Robert J. Chen

Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe: Initial experience

Objective: To prove the feasibility of hand-assisted laparoscopic liver resection for tumors located in the posterior portion of the right hepatic lobe. Summary Background Data: Use of laparoscopic liver resection remains limited due to problems with technique, especially when the tumor is located near the diaphragm, or in the posterior portion of the right lobe. Methods: Between October 2001 and June 2002, a total of 7 patients with solid hepatic tumors involving the posterior portion of the right lobe of liver underwent hand-assisted laparoscopic hepatectomy with the HandPort system at our hospital. Surgical techniques used included CO2 pneumoperitoneum and the creation of a wound on the right upper quadrant of the abdomen for HandPort placement. The location of tumor and its transection margin were decided by laparoscopic ultrasound. The liver resection was performed using the Ultrashear without portal triad control, with the specimens obtained then placed in a bag and removed directly via the HandPort access. Results: The 5 male and 2 female patients ranged in age from 41 to 76 years (mean 62.3 ± 14.4). Surgical procedures included partial hepatectomy for 6 patients and segmentectomy for one, all successfully completed using a variant of the minimally invasive laparoscopic procedure without conversion to open surgery. The mean duration of the operation was 140.7 ± 42.2 minutes (90–180). The blood loss during surgery was 257.1 ± 159 mL (250–500), without any requirement for intraoperative or postoperative transfusion. Pathology revealed hemagioma (n = 2), colon cancer metastasis (n = 2), and hepatocellular carcinoma (n = 3). There were no deaths postoperatively, with 1 patient suffering bile leakage. Mean hospital stay was 5.3 ± 1.3 days postsurgery. Conclusion: The results of this study suggest that laparoscopic liver resection using the HandPort system is feasible for selected patients with lesions in the posterior portion of the right hepatic lobe requiring limited resection. Individuals with small tumors may benefit; because a large abdominal incision is not required, the wound-related complication rate might be reduced.

Risk Factors for Primary Bacteremia and Endovascular Infection in Patients without Acquired Immunodeficiency Syndrome Who Have Nontyphoid Salmonellosis

This study sought to find the risk factors for primary bacteremia, endovascular infection, and in-hospital death for patients without acquired immunodeficiency syndrome who have nontyphoid salmonellosis. From September 1995 through September 2001, 301 patients with nontyphoid salmonellosis were admitted to our hospital; of these patients, 121 had primary bacteremia, and 28 had endovascular infection. Of the 121 patients with primary bacteremia, 64 were aged >50 years, and 26 had endovascular infection. Overall, 90 patients (29.9%) had immunodeficiency. Predictors of primary bacteremia were age; presence of systemic lupus erythematosus; group B, group C, or group D Salmonella infection; and immunodeficiency. The positive predictor of endovascular infection in adult patients with primary bacteremia was group C Salmonella infection, and negative predictors were immunodeficiency and solid-organ cancer. The overall in-hospital mortality rate was 12%; for primary bacteremia, it was 24.8%; for endovascular infection, it was 14.3%. Predictors of in-hospital death were age, extraintestinal infection, and solid-organ malignancy.

Needlescopic versus conventional video-assisted thoracic surgery for primary spontaneous pneumothorax: a comparative study

BACKGROUND Management of primary spontaneous pneumothorax by needlescopic video-assisted thoracic surgery (VATS) has rarely been attempted and no comparison study with conventional VATS is available. In this study, we compared the clinical outcomes of needlescopic VATS with conventional VATS in treating primary spontaneous pneumothorax. The technique and our experience with needlescopic VATS are reported. METHODS Between April 2001 and April 2002, a total of 63 patients with recurrent, persistent, or contralateral primary spontaneous pneumothorax were recruited for this study. Operative procedures included needlescopic VATS in 28 patients and conventional VATS in 35 patients. We used a modified operative technique to improve the poor and narrower vision of the needle-videothoracoscope. RESULTS There was no mortality or major complications in either of the two groups. Needlescopic and conventional VATS groups had comparable operation times, postoperative pain, requested doses of meperidine hydrochloride, durations of postoperative chest drainage, and length of hospital stay. After a mean follow-up of 8 months, the needlescopic VATS group had less residual neuralgia (p = 0.021) and better wound satisfaction (p = 0.043) than the conventional VATS group. Ipsilateral recurrence of pneumothorax occurred in 1 patient (3.6%) in the needlescopic VATS group but not in any patients in the conventional VATS group. CONCLUSIONS Our experience showed that needlescopic VATS is technically feasible and can be a satisfactory alternative to conventional VATS in treating primary spontaneous pneumothorax. Limited vision of needlescopic VATS can be improved by the modified technique we used. However, conversion to conventional VATS or minithoracotomy is suggested in selected patients to prevent early recurrence.

