Wing-Yiu Lui

Factors Influencing Postoperative Morbidity, Mortality, and Survival After Resection for Hilar Cholangiocarcinoma

UNLABELLED OBJECTIVE; Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patients survival also were re-evaluated. SUMMARY BACKGROUND DATA Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis. METHODS The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival. RESULTS There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that co-existent hepatolithiasis and lower serum asparate aminotransferase levels (<90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin > or = 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin > or = 10 mg/dL, curative resection, and histologic type as the three most significant independent variables. CONCLUSIONS Surgical resection provides the best survival for hilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3 g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well-differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.

Mucin-producing neoplasms of the pancreas. Intraductal papillary and mucinous cystic neoplasms.

OBJECTIVE The authors compared the clinicopathologic features of the intraductal papillary and mucinous cystic neoplasms of the pancreas and clarified the similarities as well as the differences between these two tumors. In addition, they reviewed 104 cases of the intraductal papillary neoplasm in the English literature to provide a global view of the condition. SUMMARY BACKGROUND DATA Controversy about the term and clinicopathologic entity still exist regarding intraductal papillary neoplasm of the pancreas. Currently, with only a few cases of this rare tumor in each report, there continues to be inadequate knowledge available regarding the tumor and methods by which to distinguish it from the mucinous cystic neoplasm. METHODS Multiple demographic and clinicopathologic parameters were compared between intraductal papillary and mucinous cystic neoplasms identified from 1985 to 1994 in the Medical Center, Veterans General Hospital--Taipei. RESULTS There were four intraductal papillary adenocarcinomas and 10 mucinous cystic neoplasms (8 cystadenocarcinoma and 2 cystadenoma). The sex, age, size, tumor location, and pathologic findings were quite different between these two groups. Clinical presentation of intraductal papillary adenocarcinomas were similar to those of periampullary tumors. The most common presentations of mucinous cystic neoplasm were epigastric pain and abdominal mass. All four intraductal papillary adenocarcinoma showed mucin secretion from a patulous orifice of the ampulla of Vater and filling defects in the dilated main pancreatic duct by endoscopic retrograde cholangiopancreatography (ERCP). Accurate preoperative diagnosis was not easy regarding either group. Serum carbohydrate antigen 19-9 (CA 19-9) was more useful for diagnosis in both groups. CONCLUSIONS The intraductal papillary neoplasm is a unique clinical entity but not a variant of mucinous cystic neoplasm in terms of sex, age, size, tumor location, or pathologic picture. The pathognomonic findings of ERCP should lead to diagnosis. Very aggressive surgical procedures should be attempted for these two mucin-producing neoplasms with low-grade malignancy.

Serum Interleukin-10 But Not Interleukin-6 Is Related to Clinical Outcome in Patients With Resectable Hepatocellular Carcinoma

OBJECTIVE To evaluate the clinical significance of preoperative serum levels of interleukin-10 (IL-10) and interleukin-6 (IL-6) in patients with resectable hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA IL-10 is an immunosuppressive factor and IL-6 is a multifunctional cytokine that plays a role in host defense mechanisms. Both have been reported to be related to the disease prognosis in some human solid tumors. Their role in human HCC has not been investigated. METHODS Preoperative serum samples of 67 patients with HCC who underwent potentially curative resection and 27 normal healthy donors were assayed. Levels of IL-10 and IL-6 were determined by enzyme-linked immunosorbent assay. The clinical significance of serum IL-10 and IL-6 was evaluated and compared with conventional clinicopathologic factors. RESULTS Levels of IL-10 and IL-6 were significantly higher in patients with HCC than in healthy subjects. There was no correlation between IL-10 and IL-6 levels. Tumor resection resulted in a decrease in IL-10 and IL-6 levels. On univariate analysis, patients with high IL-10 levels had a worse disease-free survival, but IL-6 levels had no correlation with the disease-free survival. Multivariate analysis identified IL-10 levels as a predictor of postresectional outcome, in addition to the well-established clinical risk factors. CONCLUSIONS In patients with HCC, the preoperative serum IL-10 level is related to the clinical outcome. IL-10 may play an important role in the progression of HCC.

Prognostic indicators for survival after curative resection for patients with carcinoma of the stomach

This study aims to determine prognosticindicators among patient-, tumor-, and treatmentrelatedfactors of gastric cancer patients. A total of 510patients who underwent curative gastric resection were studied. Univariate analysis of patient-relatedfactors showed a significantly lower survival inpatients with a history of obstruction, hypoalbuminemia,and anemia. Tumor-related factors including gross appearance, location, and size of tumor; depthof cancer invasion; level, number, and frequency oflymph node metastasis; stromal reaction and tumor growthpattern; and histological classification allsignificantly affected survival. Surgical treatment relatedfactors such as total or distal subtotal gastrectomy,extent of lymphadenectomy, and combined resection ofadjacent organ(s) showed a statistically significant adverse influence on survival. Multivariateanalysis identified only four tumor-related factors— number of metastatic lymph nodes, depth ofcancer invasion, stromal reaction, and gross appearanceof the tumor — as independently affectingsurvival. These findings suggest that only fourtumor-related factors were prognostic indicators inpatients with gastric cancer.

