Chylous ascites after hepatopancreatobiliary surgery

Background

Postoperative chylous ascites following abdominal surgery is uncommon. It potentially induces malnutrition and immunodeficiency, contributing to increased mortality. In the field of hepatopancreatobiliary (HPB) surgery, no large studies have been conducted that focused on postoperative chylous ascites. The aim of this study was to determine the incidence, risk factors and management of chylous ascites following HPB surgery, with particular emphasis on pancreatic resection.

Methods

Consecutive patients who had HPB surgery between 2000 and 2011 at a single institution were reviewed retrospectively. Chyle leak was defined as 100 ml/day or more of milky, amylase-free peritoneal fluid with a triglyceride concentration of 110 mg/dl or above. Risk factors for chylous ascites associated with pancreatic resection and the clinical efficacy of octreotide in treating chylous ascites were evaluated.

Results

Of 2002 consecutive patients who underwent HPB surgery during the study period, 21 (1·0 per cent) developed chylous ascites. Chylous ascites occurred relatively frequently in patients who had a pancreatic resection, such as pancreaticoduodenectomy (3·3 per cent) or distal pancreatectomy (3·8 per cent). Multivariable analysis revealed that manipulation of the para-aortic area (P < 0·001), retroperitoneal invasion (P = 0·031) and early enteral feeding after operation (P < 0·001) were independent risk factors for chylous ascites following pancreatic resection. Octreotide treatment decreased drainage output of chylous ascites on day 1 after initiation of treatment (P = 0·002).

Conclusion

Chylous ascites is a rare complication following HPB surgery. It is more common after pancreatic resection. Treatment with octreotide combined with total parenteral nutrition is recommended.

Chu H, Peters AT, Tan BK, Conley DB, Grammer LC, Kern RC, Schleimer RP. Reduced expression of antimicrobial PLUNC proteins in nasal polyp tissues of patients with chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a disease characterized by inflammation of the nasal mucosa and paranasal sinuses. This inflammation may result in part from decreased epithelial barrier and innate immune responses, leading to frequent bacterial and fungal colonization. The objectives of this study were to investigate the expression of innate immune proteins of the palate lung and nasal epithelium clone (PLUNC) family in patients with CRS.

METHODS

Nasal tissue samples were collected from control subjects and CRS patients with and without nasal polyps. Expression of the members of the PLUNC family was analyzed by real-time PCR. Expression of SPLUNC1 and LPLUNC2 proteins was analyzed by ELISA, immunoblot, and immunohistochemical analysis.

RESULTS

Levels of mRNA for most of the members of the PLUNC family were profoundly reduced in nasal polyps (NPs) compared to uncinate tissue from control subjects or patients with CRS. LPLUNC2 and SPLUNC1 proteins were decreased in NPs of patients with CRS compared to uncinate tissue from control subjects. Immunohistochemical data revealed that within submucosal glands of sinonasal tissues, SPLUNC1 and LPLUNC2 were differentially expressed, in serous and mucous cells, respectively. The decrease in the expression of these molecules is probably explained by a decrease in the number of glands in NPs as revealed by correlations with levels of the glandular marker lactoferrin.

CONCLUSIONS

Decreased SPLUNC1 and LPLUNC2 in NPs reflect a profound decrease in the number of submucosal glands. Decreased glands may lead to a localized defect in the production and release of glandular innate defense molecules.

Application of collagen hydrogel/sponge scaffold facilitates periodontal wound healing in class II furcation defects in beagle dogs

BACKGROUND AND OBJECTIVE

A three-dimensional scaffold may play an important role in periodontal tissue engineering. We prepared bio-safe collagen hydrogel, which exhibits properties similar to those of native extracellular matrix. The aim of this study was to examine the effect of implantation of collagen hydrogel/sponge scaffold on periodontal wound healing in class II furcation defects in dogs.