Absence of Integrin αvβ3 Enhances Vascular Leak in Mice by Inhibiting Endothelial Cortical Actin Formation

RATIONALE Sepsis and acute lung injury (ALI) have devastatingly high mortality rates. Both are associated with increased vascular leak, a process regulated by complex molecular mechanisms. OBJECTIVES We hypothesized that integrin αvβ3 could be an important determinant of vascular leak and endothelial permeability in sepsis and ALI. METHODS β3 subunit knockout mice were tested for lung vascular leak after endotracheal LPS, and systemic vascular leak and mortality after intraperitoneal LPS and cecal ligation and puncture. Possible contributory effects of β3 deficiency in platelets and other hematopoietic cells were excluded by bone marrow reconstitution experiments. Endothelial cells treated with αvβ3 antibodies were evaluated for sphingosine-1 phosphate (S1P)–mediated alterations in barrier function, cytoskeletal arrangement, and integrin localization. MEASUREMENTS AND MAIN RESULTS β3 knockout mice had increased vascular leak and pulmonary edema formation after endotracheal LPS, and increased vascular leak and mortality after intraperitoneal LPS and cecal ligation and puncture. In endothelial cells, αvβ3 antibodies inhibited barrier-enhancing and cortical actin responses to S1P. Furthermore, S1P induced translocation of αvβ3 from discrete focal adhesions to cortically distributed sites through Gi- and Rac1-mediated pathways. Cortical αvβ3 localization after S1P was decreased by αvβ3 antibodies, suggesting that ligation of the αvβ3 with its extracellular matrix ligands is required to stabilize cortical αvβ3 focal adhesions. CONCLUSIONS Our studies identify a novel mechanism by which αvβ3 mitigates increased vascular leak, a pathophysiologic function central to sepsis and ALI. These studies suggest that drugs designed to block αvβ3 may have the unexpected side effect of intensifying sepsis- and ALI-associated vascular endothelial leak.

Association of Angiotensin-Converting Enzyme Insertion/Deletion Polymorphism With Serum Level and Development of Pulmonary Complications Following Esophagectomy

Background:Pulmonary complications remain the major cause of postoperative mortality in patients with esophageal cancer undergoing esophagectomy. It was unclear whether this dismal complication has a genetic predisposition. We therefore investigated the role of an angiotensin-converting enzyme (ACE) insertion/deletion polymorphism in developing these complications. Methods:We conducted a prospective study including 152 patients with esophageal cancer who underwent esophagectomy in National Taiwan University Hospital between 1996 and 2002. The ACE genotype was determined by polymerase chain reaction amplification of leukocyte DNA obtained before surgery. The serum ACE concentration was determined by enzyme-linked immunosorbent assay. Results:Thirty-five patients (23%) developed pulmonary complications following esophagectomy. As compared with patients with the I/I and I/D genotypes, those with the D/D genotype had a higher risk for pulmonary complications (adjusted odds ratio [OR], 3.12; 95% confidence interval [CI], 1.01–9.65). The risk was additively enhanced by combination of the ACE D/D genotype with other clinical risk factors (old age, hypoalbuminemia, and poor pulmonary function). The circulating ACE level was also dose-dependently with the presence of ACE D allele. As compared with the patients with circulating ACE less than 200 ng/mL, the patients with circulating ACE of 200 to 400 ng/mL and over 400 ng/mL had ORs (95% CI) of 2.75 (1.12–6.67) and 15.00 (4.3–52.34) to present with ACE D allele, respectively. Conclusions:An ACE insertion/deletion polymorphism might modulate the function of ACE gene and play a role in affecting individual susceptibility to pulmonary injury following esophagectomy in patients of esophageal cancer.

