Correlation between salpingoscopic score and subsequent pregnancy outcome in patients with tubal infertility

PURPOSE

This study evaluated the efficacy of the salpingoscopic scoring system of tubal function.

METHODS

Twenty-seven infertile patients, including 10 patients with proximal tubal occlusion, 12 with endometriosis and 5 with inflammatory hydrosalpinx, were studied. All 54 tubes were examined using a 0.5-mm-diameter salpingoscope and scored.

RESULTS

The mean scores for patients with proximal tubal occlusion, endometriosis, and inflammation were 18.6 +/- 2.0, 15.6 +/- 0.7, and 20.8 +/- 3.4, respectively. Eight patients (29.6%) conceived; their mean tubal score was 12.6 +/- 0.5 (12-16). Nineteen patients did not conceive, and their mean score was 18.8 +/- 1.4 (12-31). There was a significant difference between these two scores (P < 0.001).

CONCLUSIONS

Scoring of the tubes by salpingoscopic examination is useful for evaluating tubal function with regard to prediction of pregnancy and also for selecting IVF or tubal reconstructive surgery as the preliminary treatment.

Hemorrhagic shock induces G-CSF expression in bronchial epithelium

Hemorrhagic shock (HS) initiates a series of inflammatory processes that includes the activation of polymorphonuclear granulocytic neutrophils (PMN). We tested the hypothesis that HS induces granulocyte colony-stimulating factor (G-CSF), a cytokine that augments PMN effector functions, in the lungs of rats. Sprague-Dawley rats were subjected to compensated or decompensated HS followed by resuscitation and death at 4 or 8 h. Animals subjected to HS demonstrated acute lung injury with PMN infiltration, edema, and hypoxia. Using semiquantitative reverse transcriptase-polymerase chain reaction, we detected a 1.9- to 7.1-fold increase in G-CSF mRNA levels in the lung of animals subjected to HS compared with sham controls. Levels of G-CSF mRNA increased with increased duration of the ischemic phase of resuscitated shock. In situ hybridization revealed that bronchoepithelial cells were the major cellular site of G-CSF mRNA. Thus production of G-CSF mRNA by bronchoepithelial cells is dramatically increased in a rat model of HS that also demonstrated lung injury. Increased local G-CSF levels may contribute to PMN recruitment and activation and resultant lung injury in HS.

Acute portal hypertension reflecting shear stress as a trigger of liver regeneration following partial hepatectomy

The concept of injury in liver regeneration after partial hepatectomy (PHx), and the reason hepatocytes that have not been directly injured regenerate, remain unclear. It is known that shear stress resulting from blood flow plays an important role in the mechanism of remodeling blood vessels, and portal pressure reflects shear stress. This study was conducted to determine whether acute portal hypertension (APH) can become a trigger of liver regeneration as shear stress following PHx in a rat model. Portal pressures became elevated immediately after 70% and 90% PHx, peaking on postoperative day (POD) 3, and thereafter decreasing in proportion to the diminution of liver regeneration. The portal pressures after 90% PHx were significantly higher than those after 70% PHx even on POD 7, while those of the portocaval (PC) shunt groups decreased following PC shunting both with and without 70% PHx. The liver/body weight (LW/BW) ratio also decreased in the PC shunt both with and even without 70% PHx. The gradient expressions of class I antigen on sinusoidal endothelial cells (SEC) were found only in the periportal area, which has the highest portal pressure in the healthy rat liver. However, after hepatectomy these expressions were detected from the periportal area to the central venous area. These results suggest that APH as shear stress following PHx may not only become a trigger of hepatocyte regeneration, but also of SEC regeneration, and that surplus APH induces liver dysfunction.

Lymph node recurrence of gallbladder carcinoma successfully managed by systemic chemotherapy with 5-fluorouracil and mitomycin C: report of a 5-year survivor

Although gallbladder cancer (GBC) is believed to be chemoresistant, the effectiveness of chemotherapy against lymph node metastasis has been reported. We report a 70-year-old woman with advanced GBC in whom isolated, widespread lymph nodal recurrence after a radical resection responded completely to systemic chemotherapy with mitomycin C and 5-fluorouracil. This patient remains symptom-free with no evidence of disease at 6 years after surgery (5 years after the initiation of chemotherapy). Both our case and a literature review suggest that nodal disease appears more chemosensitive than the primary lesion in GBC. Chemotherapy may provide long-term palliation for selected patients with isolated nodal recurrence.

