Hirohiko Onoyama

K-ras gene mutation in gall bladder carcinomas and dysplasia.

Epithelial dysplasia of gall bladder is an important precancerous lesion of gall bladder carcinogenesis. To investigate the frequency of K-ras gene mutation in gall bladder carcinoma and dysplasia, K-ras codon 12 mutations were investigated by the polymerase chain reaction/restriction enzyme based method following direct sequencing. Mutation was detected in 59% (30 of 51) of gall bladder carcinomas, in 73% (8 of 11) of gall bladder dysplasia in gall stone cases, and in 0% of the normal gall bladder epithelium. There was, however, no correlation between K-ras mutation and clinicopathological factors of gall bladder carcinoma. K-ras gene mutation occurs even in gall bladder dysplasia at an incidence similar to that in carcinomas, suggesting that testing for K-ras gene mutation may prove useful as an adjunct to bile cytological or biopsy analysis.

Diagnostic imaging of early gallbladder cancer: retrospective study of 53 cases.

Abstract. To diagnose early gallbladder carcinoma is difficult but essential to improve the survival of the patients with this cancer. Fifty-three early gallbladder cancers were macroscopically divided into protruding and flat types. The diagnostic devises [ultrasonography (US), computed tomography (CT), and drip infusion cholangiography (DIC)] were compared for their ability of early detection. The specimens were examined cytologically for diagnosis during operation and the p53 protein was investigated. Thirty-three cases were of the protruding type, eighteen of the flat type, and two unclassified. Carcinoma tended to be missed when gallstones were present. Preoperative diagnosis of the flat type was difficult. Tumor location did not always correlate with the preoperative diagnosis. Of the misdiagnosed cases of the protruding type, half were missed with US and CT and were not visualized clearly by DIC. Among the flat type cancers, only three had no abnormal findings by diagnostic imaging. Cytologic examination was effective, and p53 was expressed only in early carcinoma, not in adenoma or dysplasia. Even in the presence of gallstones or cholecystitis, any abnormal findings should make one suspicious of gallbladder cancer. Cytology and p53 expression may be useful for the intraoperative diagnosis, and a combination of diagnostic methods is important.

Spontaneous rupture of an intrahepatic bile duct with biloma treated by percutaneous drainage and endoscopic sphincterotomy

A case of spontaneous rupture of an intrahepatic bile duct with biloma formation treated by percutaneous drainage and endoscopic sphincterotomy is reported. A 73-yr-old woman was admitted with fever and abdominal pain. There was no past history of abdominal surgery, instrumentation, or trauma. Ultrasound and computed tomography revealed a massive fluid collection in the abdominal cavity. Endoscopic retrograde cholangiography demonstrated extravasation of contrast medium from a distal biliary radicle in the left lobe of the liver. After successful treatment by percutaneous drainage and endoscopic sphincterotomy, the patient did well. Ultrasound and computed tomography showed resolution of the biloma. Nontraumatic bilomas are very rare: in fact, only 24 cases of spontaneous biloma have been reported. Endoscopic treatment for patients with spontaneous bilomas can be safe and effective, and should be considered.

Increased activity of group II phospholipase A2 in plasma in rat sodium deoxycholate induced acute pancreatitis

Background—Two different types of secretory phospholipase A2 (PLA2), pancreatic group I (PLA2-I) and non-pancreatic group II (PLA2-II), have been identified and postulated to be associated with the pathogenesis of various diseases, such as acute pancreatitis, septic shock, and multiple organ failure. Aims—To investigate the type of secretory PLA2 responsible for its catalytic activity found in plasma and ascites of experimental acute pancreatitis. Methods—Acute pancreatitis of differing severity was induced by the injection of different concentrations (1% or 10%) of sodium deoxycholate (DCA) into the common biliopancreatic duct in rats, and catalytic PLA2 activity in plasma and ascites were differentiated by anti-PLA2-I antibody and specific inhibitor of PLA2-II. Survival rate and plasma amylase, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were also measured. Results—In 1% and 10% DCA induced acute pancreatitis, plasma amylase values as well as PLA2activity in ascites were greatly increased. PLA2 activity in plasma was also notably increased in 10% DCA induced acute pancreatitis, but not in 1% DCA induced acute pancreatitis. PLA2-I specific polyclonal antibody significantly inhibited PLA2 activity in ascites but not that in plasma. In contrast, plasma PLA2 activity was completely suppressed by PLA2-II specific inhibitor. In addition, a high mortality (93% at five hours) and a significant increase in plasma AST and ALT were noted in 10% DCA induced pancreatitis. Conclusion—Ascites PLA2 activity is mainly derived from PLA2-I, whereas plasma PLA2activity is mostly derived from PLA2-II in severe acute pancreatitis, suggesting that increased plasma PLA2-II activity might be implicated in hepatic failure arising after severe acute pancreatitis.