Infective endocarditis in patients with liver cirrhosis

BACKGROUND AND PURPOSE Infective endocarditis complicating liver cirrhosis is infrequently reported. This study evaluated the clinical features of infective endocarditis in Taiwanese patients with liver cirrhosis. METHODS All cases of infective endocarditis occurring in patients with liver cirrhosis from December 1995 to December 2002 were included in this study. Data were collected by retrospective chart review. RESULTS Twenty six patients (18 males, 8 females) with median age 6 years (range, 43 to 87) were included. The etiology of liver cirrhosis was hepatitis virus infection in 20 patients. There were 7 nosocomial infections. Bacterial pathogens were identified in 25 patients, with Staphylococcus aureus (n = 8), viridans streptococci (n = 4), Streptococcus sanguis (n = 2), Pseudomonas aeruginosa (n = 2), and Enterococcus faecalis (n = 2) the most common isolates. The hospital mortality rate was 27%. Patients with in-hospital death were more likely to have a history of uremia, staphylococcal infection, nosocomial infection and less likely to have aortic valve infection. CONCLUSIONS The prognosis of patients with infective endocarditis and liver cirrhosis was poor. Infection with Staphylococcus species was a dominant cause and methicillin resistance was common.

The Influence of Donor Characteristics on Survival After Heart Transplantation

With improved immunosuppressive regimens, transplantation techniques, and postoperative care, heart transplantation (HTx) has been established as a definite therapy for end-stage heart disease. Because of a donor shortage, we have accepted marginal individuals. In this study, we identified donor-related factors influencing survival after HTx by retrospective analysis of recipient data after primary HTx from February 2002 to December 2006. The Cox regression model was used to examine the effects of the following variables on survival of 112 heart transplant recipients: demographic data of gender, age, body weight, donor-recipient body weight ratio; history of smoking, alcohol drinking, diabetes mellitus, hypertension, hepatitis B surface antigen, anti-hepatitis C virus antibody; donor condication before transplantation including catecholamine doses, hypotension, cardiopulmonary resuscitation, creatine MB isoenzyme of creatine kinase (CK-MB), tropinin I, and cold ischemic time of the allograft. Catecholamines and smoking showed significant influences on HTx survival. In our series, the percentage of donors receiving inotropic support before donation was 88% (n = 99), and the percentage of donors with a history of smoking was 25% (n = 28). There was no influence of donor status of diabetes, hypertension, or hepatitis B or C infection on postoperative survival. Our results showed that inotropic support of and a history of smoking by the donor were significant factors influencing posttransplant survival.

Connective Tissue Growth Factor Acts as a Therapeutic Agent and Predictor for Peritoneal Carcinomatosis of Colorectal Cancer

Purpose: Here, we aimed to investigate the role of connective tissue growth factor (CTGF) in peritoneal carcinomatosis (PC) associated with colorectal cancer (CRC) and to characterize the underlying mechanism of CTGF mediating adhesion. Experimental Design: A cohort of 136 CRC patient specimens was analyzed in this study. CRC cell lines were used for in vitro adhesion assay and in vivo peritoneal dissemination experiment. Recombinant CTGF protein treatment, transfection of CTGF expression plasmids, and knockdown of CTGF expression in CRC cells were utilized to evaluate the integrin α5, which served as a target of CTGF in inhibiting peritoneal seeding. Results: The analysis of CRC tissues revealed an inverse correlation between CTGF expression and prevalence of PC. Lower CTGF level in CRC patients was associated with higher peritoneal recurrence rate after surgery. Inducing CTGF expression in cancer cells resulted in decreased incidence of PC and increased rate of mice survival. The mice received intraperitoneal injection of recombinant CTGF protein simultaneously with cancer cells or following tumor formation; in both cases, peritoneal tumor dissemination was found to be effectively inhibited in the mouse model. Functional assay revealed that CTGF significantly decreased the CRC cell adhesion ability, and integrin α5 was confirmed by reverse transcriptase PCR and functional blocking assay as a downstream effector in the CTGF-mediated inhibition of CRC cell adhesion. Conclusions: CTGF acts as a molecular predictor of PC and could be a potential therapeutic target for the chemoprevention and treatment of PC in CRC patients. Clin Cancer Res; 17(10); 3077–88. ©2011 AACR.

