Sen-Chang Yu

Placenta growth factor expression is correlated with survival of patients with colorectal cancer

Background: Overexpression of vascular endothelial growth factor (VEGF) correlates with vascularity, metastasis, and proliferation in colorectal cancer but the role of its homologue, placenta growth factor (PlGF), is unknown. The aim of this study was to evaluate expression and clinical implications of PlGF in colorectal cancer. Methods: We investigated 74 tumour/non-tumour pairs of colorectal cryosections. Clinical staging was based on the UICC-TNM classification. Expression levels of mRNA for PlGF and VEGF were analysed with quantitative real time reverse transcription-polymerase chain reaction. Proteins were analysed by immunohistochemical staining and enzyme linked immunoabsorbant assay. Analysis of the differences in PlGF and VEGF levels between tumour and non-tumour tissues in the same patient were performed by paired t test; differences between localised and advanced disease patients by the Mann-Whitney, χ2, and Fisher’s exact tests and survival curves by the Kaplan-Meier method. Results: Expression levels for both growth factors were significantly higher in tumour than in non-tumour tissues (p⩽0.001). The ratio of PlGF expression in tumour to non-tumour in the advanced disease group was significantly higher than for the localised disease group (p = 0.009). Patients with more tumour PlGF mRNA had shorter survival (p = 0.028). The majority of PlGF was expressed in tumour cells. Conclusions: Our results suggest that PlGF expression correlates with disease progression and patient survival and may be used as a prognostic indicator for colorectal cancer.

Minimally invasive surgery for gastric stromal cell tumors : Intermediate follow-up results

Laparoscopic wedge resection of the stomach (LWS) has become the treatment of choice for patients with benign gastric tumors. The technical consideration and long-term follow-up data of LWS for gastrointestinal stromal tumors (GISTs) of the stomach are limited. We present our experience of 28 LWSs for gastric GISTs with a mean follow-up of 43 months. From October 1995 to December 2002, we successfully performed 28 LWSs for 29 patients with GISTs of the stomach, and one patient needed conversion to laparotomy because of suspected bowel injury when establishing pneumoperitoneum. Patient demographics, perioperative parameters, and outcomes of the 28 patients were assessed retrospectively. The tumors were located in the upper third of the stomach in 13 patients, in the middle third, in eight patients, and in the lower third, in seven patients. The mean size of tumors was 3.4 ± 1.6 cm in diameter. The duration of operation ranged from 95 to 390 minutes: 189.6 ± 79.5 minutes with the stapler method and 194.3 ± 50.5 minutes with the hand-sewn method (P = 0.8870). No blood transfusion was given in the perioperative period in all cases. Cholecystectomy in three patients and repair of hiatal hernia in one patient were performed during the same operation. The oral intake was restored at the third to fourth postoperative days. The hospital stay ranged from 3 to 11 days (mean, 6.7 ± 1.8 days). The follow-up period ranged from 12 to 95 months (mean, 43.3 ± 23.5 months, median 42 months). There has been no evidence of tumor recurrence, including one patient with microscopic invasion of section margin. LWS can be performed safely with a satisfactory remission rate for patients with gastric stromal cell tumors.

Minilaparoscopic (needlescopic) cholecystectomy: a study of 1,011 cases

Background:The safety and feasibility of minilaparoscopic cholecystectomy has not been documented with a large patient sample. This study reports the results of 1,011 minilaparoscopic cholecystectomies performed in a single institution.Methods:From November 1997 to May 2002, 1,023 consecutive patients underwent minilaparoscopic cholecystectomy at National Taiwan University Hospital, Taipei, Taiwan. Patients with clinical evidence of common bile duct stones (1 patient) and combined surgery for other purposes (11 patients) were excluded. The operative indication, total operative time, conversion rate, hospital stay, morbidity and mortality of 1,011 patients were reviewed and statistically analyzed.Results:Minilaparoscopic cholecystectomy was performed in 1,009 of 1,011 patients (375 males and 636 female; mean age, 54.8 years; range 13–92 years). The total operative time was 68.8 ± 31.9 min. The total hospital stay was 2.5 ± 2 days. One patient (0.10%) underwent conversion to open cholecystectomy because of common hepatic duct laceration. One patient (0.10%) underwent conversion to standard laparoscopic cholecystectomy for control of cystic artery bleeding. Ten patients (0.99%) experienced major complications including intraabdominal abscess (1 patient), bile leakage (5 patients), major bile duct injury (2 patients), bowel injury (1 patient), and postoperative hemorrhage (1 patient). Eleven patients (1.09%) had minor complications including wound infection, incisional herniation, postoperative ileus, and acute urine retention. One patient (0.10%) with bleeding tendency succumbed to postoperative hemorrhage.Conclusions:Minilaparoscopic cholecystectomy is a technically demanding approach. Our results indicate that this procedure could be performed successfully and safely by experienced surgical teams.

Initial experience with ABO-incompatible live donor renal transplantation.