Detection of point mutations in K-ras gene at codon 12 in bile from percutaneous transhepatic choledochal drainage tubes for diagnosis of biliary strictures

SummaryDetection of K-ras mutations at codon 12 constitutes one modality for diagnosis of pancreatic tumors. We attempted to detect K-ras mutations in DNA from bile collected through percutaneous transhepatic choledochal drainage (PTCD) tubes as a diagnostic approach to biliary strictures. Since bile salts induce cell damage, we first investigated the degeneration of cells according to bile exposure time using cell lines. High-mol-wt DNA could be extracted from cells exposed to bile for 6 h, but not from those exposed for 12 h. However, DNA exposed to bile for up 12 h could be amplified by the polymerase chain reaction (PCR) method. Therefore, K-ras mutations in fresh bile specimens collected from 15 patients through PTCD tubes were examined using PCR with restriction enzyme digestion. K-ras mutations were found in five out of five (100%) pancreatic cancers, all of which were negative according to cytodiagnosis of the same bile. On the other hand, K-ras mutations were not detected in bile from biliary tract cancers or metastatic neoplasms, except for one bile duct carcinoma and one metastatic case. Thus, although K-ras mutation alone is not an absolute marker for cancer, detection of K-ras mutations in fresh bile from PTCD tubes is a useful adjunct for diagnosis of pancreatic carcinomas in cases of biliary tract strictures.

Does radical resection improve the survival in patients with carcinoma of the gallbladder who are 75 years old and older

Radical resections have been reported to improve the surgical outcome for patients with carcinoma of the gallbladder, in recent years surgeons have had more opportunities to operate on elderly patients. We investigated whether the survival rate of aged patients who had radical resections were better than rates for those who had simple cholecystectomy. Of the 300 patients treated for carcinoma of the gallbladder between 1971 and 1999, 206 resected cases (except pancreaticoduodenectomy and hepatectomy) were divided into two groups: age 75 years or older, 54 patients (the older group), and age less than 75 years, 152 patients (the younger group). Clinical features and progression of the carcinomas did not differ between the two groups. In the older group, 22 patients (40.7%) had simple cholecystectomy, 32 (59.3%) had radical resections; in the younger group, 65 patients (42.8%) had simple cholecystectomy, and 87 (57.3%) had radical resection. None of the older patients who had radical resection died postoperatively. Postoperative survival was not different between the two groups. In the older group the 5-year survival rate for patients who had radical resections was better (60.9%) than the rate for those who had simple cholecystectomy (14.1%) (p=0.0098). Radical resection is effective for the aged patients with the carcinoma of gallbladder. On a rapporté que les résection radicales amélioraient le pronostic des patients atteints de cancer de la vésicule biliaire. Actuellement, on opère des patients de plus en plus âgés. Nous avons cherché à savoir si le taux de survie des patients âgés ayant eu une résection radicale était meilleur que celui de ceux qui ont eu une cholécystectomie simple. Parmi 300 patients traités pour cancer de la vésicule biliaire entre 1971 et 1999, 206 cas réséqués (exceptés les duodénopancréatectomies et les hépatectomies) ont été divisés en deux groupes: ceux âgés de 75 ans ou plus, 54 patients (le groupe «âgé»), et ceux âgés de moins de 75 ans, 152 patients (le groupe «jeune»). Les données cliniques et l’évolution des cancers ne différaient pas entre les deux groupes. Dans le groupe «âgé», 22 (40.7%) ont eu une cholécystectomie simple, 32 (59.3%) ont eu une résection radicale; dans le groupe «jeune», 65 (42.8%) ont eu une cholécystectomie simple alors que 87 (57.3%) ont eu une résection radicale. Aucun patient ayant eu une résection radicale n’est décédé après l’intervention. La survie postopératoire ne différaient pas entre les deux groupes. Dans le groupe «âgé», la survie à 5 ans pour les patients qui ont eu une résection radicale était meilleure (60.9%) que celle de ceux qui ont eu une cholécystectomie simple (14.1%) (p=0.0098). La résection radicale est efficace chez le patient âgé porteur de cancer de la vésicule biliaire. Según algunas publicaciones, la resección radical puede mejorar los resultados en pacientes con carcinoma de vesícula. En la actualidad, ante el incremento de pacientes añosos son más frecuentes estas intervenciones. Por ello, en este trabajo se pretende averiguar sí la tasa de supervivencia en estos enfermos, es mayor tras resección radical que tras la simple colecistectomía. Entre 1971 y 1999 se intervinieron 300 pacientes por padecer un carcinoma de vesícula; 206 casos fueron resecados (excepción hecha de las duodenopacreatectomías y hepatectomías) dividiéndose en dos grupos: grupo de viejos (≥ 75 años, n=54) y grupo de jóvenes (< 75 años, n=152). La clínica y la progresión del carcinoma fueron similares en ambos grupos. En el grupo de viejos: 22 (40.7%) fueron simplemente colecistectomizados y 32 (59.3%) sufrieron una resección radical. En el grupo de jóvenes: 65 (42.8%) fueron colecistectomizados y en 87 (57.3%) se practicó una resección radical. Ningún paciente añoso falleció en el postoperatorio. En ambos grupos, la supervivencia en el postoperatorio inmediato, fue similar. En el grupo de viejos, la supervivencia a los 5 años, tras resección radical, fue mayor 60.9% de los casos, que en los pacientes colecistectomizados (14.1%) (p=0.0098). Por tanto, la resección radical constituye el tratamiento de elección para pacientes añosos con cáncer de vesícula biliar.