Salvianolic acid b enhances in vitro angiogenesis and improves skin flap survival in sprague-dawley rats1 ☆

Abstract Insufficient angiogenesis and microcirculatory intravascular clotting have been implicated in the pathophysiology of skin flap failure. Salvianolic acid B (Sal B), isolated from Salvia miltiorrhiza, has been reported to enhance angiogenesis in vitro. This study was aimed to determine the efficacy of Sal B on ischemia-reperfusion injury of the skin flap in Sprague-Dawley rats. Sal B was administered intraperitoneally 2 h before operation, and on the 2nd and 4th days after surgical elevation of an extended epigastric adipocutaneous flap (5 × 7 cm) in ketamine-anesthetized rats. Flap ischemia was achieved by ligating the right superficial epigastric artery and vein and clamping the left superficial epigastric artery and vein for 3 h and then released. Percentage of flap necrosis area (FNA) and plasma levels of aspartate aminotransferase, alanine aminotransferase, creatinine, and malondialdehyde were measured at 7 days after the operation. Animals were divided into six groups, including: vehicle, Sal B low dose (5 mg/kg), Sal B high dose (50 mg/kg) and each with [mesh(+)] or without mesh [mesh(–)] placement. In the three groups with mesh(+), FNA in control flaps was 53.7 ± 6.9%, whereas low-dose and high-dose Sal B significantly improved flap survival with FNA 27.4 ± 3.8% and 25.3 ± 4.3%, respectively (P

Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy.

Objectives: Pancreatic exocrine insufficiency has been reported to be more common in pancreaticogastrostomy (PG) than in pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). This study aimed to evaluate the long-term outcome after PD between these 2 groups. Methods: We evaluated the long-term functional status of 42 surviving patients diagnosed with periampullary lesions who underwent PJ or PG after PD and followed up for more than 1 year. Among these, 23 patients underwent PJ and 19 patients underwent PG. To compare the 2 groups, we analyzed the (1) pancreatic exocrine insufficiency by questioning the presence or absence of steatorrhea, (2) pancreatic endocrine function by measuring glycohemoglobin A1c, fasting blood glucose, and history of new-onset diabetes, (3) nutritional status by measuring serum total protein, albumin, cholesterol, and triglyceride, (4) gastric emptying time, (5) panendoscopic findings, (6) changes of pancreatic duct diameter by computed tomography, and (7) relaparotomy rate. Results: The mean follow-up time for PG and PJ were 37 ± 23 and 103 ± 52 months, respectively (P < 0.05). A total of 52.4% patients developed pancreatic exocrine insufficiency, and 11.9% had new-onset diabetes. There was no significant difference between PJ and PG groups. A significantly improved postoperative nutritional state regarding serum total protein and albumin were noticed in both groups. There was no significant difference in terms of gastric emptying time, positive panendoscopic findings, and changes in pancreatic duct diameter. The pancreatic remnant-related relaparotomy rate was higher in the PJ group as compared with the PG group (17.4% vs 0%; P = 0.056). Conclusions: There is no significant difference in pancreatic exocrine or endocrine insufficiency, gastric emptying time, and positive panendoscopic findings between PJ and PG. Pancreaticojejunostomy was associated with a higher pancreatic remnant-related relaparotomy rate; however, because of a shorter follow-up in the PG group, a continuous long-term follow-up is still needed.

Effect of Transcutaneous Electrical Nerve Stimulation for Pain Relief on Patients Undergoing Hemorrhoidectomy: Prospective, Randomized, Controlled Trial

PURPOSE: Posthemorrhoidectomy pain control remains a challenging problem. Transcutaneous electrical nerve stimulation is known to be effective in the treatment of many diseases. Our aim was to investigate the effect of transcutaneous electrical nerve stimulation on pain relief in patients undergoing hemorrhoidectomy. METHODS: Sixty patients with symptomatic hemorrhoids were randomly allocated into two groups, the acupoint group (n=30) and the nonpoint control group (n=30). Transcutaneous electrical nerve stimulation was applied to those patients who received hemorrhoidectomy, and patient-controlled analgesia was achieved by injection of morphine through ambulatory infusion pumps. The dependent measures in this study were pain score from 0 (no pain) to 10 (agonizing pain), analgesic doses administrated through patient-controlled analgesia, and postoperative complications. RESULTS: The subjective pain scores evaluated 8, 12, 16, and 24 hours after hemorrhoidectomy in the control group and the acupoint group were 5.9±0.5 and 4.1±0.5, 5.7±0.5 and 3.5±0.4, 4.1±0.4 and 2.3±0.3, and 3.2±0.4 and 1.9±0.2, respectively (two-way analysis of variance;P<0.05). There was a significant difference between treatment groups in morphine use, with 11.6±2.2 mg in the control group and 6.2±1.3 mg in the acupoint group (P<0.05). The acupoint group tended to have less postoperative acute urinary retention (Fishers exact probability test;P=0.145) and less need for analgesics than the control group (P=0.112, Fishers exact test). CONCLUSION: Transcutaneous electrical nerve stimulation is effective for pain relief in patients receiving hemorrhoidectomy. Its efficacy and safety could assist outpatient pain management after hemorrhoidectomy.