Lymph node spread from carcinoma of the gallbladder

BACKGROUND

Lymph node spread is the most common pattern of progression in gallbladder carcinoma (GBC) and is a prognostic factor. The purpose of this study was to determine the prevalence of lymph node metastases in patients with resected advanced GBC, and to evaluate the curative effects of radical surgery for patients with lymph node metastasis.

METHODS

One hundred and eleven consecutive patients who had undergone radical surgery for GBC were included in this study. The pattern of lymph node metastases was examined histopathologically, using the TNM staging of the American Joint Committee on Cancer.

RESULTS

There was no neurovascular invasion or lymph node involvement in 15 patients with pT1 tumors. Sixty of 96 patients with pT2-4 tumors had lymph node metastases. The pericholedochal lymph node was the most common metastatic lymph node, followed by the cystic lymph node. The frequency of metastases in retroportal, posterosuperior pancreaticoduodenal, and interaorticocaval lymph nodes was >15% in all cases. pT3-4 tumors had significantly more lymph node involvement (79%) and significantly higher N2:N1 ratios (2.5) than pT2 tumors (46% and 0.6, respectively). There was no difference in 5-year survival between N0 and N1 groups in pT2-4 tumors (66% in N0 and 53% in N1). Patients with N2 disease had a significantly worse prognosis, but 4 patients survived >5 years.

CONCLUSIONS

The cystic and pericholedochal lymph nodes are the initial site of spread from GBC. The frequency of lymph node involvement is strongly influenced by the depth of invasion of the primary tumor. GBC limited to such lymph node metastases can be cured by surgery in >50% of such cases.

Lymph node spread from carcinoma of the gallbladder

BACKGROUND

Lymph node spread is the most common pattern of progression in gallbladder carcinoma (GBC) and is a prognostic factor. The purpose of this study was to determine the prevalence of lymph node metastases in patients with resected advanced GBC, and to evaluate the curative effects of radical surgery for patients with lymph node metastasis.

METHODS

One hundred and eleven consecutive patients who had undergone radical surgery for GBC were included in this study. The pattern of lymph node metastases was examined histopathologically, using the TNM staging of the American Joint Committee on Cancer.

RESULTS

There was no neurovascular invasion or lymph node involvement in 15 patients with pT1 tumors. Sixty of 96 patients with pT2-4 tumors had lymph node metastases. The pericholedochal lymph node was the most common metastatic lymph node, followed by the cystic lymph node. The frequency of metastases in retroportal, posterosuperior pancreaticoduodenal, and interaorticocaval lymph nodes was >15% in all cases. pT3-4 tumors had significantly more lymph node involvement (79%) and significantly higher N2:N1 ratios (2.5) than pT2 tumors (46% and 0.6, respectively). There was no difference in 5-year survival between N0 and N1 groups in pT2-4 tumors (66% in N0 and 53% in N1). Patients with N2 disease had a significantly worse prognosis, but 4 patients survived >5 years.

CONCLUSIONS

The cystic and pericholedochal lymph nodes are the initial site of spread from GBC. The frequency of lymph node involvement is strongly influenced by the depth of invasion of the primary tumor. GBC limited to such lymph node metastases can be cured by surgery in >50% of such cases.

Molecular cloning of rat p38 mitogen-activated protein kinase and it's osmotic regulation in rat kidney

Rat p38 mitogen-activated protein (MAP) kinase cDNA was isolated from rat kidney cDNA library using a PCR cloning strategy. The deduced amino acid sequence consists of 360 amino acids and shares 95.3% similarity with human p38 MAP kinase. The message for rat p38 MAP kinase was about 3.4 kilobases and was highly expressed in the kidney. In water-deprived rat kidneys, the steady-state levels of p38 MAP kinase mRNA increased about 2.7-fold as compared with those of control rats. This result suggests that p38 MAP kinase may play an important role in the osmoregulation in the kidney.

Validity and reliability of Structured Interview for Competency Incompetency Assessment Testing and Ranking Inventory

The Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory (SICIATRI) is a structured interview guide to assess the competency for giving informed consent to treatment among psychiatric and medical patients. The competency levels of 48 psychiatric and medical inpatients were assessed by SICIATRI. A relatively high- inter-rater reliability of the SICIATRI items (over half of the items had kappa > or = .60) and concurrent validity (sensitivity = .83, specificity = .67 as measured against the global judgement of competency rating by the attending physician) were obtained. In addition to its brevity (it takes about 20 minutes to complete), these findings may warrant application of this instrument in a clinical setting.