MATERIAL AND METHODS

The collagen hydrogel/sponge scaffold was prepared by injecting collagen hydrogel, cross-linked to the ascorbate-copper ion system, into a collagen sponge. Class II furcation defects (of 5 mm depth and 3 mm width) were surgically created in beagle dogs. The exposed root surface was planed and demineralized with EDTA. In the experimental group, the defect was filled with collagen hydrogel/sponge scaffold. In the control group, no implantation was performed. Histometric parameters were evaluated 2 and 4 wk after surgery.

RESULTS

At 2 wk, the collagen hydrogel/sponge scaffold displayed high biocompatibility and biodegradability with numerous cells infiltrating the scaffold. In the experimental group, reconstruction of alveolar bone and cementum was frequently observed 4 wk after surgery. Periodontal ligament tissue was also re-established between alveolar bone and cementum. Volumes of new bone, new cementum and new periodontal ligament were significantly greater in the experimental group than in the control group. In addition, epithelial down-growth was suppressed by application of collagen hydrogel.

CONCLUSION

The collagen hydrogel/sponge scaffold possessed high tissue compatibility and degradability. Implantation of the scaffold facilitated periodontal wound healing in class II furcation defects in beagle dogs.

Differential expression of interleukin-32 in chronic rhinosinusitis with and without nasal polyps

BACKGROUND

  Chronic rhinosinusitis (CRS) is a heterogeneous disease characterized by local inflammation of the upper airways and sinuses and is frequently divided into polypoid CRS (CRSwNP) and nonpolypoid CRS (CRSsNP). However, the mechanism of inflammation in CRS has still not been fully elucidated. The aim of the study was to investigate the role of interleukin-32 (IL-32), a recently discovered proinflammatory cytokine, in CRS.

METHODS

  We collected nasal epithelial cells and nasal tissue from patients with CRS and control subjects. We assayed mRNA for IL-32 by real-time PCR and measured IL-32 protein using ELISA, Western blot, and immunohistochemistry.

RESULTS

  The expression of mRNA for IL-32 was elevated in epithelial cells from uncinate tissue from patients with CRSsNP compared with patients with CRSwNP (P < 0.05), control subjects (P=0.06), and epithelial cells from nasal polyp (NP) tissue (P < 0.05). Production of IL-32 was induced by IFN-γ, TNF, and dsRNA in primary airway epithelial cells. In whole-tissue extracts, the expression of IL-32 protein was significantly elevated in patients with CRSwNP compared with patients with CRSsNP and control subjects. Immunohistochemistry data showed that IL-32 was detected in mucosal epithelial cells and inflammatory cells in the lamina propria. Levels of IL-32 were correlated with the levels of CD3 and macrophage mannose receptor in NP tissue. Immunofluorescence data showed IL-32 co-localization with CD3-positive T cells and CD68-positive macrophages in NPs.

CONCLUSION

  Overproduction of IL-32 may be involved in the pathogenesis of CRS, although the role of IL-32 in the inflammation in CRSsNP and CRSwNP may be different.

Spontaneous glomerular and tubulointerstitial lesions in common marmosets (Callithrix jacchus)

Spontaneous progressive nephropathy dominated by glomerular lesions in common marmosets has been reported. However, the histopathologic characteristics, including the relationship between glomerular and tubulointerstitial lesions, have not been described in detail. In the present study, the authors examined the histopathologic characteristics of the background renal lesions in common marmosets (3 males and 9 females, 3 to 8 years old). The severity of glomerular lesions was graded into 3 classes: grade I, no alteration; grade II, hilar/focal increase of mesangial matrix; grade III, global/diffuse increase of mesangial matrix. Tubulointerstitial lesions (tubular regeneration and hyperplasia and interstitial inflammation and fibrosis) were scored according to the area of each lesion. The renal lesions were characterized by enlargement of glomeruli, expanded mesangial area with increase of periodic acid-Schiff reaction-positive matrix, tubular regeneration and hyperplasia, and interstitial inflammation and fibrosis. Glomerular lesions progressed with increasing mesangial matrix and aging. Additionally, the tubulointerstitial lesions became exacerbated with progressing glomerular lesions. Tubular hyperplasia was divided into 4 types according to the structure of the cell layer (simple or stratified-like), the area of increased lining cells (partial or entire), cytoplasmic staining (eosinophilic or basophilic), brush border and thickness of basement membrane, and the activity of cell proliferation. In conclusion, the background renal lesions in common marmosets were characterized by glomerular lesions with increase of mesangial matrix, which progressed with aging, and secondary tubulointerstitial lesions, including tubular hyperplasia. Those lesions were thus diagnosed as progressive glomerulonephropathy in common marmosets.