The serious shortage of cadaveric organs has prompted the development of ABO-incompatible live donor renal transplantation. We report our experience of the initial two live donor ABO incompatible renal transplants at our hospital. The first patient was a 55-year-old type A female who received a kidney from her AB type husband. The second patient was a 27-year-old type O male who received renal transplantation from his type A father. Preconditioning immunosuppressive therapy in the two patients with tacrolimus, mycophenolate mofetil and methylprednisolone was started 7 days before transplantation. During the period of preconditioning, double filtration plasmapheresis (DFPP) was employed to remove anti-A and -B antibodies. Laparoscopic splenectomy and renal transplantation were performed after the anti-donor ABO antibodies were reduced to a titer of 1:4. Rituximab, a humanized monoclonal anti-CD20 antibody, was administered to the second patient due to a rebound in the anti-A antibody titer during the preconditioning period. Under a tacrolimus-based immunosuppressive regimen, both patients recovered very well without any evidence of rejection. Serum creatinine levels were 1.0 and 1.4 mg/dL at 6 and 3 months after transplantation, respectively. These cases illustrate that with new immunosuppressive agents, DFPP and splenectomy, ABO-incompatible renal transplantation can be successfully conducted in end-stage renal disease patients whose only available live donors are blood group incompatible.

Automated Endoscopic System for Optimal Positioning-assisted Mini-laparoscopic Cholecystectomy: Preliminary Report

Objective: The use of mini-instruments in laparoscopic cholecystectomy (LC) was more technique-demanding and manpower-demanding than conventional LC. The feasibility of using a vocally controlled manipulator AESOP (Automated Endoscopic System for Optimal Positioning) to assist mini-LC, however, has not been established as yet. This study compared the outcome of AESOP-assisted mini-LC (A-MLC) with that of human-assisted mini-LC (M-MLC). Methods: The outcomes of 28 patients undergoing M-MLC were compared with those of a subsequent series of 28 patients undergoing A-MLC. Patient demographics including surgical indications, body mass index, and peri-operative parameters such as preparation time, operation time, hospital stay, and surgical complications were compared between the two groups. Results: The patient demographics were similar between the two groups. MLC was successfully performed in 48 patients. Three patients in the A-MLC group and five patients in the M-MLC group had to change one of the 2 mm working ports to a 5 or 10 mm working port to complete the procedures. Both approaches resulted in good recovery. The mean preparation time in A-MLC (22.93±10.50 minutes) was shorter than that in M-MLC (25.21±8.38) minutes, but the difference was not statistically significant. The mean operation time in A-MLC (43.39±20.45 minutes) was significantly shorter than that in M-MLC (64.46±26.78 minutes). No biliary tract complications were recorded in either group. The length of hospital stay, resumption of diet, and the use of narcotic analgesics were not significantly different between the two groups. Conclusions: As compared with a human-assisted surgery, AESOP facilitated the performance of mini-laparoscopic cholecystectomy by providing a stable camera platform and avoiding unwanted movement during the laparoscopic procedure.

The Role of Extended Lymphadenectomy and Adjuvant Immunochemotherapy for Gastric Cancer

To evaluate recent improvements in gastric cancer surgery, we performed a retrospective analysis of data from 482 patients who underwent primary gastrectomies from 1978 to 1987 (the recent group) and 264 patients who had been treated from 1965 to 1973 (the early group). Radical gastric resection with R2/3 lymphadenectomy was the standard procedure in the recent group as compared to a simple gastrectomy in the early group. In addition, postoperative long-term adjuvant immonochemotherapy with 5-fluorouracil, Mitomycin C, and PSK (Krestin) was given to 169 (35.1%) patients of the recent group. There were no significant differences in the characteristics of patients and location, stage or histological classification of gastric cancer between these two groups. Early gastric cancers accounted for 11.5% of the patients in the early group and 14.7% of the patients in the recent group. The resection rate increased from 57.8% to 686.7% and the 5-year survival rate increased from 24.7% to 37.9%. A comparison of patients with simple gastrectomies and those with radical gastrectomies showed a slight increase in the 5-year survival rate from 24.7% to 35.9% (p＜0.05). The advantage of radical resections was limited to patients at early stages and those with serosa invasion but without lymph node involvement. Patients who received adjuvant immunochemotherapy after radical gastrectomy had a 5-year survival rate of 41.5% an insignificant difference (p＞0.05) compared to 35.9% of those who received radical gastrectomy alone. However, fro patients with serosa invasion, combined adjuvant immunochemotherapy after curative resction was associated with an increased survival rate from 37.8% to 63.9% (p＜0.05). For patients with lymph node involvement, adjuvant immunochemotherapy was also associated with an increased survival rate from 10.4% to 26.4% (p＜0.01). In conclusion, the survival of gastric cancer patient after surgery appeared to have improved recently. The advantages of the radical gastrectomy seemed limited fro patients at an early stage, especially for those without lymph node involvement. For patients with advanced gastric cancer with serosa and lymph node involvement, adjuvant immunochemotherapy may be beneficial in addition to extended lymphadenectomy. Further randomized, controlled trials are warranted to clarify these issues. (Tzu Chi Med J 1994;6: 153-161)