BACKGROUND/PURPOSE Hepatectomy remains the standard treatment for primary hepatocellular carcinoma (HCC). However, its role in the treatment of multinodular HCC (MNHCC) is unknown. METHODS The study consisted of 599 patients undergoing curative hepatic resection for HCC between October 1990 and June 2006, in which 112 patients had MNHCC (tumor number > or = 2). The type of MNHCC was classified into: A, nodules involving one or two adjoining segments; B, large tumor with satellite nodules involving three or more segments; C, three or fewer nodules that are scattered in remote segments; and D, more than three separate tumors. Univariate and multivariate analyses were used to identify the prognostic factors related to postoperative survival. During the same period of time, and from our database of 178 patients with pathologically proven MNHCC who were undergoing nonsurgical multidisciplinary therapy, 48 patients with serum albumin level > or = 3.5 g/dL, total bilirubin < 2 mg/dL, tumor number < or = 3, and tumor size < or = 5 cm were compared with 38 patients with the same condition treated with hepatectomy, in which 16 received one-block resection and 22 underwent multiple-site resection. RESULTS The overall 1-, 3- and 5-year survival rates for patients with single-tumor HCC and MNHCC were 88.0%, 69.2% and 58.4%, and 86.1%, 55.5% and 29.9%, respectively (p < 0.001). Alpha-fetoprotein > 400 ng/mL, total tumor size > 5 cm, largest tumor size > 5 cm, total tumor number > 3, microvascular invasion, non-A type MNHCC and multiple-site resection were poor prognostic factors for MNHCC in the hepatectomy group. Multivariate analysis revealed that only multiple-site hepatic resection was an independent adverse factor related to postoperative survival. In addition, patients who underwent one-block resection had significantly better survival compared with the nonsurgical group (p = 0.0016), but the multiple-site resection subgroup did not. CONCLUSION The prognosis of MNHCC is poor in comparison with that of single-nodular HCC. Hepatectomy is the treatment of choice if the tumors can be removed by one-block resection and liver function reserve is acceptable.

APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer

BACKGROUND Operating for bleeding gastric ulcer remains controversial. Gastric resection bears a higher surgical risk while limited operation may result in more postoperative hemorrhage. There has been little discussion of effective risk assessment of patients. The aim of this study is to define surgical risk by using the APACHE II scoring system, and to determine optimal management. STUDY DESIGN Records from October 1990 to December 1996 were retrospectively reviewed for patients (n=101) with bleeding gastric ulcer who had undergone emergency operation after failed endoscopic therapy. Mortality rates were examined according to different APACHE II scores, and the surgical risk was defined. From January 1997 to December 1997, 35 consecutive patients were enrolled for prospective study. Partial gastric resection (PGR) was performed for patients with huge ulcers (>2 cm) and for low-risk patients with ulcers at the antrum or angularis, while limited operation (oversewing or excision of bleeding ulcer) was reserved for others. The results were compared with the retrospective study. RESULTS In the retrospective study, the mortality rates for the group with a score < 15 and > or = 15 were 5% (3 of 63) and 58% (22 of 38), respectively (p < 0.05). In the group with a score < 15, PGR was performed on 27 patients, and one died. For those patients with a score > or = 15, PGR carried a lower mortality than limited operation, although this was not statistically significant (47% vs 65%). Limited operation resulted in an overall rate of 22% postoperative hemorrhage and 12% reoperation rate, in which all patients with a score > or = 15 died. In the prospective study, the mortality rates in those scoring <15 and > or = 15 were 6% and 50%, respectively. This is not significantly different than the retrospective study. However, the rate of postoperative hemorrhage was diminished (5%). CONCLUSIONS APACHE II score is a useful tool for assessing risk in patients with bleeding gastric ulcer. The mortality is minimal in those with a score <15, and PGR can be performed with low risk. Although high-risk patients have dreadful outcomes, limited operation cannot improve them if postoperative hemorrhage occurs. Decision making in emergency operation for such patients should be based on the ulcer conditions and the patients hemodynamic status.

Hepatitis B Genotype C Correlated with Poor Surgical Outcomes for Hepatocellular Carcinoma

BACKGROUND Genotype B and C are the predominant hepatitis B virus (HBV) strains in Taiwan. We aimed to investigate the role of genotype in HBV-related hepatocellular carcinoma (HCC) after resection. STUDY DESIGN From October 2005 to November 2008, 64 patients who underwent liver resection for HBV-related HCC were enrolled. HBV genotypes were determined by molecular method. Patient characteristics, biochemical, tumor, and viral factors were evaluated for their prognostic significance. RESULTS During a mean follow-up of 26.6 ± 13.2 months, patients infected with genotype C had higher HBV viral load (p = 0.007) and worse disease-free survival rate (p = 0.028) than patients with genotype B. By univariate analysis, genotype C, alanine transaminase >50 U/L, tumor size ≥5 cm, and microvascular invasion were associated with tumor recurrence. Further multivariate analysis demonstrated genotype C remained a significant risk factor (p = 0.034). CONCLUSIONS Genotype C is a strong risk factor for HCC recurrence after resection. More intensive monitoring for recurrence should be considered in patients with genotype C.