Angiopoietin-like protein 2 sensitively responds to weight reduction induced by lifestyle intervention on overweight Japanese men

OBJECTIVE

Overexpression of Angiopoietin-like protein 2 (Angptl2) in obese adipose tissues promotes adipose tissue inflammation and its-related metabolic abnormalities. In a comparative study with adiponectin, we investigated whether alterations in serum Angptl2 concentrations reflect the effect of lifestyle intervention on weight loss and improved metabolic parameters in overweight subjects.

METHODS

A total of 154 Japanese men (age, 40.9±5.1 years; body mass index, 26.9±3.6 kg m(-2); abdominal circumference, 94.1±8.9 cm) underwent a 3-month lifestyle intervention and underwent follow-up for 3 months thereafter.

RESULTS

Decreased serum Angptl2 levels, but not increased serum adiponectin levels, were immediately apparent at the end of 3-month lifestyle intervention. Angptl2 levels continued to decrease for 3 months in parallel with body weight loss and improvement in metabolic indicators. In subjects showing 6% weight reduction, markedly reduced Angptl2 levels were detected at the end of 3-month intervention, whereas increased adiponectin levels were detected 3 months after the end of intervention. Multivariate analysis revealed changes in serum Angptl2 levels associated with changes in triglycerides (TGs), aspartate aminotransferase and alanine aminotransferase. In contrast, changes in serum adiponectin levels were associated with altered high-density lipoprotein cholesterol (HDL-C) and fasting plasma glucose levels.

CONCLUSION

A 3-month lifestyle intervention promoted weight reduction and improved glucose and lipid metabolism, an effect maintained 3 months later. Notably, our findings indicate that decreased Angptl2 levels are a good indicator of reduced visceral fat and metabolic improvement at early stages of lifestyle intervention. Thus, Angptl2 reflects adiposity and might be a key protein to regulate inflammation and TG metabolism, whereas adiponectin levels could reflect improved glucose and HDL-C metabolism.

Preparation of Spherical Titania Particles from Inorganic Precursor by Homogeneous Precipitation

Spherical titania particles can be prepared in a short time period from an aqueous solution of TiOSO4 by homogeneous precipitation using urea at 70–90°C. Although the hydrolysis of TiOSO4 continues to a considerable extent even in the absence of urea, the presence of urea is essential for the formation of spherical particles. The average particle size produced was l–4μm and changed mainly with the concentration of TiOSO4. As-synthesized powders are amorphous hydrates of titania containing sulfate group and crystallize by calcination into anatase(>500°C) and rutile(>900°C). In calcination, the particles shrink, but hold their original spherical shapes.

"Bonnet" bypass to proximal trunk of middle cerebral artery with a radial artery interposition graft: technical note

BACKGROUND

Anastomosis of the superficial temporal artery (STA) to the middle cerebral artery (MCA) is useful for treating certain patients with internal carotid artery occlusion or MCA occlusion. However, in the case of common carotid artery (CCA) occlusion, since the blood flow in the STA is insufficient, another artery should be used as the donor artery. The cortical branches of the MCA are usually selected as recipients in the STA-MCA bypass. However, the intracranial vascular filling gradually increases over a few months after conventional cortical MCA bypass grafting, while early or even immediate vascular filling is observed after proximal MCA bypass grafting. This study aims to develop an elongation technique of the contralateral STA to reach the proximal segment of the ipsilateral MCA.