Analysis of bicanalicular nasal intubation in the repair of canalicular lacerations.

PurposeTo analyze the outcomes (success, failure) and complications of surgical repair of canalicular lacerations by bicanalicular nasal intubation in a series of patients treated over a 7-year period.MethodsThe case records of 98 patients undergoing surgical repair of canalicular lacerations were retrospectively reviewed. Patient characteristics and results of the surgical repair were analyzed to identify factors that may influence the outcomes. Two groups (success and failure) were statistically compared with the Mann-Whitney U test for scale variables and with Fisher’s exact test for categorical variables.ResultsOf the 98 patients, 78 (79.6%) had patency after irrigation (anatomic success) and 83 (84.7%) were asymptomatic (functional success). Patients age, sex, injury location, anesthetic methods, and timing of surgical repair were not significantly associated with the postoperative patency of the lacerated canaliculus. Having a stent left for more than 90 days was significantly associated with restoration of the canalicular anatomy (P < 0.01). Patients with postoperative anatomic patency had a significantly lower rate of symptomatic epiphora than patients with anatomic obstruction (P < 0.001). Symptomatic epiphora was significantly more frequent in patients with combined upper and lower canalicular injuries (P < 0.01).ConclusionOur results suggest that retaining bicanalicular silicone nasal intubation for more than 90 days can provide satisfactory results in restoring both canalicular anatomy and function. With an experienced operating team, repair of canalicular lacerations can be delayed for up to 11 days. However, patients with combined upper and lower canalicular lacerations are at an increased risk of developing postoperative symptomatic epiphora.

Effective treatment of mouse sepsis with an inhibitory antibody targeting integrin αvβ5.

Objective:Integrin &agr;v&bgr;5 has been identified as a regulator of vascular leak and endothelial permeability. We hypothesized that targeting &agr;v&bgr;5 could represent a viable treatment strategy for sepsis. Design:Integrin &bgr;5 subunit knockout and wild-type 129/svJae mice and wild-type mice treated with &agr;v&bgr;5 blocking or control antibodies were tested in models of intraperitoneal lipopolysaccharide and cecal ligation and puncture. Human umbilical vein endothelial cell and human lung microvascular endothelial cell monolayers were treated with &agr;v&bgr;5 antibodies to assess for effects on lipopolysaccharide-induced changes in transendothelial resistance and on patterns of cytoskeletal reorganization. Setting:Laboratory-based research. Subjects:Mice and endothelial cell monolayers. Interventions, Measurements, and Main Results:Measurements taken after intraperitoneal lipopolysaccharide and/or cecal ligation and puncture included mortality, vascular leak, hematocrit, quantification of a panel of serum cytokines/chemokines, and assessment of thioglyccolate-induced leukocyte migration. &bgr;5 knockout mice had decreased mortality after intraperitoneal lipopolysaccharide and cecal ligation and puncture and decreased vascular leak, as measured by extravasation of an I125-labeled intravascular tracer. Treating clinically ill mice with &agr;v&bgr;5 antibodies, up to 20 hrs after intraperitoneal lipopolysaccharide and cecal ligation and puncture, also resulted in decreased mortality. &agr;v&bgr;5 antibodies attenuated lipopolysaccharide-induced transendothelial resistance changes and cytoskeletal stress fiber formation in both human umbilical vein endothelial cell and human lung microvascular endothelial cell monolayers. &agr;v&bgr;5 antibodies had no effect on cytokine/chemokine serum levels after cecal ligation and puncture. &bgr;5 knockout mice and wild-type controls did not exhibit differences in thioglyccolate-induced leukocyte migration. Conclusions:Our studies suggest that &agr;v&bgr;5 is an important regulator of the vascular endothelial leak response in sepsis and that &agr;v&bgr;5 blockade may provide a novel approach to treating this devastating disease syndrome.