DESIPRAMINE-INDUCED Ca2+-INDEPENDENT APOPTOSIS IN MG63 HUMAN OSTEOSARCOMA CELLS: DEPENDENCE ON P38 MITOGEN-ACTIVATED PROTEIN KINASE-REGULATED ACTIVATION OF CASPASE 3

1 It has been shown that the antidepressant desipramine is able to induce increases in [Ca2+]i and cell death in MG63 human osteosacroma cells, but whether apoptosis is involved is unclear. In the present study, the effect of desipramine on apoptosis and the underlying mechanisms were explored. It was demonstrated that desipramine induced cell death in a concentration‐ and time‐dependent manner. 2 Cells treated with 100–800 mmol/L desipramine showed typical apoptotic features, including an increase in sub‐diploid nuclei and activation of caspase 3, indicating that these cells underwent apoptosis. Immunoblotting revealed that 100 mmol/L desipramine activated extracellular signal‐regulated kinase (ERK), c‐Jun N‐terminal kinase (JNK) and p38 mitogen‐activated protein kinase (MAPK). Although pretreatment of cells with 20 mmol/L PD98059 (an ERK inhibitor) or 20 mmol/L SP600125 (an inhibitor of JNK) did not inhibit cell death, the addition of 20 mmol/L SB203580 (a p38 MAPK inhibitor) partially rescued cells from apoptosis. Desipramine‐induced caspase 3 activation required p38 MAPK activation. 3 Pretreatment of cells with BAPTA/AM (20 mmol/L) to prevent desipramine‐induced increases in [Ca2+]i did not protect cells from death. 4 The results of the present study suggest that, in MG63 human osteosarcoma cells, desipramine causes Ca2+‐independent apoptosis by inducing p38 MAPK‐associated activation of caspase 3.

Recurrence after skin-sparing mastectomy and immediate transverse rectus abdominis musculocutaneous flap reconstruction for invasive breast cancer

BackgroundThe aim of this study was to evaluate the recurrence pattern after skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) using transverse rectus abdominis musculocutaneous (TRAM) flap in patients with invasive breast cancer.MethodsFrom 1995 to 2010, patients with invasive breast cancer who underwent SSM followed by IBR using TRAM flap were retrospectively reviewed. The pattern of the first recurrence event was recorded.ResultsWe identified 249 consecutive patients with invasive breast cancer, two-thirds of whom (67.1%) were diagnosed with stage II or stage III disease. During a median follow-up period of 53 months, three (1.2%) local, 13 (5.2%) regional, 34 (13.7%) distant, and five (2.0%) concurrent locoregional and distant recurrences were observed. The median time to recurrences was 26 months (range, 2 to 70 months) for all recurrences, 23 months (range, 2 to 64 months) for locoregional recurrences, and 26 months (range, 8 to 70 months) for distant recurrences. All local recurrent lesions were detectable by careful physical examination, and detection of local recurrence suggested the presence of distant metastasis (60.0%). In contrast to distant metastasis, the risk of locoregional recurrence did not increase significantly with an increase in disease stage. The 5-year overall, locoregional relapse-free, and distant relapse-free survival rates were 89.7%, 90.8%, and 81.6%, respectively.ConclusionsSSM followed by immediate reconstruction using TRAM flap is an oncologically safe procedure even in patients with advanced-stage disease. Detection of local recurrence is crucial and can be aided by a thorough physical examination.

Intraoperative hyperthermic intraperitoneal chemotherapy as adjuvant chemotherapy for advanced gastric cancer patients with serosal invasion

Background: To evaluate hyperthermic intraperitoneal chemotherapy (HIPEC) as an adjuvant chemotherapy in advanced gastric cancer (AGC) patients with serosal invasion. Methods: Patients who received radical surgery and palliative surgery between January 2002 and December 2010 were retrospectively examined. Patients were divided into two groups, namely, one group that underwent surgery and another group that underwent surgery with HIPEC. All patients who received HIPEC had suspected serosal invasion on an abdominal computed tomography or by the surgeons assessment during the operation. Results: The prophylactic groups included 83 patients who underwent gastrectomy alone. A total of 29 patients underwent gastrectomy with HIPEC. The 5‐year survival rates were 10.7% and 43.9%, respectively. The 5‐year mean survival times were 22.66 (17.55–25.78) and 34.81 (24.97–44.66) months (p = 0.029), respectively. There were 52 patients who had a recurrence of carcinomatosis among 133 patients who had resections (52/133, 39.1%). The 3‐year disease‐free survival rate for carcinomatosis was 28.87% in the group that received surgery alone, whereas it was 66.03% in the group that received HIPEC. There was no significant difference in the rate of complication between the two groups in the prophylactic group (p = 0.542). Thus, curative surgery with HIPEC had a better prognosis for AGC with serosal invasion. The carcinomatosis recurrence time was longer in patients who underwent gastrectomy with HIPEC and received R0 resection. Conclusion: The survival benefit of HIPEC as an adjuvant therapy for gastric cancer patients with serosal invasion should be validated in a large cohort.