METHODS

Anastomosis of the contralateral STA to the secondary trunk of the ipsilateral MCA was performed in 2 patients with occlusion of the CCA and ipsilateral vertebral artery (VA). The contralateral STA was extended with a radial artery (RA) graft in order to supply blood to the ischemic area. Elongation of the STA by using an RA interposition graft sufficiently lengthens the graft to enable its anastomosis with the contralateral M2 segment. Postoperative imaging revealed good bypass patency even at 1 year after the surgery.

CONCLUSION

This novel technique of performing the "bonnet" bypass was effective in treating both CCA and ipsilateral VA occlusion; moreover, this procedure of elongation of the STA can increase candidates of the recipient, and enables one to perform a double bypass to the anterior cerebral artery (ACA) or posterior cerebral artery (PCA).

Increased circulating cell signalling phosphoproteins in sera are useful for the detection of pancreatic cancer

BACKGROUND

Intracellular phosphoprotein activation significantly regulates cancer progression. However, the significance of circulating phosphoproteins in the blood remains unknown. We investigated the serum phosphoprotein profile involved in pancreatic cancer (PaCa) by a novel approach that comprehensively measured serum phosphoproteins levels, and clinically applied this method to the detection of PaCa.

METHODS

We analysed the serum phosphoproteins that comprised cancer cellular signal pathways by comparing sera from PaCa patients and benign controls including healthy volunteers (HVs) and pancreatitis patients.

RESULTS

Hierarchical clustering analysis between PaCa patients and HVs revealed differential pathway-specific profiles. In particular, the components of the extracellular signal-regulated kinase (ERK) signalling pathway were significantly increased in the sera of PaCa patients compared with HVs. The positive rate of p-ERK1/2 (82%) was found to be superior to that of CA19-9 (53%) for early stage PaCa. For the combination of these serum levels, the area under the receiver-operator characteristics curves was showing significant ability to distinguish between the two populations in independent validation set, and between cancer and non-cancer populations in another validation set.

CONCLUSION

The comprehensive measurement of serum cell signal phosphoproteins is useful for the detection of PaCa. Further investigations will lead to the implementation of tailor-made molecular-targeted therapeutics.

A novel nonsecosteroidal VDR agonist (CH5036249) exhibits efficacy in a spontaneous benign prostatic hyperplasia beagle model

To date, there have been no reports showing the efficacy of nonsecosteroidal vitamin D receptor (VDR) agonists in a benign prostatic hyperplasia (BPH) animal model. To examine the efficacy of CH5036249, a novel nonsecosteroidal VDR agonist, we orally administered the compound at 0.03 microg/kg to a beagle model with spontaneous BPH. Prostate volume was checked by rectal ultrasonic probe periodically during 11 months of administration and the prostate tissues histologically examined. CH5036249 inhibited prostate growth in two out of three dogs compared with vehicle-treated dogs. In the prostate specimens, substantial atrophy of the epithelium was observed in all dogs administered CH5036249. At the dose given, serum calcium levels slightly increased in the CH5036249-treated dogs but stayed within a normal range. We next examined the cell growth inhibition of CH5036249 using human prostate stromal cells and found the cell growth inhibitory activity of CH5036249 to be comparable to that of 1alpha,25(OH)2D3. The bioavailability from oral administration in rats was 95.1% with a t1/2 of 17.6 h. Both micro-AMES and micronucleus tests were negative. Although the results are still preliminary, we consider the novel nonsecosteroidal VDR agonist CH5036249 to be a possible new drug candidate for the treatment of BPH in humans.

Bronchogenic and Esophageal Cyst With Laryngeal Malformations in a Thoroughbred Foal

This report documents an unusual case of congenital foregut cyst with dysphagia and stridor in a Thoroughbred foal. Histologically, the bilocular cyst, near the junction of larynx and trachea, had an epithelial lining of bronchogenic and esophageal origin. Concomitant malformation of the laryngeal muscles and cartilage resulted in a combination of anomalies that have not been reported in the human or veterinary literature.