[New aspects in the liver regeneration following partial hepatectomy]

We demonstrated the new two concepts for the liver regeneration after partial hepatectomy (PHx). The first is immunological findings in the regenerating liver. Th1 type T cells, which produce IFN gamma, and extrathymic T cells may play an important role in immunological control system of liver regeneration after PHx on the basis of the cellular immunity restricted by MHC class I and II molecules. The second is the mechanism of "on and off" on liver regeneration after PHx. Portal pressure, which reflecting wall shear stress of sinusoid, may trigger the liver regeneration and control the liver volume after PHx. There are two type of intrahepatic leukocytes; one type would tend to stay associated with SEC, while the other would not. Therefore shear stress may have a great influence on the leukocytes-sinusoidal endothelial cells (SEC) adhesion immediately after partial hepatectomy.

Differential expression of S-adenosylmethionine synthetase isozymes in different cell types of rat liver

Mammalian S-adenosylmethionine (AdoMet) synthetase exists as two isozymes, liver-type and nonhepatic-type enzymes, which are the products of two different genes. It is known that the liver-type isozyme is only expressed in adult liver. Whereas, the nonhepatic-type isozyme is widely distributed in various tissues. In addition to the liver-type isozyme, a minor amount of the nonhepatic-type isozyme is also detected in adult liver. To investigate the distribution of these two isozymes in the liver in detail, the localization of these two isozymes was examined in each cell type of liver using a combination of cell fractionation technique and Western blot analysis. In the parenchymal cells, the liver-type isozyme protein was predominantly expressed, and a small amount of the nonhepatic-type isozyme protein was also detected. On the other hand, in the stellate cells the nonhepatic-type isozyme protein was exclusively or only expressed. Interestingly, a large amount of both isozymes were present in endothelial and Kupffer cell fraction. Using both antibodies to anti-rat nonhepatic-type and liver-type isozymes, respectively, immunohistochemical analysis clearly confirmed these results. In addition, in cultured hepatocellular carcinoma cells (FAA-HTC1), the nonhepatic-type isozyme protein only was detected, and the liver-type isozyme protein completely disappeared. This result indicates that the changes in the isozyme expression is regulated within the parenchymal cells. Administration of hepatotoxic drug carbon tetrachloride (CCl4) to rats resulted in about 40% to 50% reduction of enzyme activity in parenchymal cells and stellate cells compared with those of control rats. However, enzyme activity in endothelial and Kupffer cell fraction was not changed.

Phosphorylation of human general transcription factors TATA-binding protein and transcription factor IIB by DNA-dependent protein kinase--synergistic stimulation of RNA polymerase II basal transcription in vitro

DNA-dependent protein kinase (DNA-PK) has been known to catalyze phosphorylation of a number of regulatory factors involved in DNA replication and transcription such as simian virus 40 T antigen, p53, c-Myc, Sp1, and RNA polymerase II (Pol II). We examined the possibility that DNA-PK phosphorylates the general transcription factors TATA-binding protein (TBP) and transcription factor (TF) IIB, which play key roles in the formation of transcription initiation complex with Pol II. By using a highly purified preparation of DNA-PK from Raji cells, both TBP and TFIIB were shown to be phosphorylated in vitro by DNA-PK. We then investigated the effect of the phosphorylation of these factors on Pol II basal transcription. Stepwise analysis of preinitiation complex formation by electrophoretic mobility shift assay revealed that the phosphorylation of TBP and TFIIB by DNA-PK did not affect the formation of promoter (P)-TBP and P-TBP-TFIIB complexes but synergistically stimulated the formation of P-TBP-TFIIB-TFIIF-Pol II complex. Similarly, combination of the phosphorylated TBP and TFIIB synergistically stimulated Pol II basal transcription from adenovirus major late promoter. These observations suggest that DNA-PK could positively regulate the Pol II basal transcription by phosphorylating TBP and TFIIB.

Synchronous primary tumors of the extrahepatic bile duct and gallbladder

BACKGROUND AND OBJECTIVES

This study aims to clarify clinicopathologic characteristics of synchronous primaries of the extrahepatic bile duct and gallbladder. Understanding multiplicity and its histologic confirmation is an important step for successful surgical management.

METHODS

Of the 190 cases of resection of biliary tract neoplasms in this study, 10 had two separate tumors in the extrahepatic bile duct and gallbladder, which were investigated by the microscopic mapping technique for tumor extent using serial stepwise sectioning of specimens.

RESULTS

Clinical diagnosis was made successfully in only two cases. Detailed histologic examination revealed seven cases with synchronous primaries and three cases with metastatic tumors. Several microscopic parameters had additional diagnostic value. The presence of synchronous primaries is not necessarily associated with a poor prognosis, since we had four long-term survivors.