Manifestations of hypercholesterolaemia, hypoglycaemia, erythrocytosis and hypercalcaemia in patients with hepatocellular carcinoma: Report of two cases

Background : Hypercholesterolaemia, hypoglycaemia, hypercalcaemia and erythrocytosis, are well‐known paraneoplastic manifestations in patients with hepatocellular carcinoma (HCC). Hepatocellular carcinoma patients manifesting with two or three paraneoplastic manifestations have been previously reported. However, HCC patients presenting with four paraneoplastic syndromes have not been previously reported.

Cordyceps sinensis Increases the Expression of Major Histocompatibility Complex Class II Antigens on Human Hepatoma Cell Line HA22T/VGH Cells

Previous studies suggest that down-regulation of the major histocompatibility complex (MHC) antigens on the cell surface of certain tumors results in an escape of immune surveillance. Cordyceps sinensis is well known for its modulatory effect on host immune system. To investigate the modulatory effect of Cordyceps sinensis on MHC class II antigen expression on hepatoma cells, immunostaining with monoclonal antibody (MAb) L243, against the HLA DR region of MHC class II antigens on human hepatoma cell line HA22T/VGH was analyzed by using flow cytofluorimetry. The degree of fluorescence intensity on L243(+) cells was expressed as relative mean fluorescence intensity (RMFI). The extract of Cordyceps sinensis (VGH-CS-ME-82, 40 micrograms/ml) was found to increase the MHC class II antigen expression on HA22T/VGH cells with the percentage of L243(+) cells 40.2 +/- 2.5 and RMFI 6.6 +/- 0.4; whereas cells without treatment disclosed the percentage of L243(+) cells 17.2 +/- 1.4 and RMFI 5.4 +/- 0.3, respectively (p < 0.05). There was a dose-related increase in the degree of fluorescence intensity in terms of RMFI on VGH-CS-ME-82 induced cells. The RMFI in cells treated with IFN-gamma 0, 0.2 and 5 ng/ml were 5.4 +/- 0.3, 8.2 +/- 0.4, and 24.9 +/- 1.5, respectively; whereas the RMFI in cells co-incubated with VGH-CS-ME-82 (40 micrograms/ml) and IFN-gamma 0, 0.2 ng/ml and 5 ng/ml were 6.7 +/- 0.2 (p < 0.05), 9.2 +/- 0.9 (p < 0.1) and 29.5 +/- 1.2 (p < 0.005), respectively. We conclude that VGH-CS-ME-82, either alone or with IFN-gamma induction, increases the MHC class II antigen expression on hepatoma cell line HA22T/VGH, which will shed light into the present immunotherapy, and make the host immune surveillance more effective against tumor cells with down-regulated MHC class II antigen expression.

Somatic electrical nerve stimulation regulates the motility of sphincter of Oddi in rabbits and cats: evidence for a somatovisceral reflex mediated by cholecystokinin.

Cholecystokinin (CCK) plays an important role inregulating the biliary motility in herbivorous andcarnivorous animals. Little is known about how themotility of the sphincter of Oddi (SO) is regulated through a somatic stimulation. It was our aimto test the hypothesis that somatic electrical nervestimulation (SENS) affects SO motility in animals withdifferent types of SO through CCK-related mechanisms. The activity of SO in anesthetized rabbits andcats was measured by using a continuously perfusedopen-tip manometric method. SENS was brought about byapplying an electric current (2/15 Hz alternatively, 20 min) to two needles positioned near spinalnerves in the 6th and 7th intercostal space in the rightmidclavicular line. The SO motility before and X minafter the start of SENS, designated as pre-SENS and SENS-X respectively, were recorded andsaved in a computer equipped with off-line analysissoftware. The SO activity in rabbits, in terms of phasiccontraction pressure and duration of summation peak during SENS were significantly higher than thatbefore SENS. The phasic contraction pressure ofpre-SENS, SENS-10, and SENS-16 were 6.83 ± 0.39mm Hg, 9.23 ± 0.83 mm Hg and 10.46 ± 0.81mm Hg, respectively (P < 0.03, N = 13). The duration ofsummation peak in pre-SENS, SENS-10, and SENS-16 were7.26 ± 0.41 sec, 10.22 ± 0.46 sec, and13.49 ± 2.31 sec, respectively (P < 0.05, N =13). The SENS-induced SO hyperactivity was not inhibited bypretreatment with atropine, propranolol, phentolamine,or naloxone, but was blocked by pretreatment with theCCK receptor antagonist, proglumide, and by injection of anti-CCK-8 antibody during SENS in adose-dependent manner. In contrast, SENS induced aninhibitory SO response in cats. However, in bothcircumstances, an obvious elevation of plasma CCK leveldetermined by radioimmunoassay was noted after SENS. Weconclude that SENS causes secretion of CCK, which inturn affects biliary tract motility in animals withdifferent types of SO. This provides an easilyapplicable method for those patients who have hyperactiveSO function.