Mode of inhibitory action of cholecystokinin in amylase release from isolated rat pancreatic acini: inhibition of secretory process post to protein kinase C-calcium ion systems

The incubation of isolated rat pancreatic acini with low doses (1 x 10(-11)-1 x 10(-10) M) of cholecystokinin-octapeptide (CCK8) induced amylase release. This CCK8-induced amylase release has been shown to be mediated through the protein kinase C activation and the Ca2+ mobilization which are linked to the phospholipase C-mediated hydrolysis of phosphoinositides. However, the incubation of the acini with high doses (1 x 10(-9)-1 x 10(-7) M) of CCK8 reduced amylase release to the level less than that induced by the maximally effective dose (1 x 10(-10) M) of this secretagogue. Under the same conditions, the high doses of this secretagogue did not inhibit the phospholipase C-mediated hydrolysis of phosphoinositides. The stimulatory action of the maximally effective dose of CCK8 in amylase release was mimicked by the simultaneous addition of protein kinase C-activating 12-O-tetradecanoylphorbol-13-acetate (TPA) and Ca2+ ionophore A23187. A high dose (1 x 10(-7) M) of CCK8 reduced the amylase release induced by the combination of TPA and A23187. These results suggest that the high doses of CCK8 inhibit the secretory process post to the protein kinase C-Ca2+ systems and thereby reduce the amylase release induced by the maximally effective dose of CCK8 in rat pancreatic acini.

Changes in the number of gut mucosal T-lymphocytes and macrophages in patients treated by external biliary drainage

OBJECTIVE To examine the changes in the number of T cells and macrophages in the mucosal lamina propria in the presence or absence of bile in the gastrointestinal tract. DESIGN Clinical study. SETTING University hospital, Japan. SUBJECTS 6 patients with obstructive jaundice who had external biliary drainage (drainage group) and 6 patients with no signs of obstructive jaundice (control group). INTERVENTIONS Gastrointestinal specimens were taken at the time of operation. MAIN OUTCOME MEASURES The number of CD4+ T cells, CD8+ T cells and CD68+ macrophages in the lamina propria mucosae in each group measured immunohistochemically. RESULTS The numbers of CD8 T cells and CD68+ macrophages in the lamina propria of the patients treated by external drainage were significantly less than in the control group (p < 0.01). However, there was no difference in the number of CD4+ T cells between the groups (p = 0.45). CONCLUSIONS In the absence of bile, mucosal immune function fails as a result of reduced numbers of CD8+ T cells and macrophages.

Changes in Extrathymic T Cells in the Liver and Intestinal Intraepithelium in Mice with Obstructive Jaundice

Recently, T cells were classified into two categories: intrathymic T cells (ITCs; thymus-derived T cells) and extrathymic T cells (ETCs). ETC, localized in the liver and intestinal intraepithelium (IE), play an important immunologic role in the suppressed condition of T-cell development in the thymus. Given the fact that complications of surgery in patients with obstructive jaundice are often related to immunosuppression in the gut–liver circulation, we attempted to investigate the changes in the proportion of ETCs in mice with obstructive jaundice. Three mice models were prepared (n = 10 per group): sham group with simple laparotomy; ligation group with common bile duct ligation; deoxycholic acid (DCA) group with an oral intake of DCA as a model of the presence of bile salts in the gut lumen. In each model, total mononuclear cells (MNCs), ITCs in the thymus, and ETCs in the liver and IE were counted using monoclonal antibodies in conjunction with a two-color immunofluorescence test by flow cytometry. In the ligation group the number of MNCs was reduced in the thymus and IE, and only those in the IE recovered after oral intake of DCA. A decrease of ITCs in the thymus and the increase in ETCs in the liver and IE occurred simultaneously during the early phase of biliary obstruction. At day 7 after biliary obstruction, ETCs in the livers of the DCA and ligation groups decreased to nearly the level in the sham group. However, on day 7 the ETCs in the IE remained significantly higher in the DCA group than in the ligation group. These results suggested that ETCs can act in place of ITCs at an early phase of obstructive jaundice, and the presence of bile in the gut lumen may be associated with the consumption of ETCs in the IE, a reaction that may bring about improved immunoreactivity.

Assessment of Quality of Life After Pancreatoduodenectomy

The quality of life (QOL) after pancreatoduodenectomy (PD) was assessed by symptom scale scores related to physical and emotional aspects, performance status (PS) as social activity, and the Cornell Medical Index (CMI), related to psychophysiological aspects. Complete sets of data were obtained from 33 patients. A follow-up period after PD varied from 1 to 16 years. The incidence of the emotional symptoms was relatively higher than the physical symptoms. The symptom scale scores showed highest correlations with PS and CMI. Problems in the psychological condition might be related to significant differences in QOL. It is necessary to make a long-term evaluation for postoperative cholangitis, for which alkaline phosphatase levels in the blood and biliary scintigraphy are useful for diagnosis even in a symptom-free period.