CONCLUSIONS

Diagnosis of synchronous extrahepatic biliary neoplasms is rarely made preoperatively. However, aggressive resection and careful microscopic examination are essential for the successful management and diagnosis of these special cases.

Patterns of lymphatic spread of carcinoma of the ampulla of Vater

BACKGROUND

The pattern of lymphatic spread of ampullary cancer is poorly documented. This pattern was clarified in order to define the rational extent of radical lymphadenectomy.

METHOD

Thirty-nine consecutive patients who underwent pancreaticoduodenectomy with radical lymphadenectomy were included in the study. A total of 1447 lymph nodes dissected from the resected specimens was examined to detect the presence of metastatic foci.

RESULTS

Twenty-one of the 39 patients had a total of 97 positive nodes. The sites of nodal involvement were the posterior pancreaticoduodenal (20 of 21 patients), inferior pancreaticoduodenal artery (IPDA; 12 of 21), anterior pancreaticoduodenal (three of 21), trunk of the superior mesenteric artery (three of 20), pericholedochal (three of 21), retroportal (two of 21), and para-aortic (three of five) regions. No metastases were found in the hepatic artery, cystic duct, perigastric, right coeliac, middle colic artery or right caval node groups.

CONCLUSION

Ampullary cancer mainly spreads to the posterior pancreaticoduodenal node group, then to the IPDA node group, and finally to the para-aortic area. The rational extent of radical lymphadenectomy should include the pancreaticoduodenal, superior mesenteric, pericholedochal, retroportal and para-aortic nodes.

Transthoraco-phrenic esophageal transection with paraesophago-gastric devascularization and splenectomy using a stapler

BACKGROUND/AIMS

Surgery remains the most reliable treatment for bleeding esophageal varices. The aim of this study was to introduce the operative technique of transthoraco-phrenic esophageal transection with paraesophagogastric devascularization using a stapler and to evaluate surgical results.

METHODS

Forty-five patients underwent the procedure; an elective procedure was performed in 22 patients (bleeders) and a prophylactic procedure in 23 patients (nonbleeders). Twenty-nine patients were classified as Child's A, 15 as B and 1 as C. Previous sclerotherapy had been performed in 5 patients.

RESULTS

No hospital deaths occurred. No patients developed postoperative anastomotic leakage, encephalopathy, or any complications related to phrenicotomy. Three patients bled postoperatively from recurrent esophageal varices. Cumulative 5-year bleeding rates were 5.0% in bleeders and 6.6% in non-bleeders. Two patients died due to bleeding varices. Cumulative 5-year survival rates were 72.1% and 78.8% in patients classified as Child's A and Child's B, respectively.

CONCLUSIONS

This procedure may be indicated for a majority of Child's A or B patients. Although the advantages of this procedure must be evaluated further, it may be an alternative when injection sclerotherapy and endoscopic ligation fail.

Intraluminal duodenal diverticulum with malposition of the ampulla of Vater

Intraluminal duodenal diverticulum is a rare congenital anomaly, sometimes associated with malposition of the ampulla of Vater. When the diverticulum is excised, the position of the ampulla should be determined carefully to avoid injury to pancreaticobiliary ducts. We report two patients with symptomatic intraluminal duodenal diverticulum and malposition of the ampulla. The ampulla was located on the rim of the diverticulum in one patient; in the others, the ampullary site was the posterior wall of the duodenum. Both patients underwent successful excision of the diverticulum without ductal injuries. As we have been unable to find any case with an ampullary location on the anterior wall of the duodenum, anterior duodenotomy followed by identification of the ampulla must precede excision of the diverticulum in order to avoid pancreaticobiliary ductal injuries.

Groove pancreatitis with recurrent duodenal obstruction. Report of a case successfully treated with pylorus-preserving pancreaticoduodenectomy

Groove pancreatitis is a rare subtype of chronic pancreatitis that is difficult to distinguish from pancreatic carcinoma. Most reported patients have undergone a Whipple procedure because pancreatic cancer was not ruled out. We report a case of groove pancreatitis in a patient who presented with recurrent duodenal obstruction without biliary stricture. The diagnosis of groove pancreatitis was based on characteristic episodes of repeated duodenal obstruction and the absence of radiographic evidence of cancer. Subsequently, our patient underwent a successful pylorus-preserving pancreaticoduodenectomy (PPPD). PPPD is a favorable alternative to the Whipple operation for duodenal obstruction resulting from this disease.