Number of involved lymph nodes is important in the prediction of prognosis for primary duodenal adenocarcinoma

Background: The significance of lymph node involvement regarding the prognosis of primary duodenal adenocarcinoma remains controversial. This study aims to evaluate the prognostic accuracy of nodal metastasis using the seventh edition American Joint Committee on Cancer staging system in patients with primary duodenal adenocarcinoma. Methods: Between 1993 and 2010, 36 patients who had undergone surgical resection for primary duodenal adenocarcinoma at the Kaohsiung Veterans General Hospital were retrospectively reviewed. Results: The median disease‐free survival for all patients was 19 months and the median overall survival was 21 months. Lymph node metastases were found in 26 (72%) of the patients, and 14 patients (39%) patients had in excess of three positive lymph nodes (N2). Patients with N2 disease had significantly reduced overall survival, as compared to patients with three or fewer positive lymph nodes (N1; p = 0.036). In univariate analysis, factors including age >75 years, body weight loss, tumor size ≤4 cm, N2 disease and lymph node ratio >0.4 predicted shorter overall survival. Multivariate analysis demonstrated that N2 and lymph node ratio >0.4 are significant risk factors associated with overall survival (p = 0.026 and p = 0.042 respectively). N2 is also the only independent predictive factor for disease‐free survival (p = 0.023). Conclusion: Subdivision of metastatic lymph nodes into N1 and N2 improves predictive ability. The seventh edition American Joint Committee on Cancer staging system is applicable in the present study with regard to the prediction of the prognosis for primary duodenal adenocarcinoma.

External biliary drainage plus bile acid feeding is not equal to internal drainage in preserving the cellular immunity following prolonged obstructive jaundice.

This study investigates the importance of intestinal bile flow in cellular immunity. Sprague-Dawley rats undergoing bile duct ligation (BDL) and sham ceiliotomy (Sham) for 14 and 21 days were investigated. Experimental animals following BDL were further divided into an external drainage (ED) group, an ED group with rat chow mixed with 2:2:1 cholic acid, chenodeoxycholic acid, and deoxycholic acid ( ED + BF), and an internal drainage (ID) group. Fourteen days later, they were killed and analyzed for spleen lymphocytic [3H] thymidine uptake (LHU) under mitogen stimulation with phytohemagglutinin, blood biochemistry, hemogram, and liver pathology. In the 14-day BDL experiment, LHU and serum albumin level were decreased in the BDL group (P < 0.05). After drainage, they were not significantly different among sham, ED, ED + BF, and ID groups. In the 21-day BDL experiment, the red cell volume was decreased (P < 0.05). After drainage, the ED, ED + BF, and ID groups still had a significantly lower LHU than the sham group (P < 0.05). However, the ID group had higher LHU than the ED and ED + BF groups (P < 0.05). The ED + BF group had a slightly higher LHU than the ED group but not statistically significant. Liver pathology returned to normal after drainage in the 14-day BDL model. In contrast, the 21-day BDL group had prominent periportal necrosis and developed periportal fibrosis after drainage. The present study reveals the duration of BDL determines the severity of hepatic damage. In the 14-day BDL groups, all kinds of drainage completely reverse the impaired liver function and cellular immunity. In the 21-day BDL group, 14-day drainage is inadequate for recovery because irreversible pathological changes are found. The reversal of cellular immunity in ID is better and faster, because it provides a better hepatic functional, nutritional, and hematological recovery besides the presence of primarily secreted bile acids.

Nodular Regenerative Hyperplasia of the Liver

Nodular regenerative hyperplasia (NRH), characterized by diffuse hepatic micronodular transformation in groups without fibrous septa between the nodules, is a rare benign liver lesion that has many synonyms in previous literature. Pathologic evaluation is the mainstay of accurate diagnosis. Treatment is focused on its underlying conditions and complications of portal hypertension. A 39-year-old man visited our hospital due to right upper quadrant pain and a palpable liver mass. Magnetic resonance examination revealed a slightly hyperintense tumor on T2-weighted images, and focal nodular hyperplasia was diagnosed by the radiologists. Atypical radiologic findings could not yield an accurate diagnosis. Surgical intervention was therefore performed. Pathologic examination of the resected liver tumor confirmed the diagnosis of NRH. We conclude that NRH should be included in the differential diagnosis of benign liver tumor.