Pancreaticoduodenectomy for gallbladder cancer with peripancreatic nodal metastases

The prognosis of patients with advanced gallbladder carcinoma remains dismal. In the English language literature, we found only one 5-year survivor with peripancreatic lymph node metastases. We herein report a patient with marked peripancreatic nodal metastases, who has exhibited the longest survival (6 years) without recurrence after a pancreaticoduodenectomy combined with extended cholecystectomy. This outcome suggests that pancreaticoduodenectomy may be effective for clearance of peripancreatic nodal metastases from gallbladder cancer.

Right hepatectomy for pyogenic liver abscesses with true multiloculation

We report the case of 61-year-old woman with cryptogenic liver abscesses who had been profoundly ill with severe upper abdominal pain, impaired consciousness, prostration, continuous high fever secondary to sepsis, and thrombocytopenia (platelets, 1-5 x 10(4)/mm3) since admission. Ultrasonograms and computed tomograms revealed two separate multiloculated lesions in the right lobe of the liver, consistent with the liver abscesses. Immediately after diagnosis, percutaneous abscess drainage was performed under ultrasonographic guidance; however, only a small amount of pus was drained, prompting continuous irrigation of the abscess cavity. Four days later, transcatheter hepatic arterial infusion of antibiotics was attempted. However, the abscesses had enlarged and her general condition had worsened. On hospital day 8, she underwent right hepatectomy because the multiloculated lesions were refractory to drainage. The operation was successful in terms of hepatectomy, although she continued to suffer from sepsis, secondary right subphrenic abscess formation, and prolonged thrombocytopenia with associated coagulation disorders for two months. Examination of multiple cross sections of the resected specimen disclosed that the lesions consisted of aggregations of multiple small locules. There was no communication between the locules and there were true septations, rather than multiloculated lesions with pseudoseptations. The patient has been well for 2 years without recurrent abscess of the liver or any infectious disease.

Serial changes in contribution of substrates to energy expenditure after transthoracic esophagectomy for cancer

This study was designed to examine the metabolic response of patients following transthoracic esophagectomy for carcinoma of the esophagus during the administration of total parenteral nutrition. Thirty-five patients underwent a right thoracotomy and transthoracic esophagectomy with nodal dissection in the neck, mediastinum, and abdomen. The resting energy expenditure (REE) was measured preoperatively, and on the 1st, 3rd, 5th, and 7th postoperative days (PODs) using indirect calorimetry. The REE was significantly higher following transthoracic esophagectomy on PODs 1, 3, 5, and 7 than preoperatively. The caloric contribution of fat was significantly less on 3rd, 5th, and 7th PODs than on the 1st POD. In contrast, carbohydrate oxidation increased significantly on the 3rd, 5th, and 7th PODs compared to that of the 1st POD. These results may help optimize the nutritional support regimen for post-esophagectomy patients.

Omental delivery of prostaglandin E1 effectively increases portal venous blood flow in 66%-hepatectomized rats

Changes in portal venous blood flow (PVF) and systemic arterial blood pressure (SAP) were examined following prostaglandin E1 (PGE) application to the greater omentum and femoral vein in 66%-hepatectomized rats. PVF increased when PGE was administered to the omentum and femoral vein at 7.5 micrograms/kg per min for 2 min. The magnitude of PVF response due to both administrations was dose-dependent, but the duration of the PVF response in the omental application was longer than that in the femoral administration. SAP was unchanged after omental application, while femoral administration reduced SAP concomitant with an increase in PVF. These results suggest that, in this hepatectomized model, the omentum is a better site for PGE administration than the vein, and that omental PGE delivery is also effective for enhancing PVF without inducing any changes in SAP.

Preventive effect of 1-(2-tetrahydrofuryl)-5-fluorouracil in combination with uracil on colonic carcinogenesis induced by 1,2-dimethylhydrazine in rats

Thymidylate synthetase (TS) and thymidine kinase (TK) are key enzymes in de novo and salvage pathways for pyrimidine nucleotide synthesis, respectively. A high incidence of colorectal adenocarcinomas with varied grades of cell differentiation can be induced by 1,2-dimethylhydrazine (DMH) in rats. The marked increases of TS and TK activities were found in the poorly and well-differentiated adenocarcinomas of the colon, respectively. Oral administration of 1-(2-tetrahydrofuryl)-5-fluorouracil in combination with uracil (UFT) markedly reduced the number and accumulated area of colonic carcinomas, and TS activity in the poorly differentiated adenocarcinomas. A potential balance between the de novo and the salvage pathways for pyrimidine nucleotide synthesis was suggested to be related with the histopathological grades of cell differentiation. Suppression of colonic TS activity by UFT administration reduced the colonic carcinogenesis and the potency of the poorly differentiated adenocarcinomas of the colon.