Inhibitory effect of rhetsinine isolated from Evodia rutaecarpa on aldose reductase activity

Aldose reductase inhibitors have considerable potential for the treatment of diabetic complications, without increased risk of hypoglycemia. Search for components inhibiting aldose reductase led to the discovery of active compounds contained in Evodia rutaecarpa Bentham (Rutaceae), which is the one of the component of Kampo-herbal medicine. The hot water extract from the E. rutaecarpa was subjected to distribution or gel filtration chromatography to give an active compound, N2-(2-methylaminobenzoyl)tetrahydro-1H-pyrido[3,4-b]indol-1-one (rhetsinine). It inhibited aldose reductase with IC(50) values of 24.1 microM. Furthermore, rhetsinine inhibited sorbitol accumulation by 79.3% at 100 microM. These results suggested that the E. rutaecarpa derived component, rhetsinine, would be potentially useful in the treatment of diabetic complications.

Significance of repeated resection for recurrent intrahepatic cholangiocarcinoma

BACKGROUND/AIMS

Management of patients with recurrent intrahepatic cholangiocarcinoma (ICC) following surgical resection is difficult, and surgical resection is rarely indicated. We retrospectively reviewed patients with recurrent intrahepatic cholangiocarcinoma.

METHODOLOGY

Between April 1998 and March 2007, 57 consecutive patients with ICC underwent surgical resection. Mode of recurrence and treatment of recurrent tumors, especially surgical resection for these tumors, in patients with cancer recurrence were evaluated.

RESULTS

37 (65%) patients experienced tumor recurrence. Out of these patients, 24 underwent some type of cancer-directed therapy, including 9 patients (24%) for whom surgical resection was attempted: the latter included 4 hepatic resections, 2 pulmonary resections, 2 tumor resections, and 1 gastric resection. For 6 patients with recurrent tumor in the liver or the lung, microscopic complete resection was achieved, while incomplete resection was resulted in the remaining 3 patients. No postoperative mortality was encountered. Among patients with complete resection, 3 are alive without disease 32, 39 and 77 months after the second operation, one has lived with disease for 13 months, and 2 died of disease after 22 and 26 months. No significant difference in overall survival was observed between patients undergoing primary and second surgical resections, calculated from the primary and the second operations, respectively.

CONCLUSIONS

Repeated surgical resection for recurrent ICC can be performed with acceptable morbidity, and affords selected patients a chance for long-term survival.

Management of skull base defect with bFGF after extensive skull base surgery - two case reports

The basic fibroblast growth factor (bFGF) is one of the most powerful growth factors to promote wound healing. In this paper we describe two cases of skull base tumor requiring extensive skull base reconstruction, in which the application of bFGF was effective in the management and prevention of CSF leaks. The role and safeness of bFGF for skull base reconstruction are discussed.

Pathological evidence of rhabdomyolysis-induced acute tubulointerstitial nephritis accompanying Legionella pneumophila pneumonia: Figure 1

A case of Legionella pneumophila pneumonia with rhabdomyolysis-induced acute tubulointerstitial nephritis (ATIN) and prolonged renal dysfunction is presented. The patient was a 54-year-old man, admitted with high-grade fever, ataxia and muscle dysfunction; chest roentgenogram showed multilobular infiltrations. L pneumophila was detected in his sputum and urine, by PCR and by culture, and L pneumophila pneumonia was diagnosed. Despite antimicrobial treatment, he developed renal failure and rhabdomyolysis. Renal biopsy showed the presence of myoglobin casts that occluded the distal tubuli and tubulointerstitial nephritis, leading to the diagnosis of rhabdomyolysis-induced ATIN. Renal function subsequently normalised, and he was discharged. This is believed to be the first pathological evidence of involvement of rhabdomyolysis in legionellosis-associated ATIN.

Construction of three-dimensional tooth model by micro-computed tomography and application for data sharing

The study of dental morphology is essential in terms of phylogeny. Advances in three-dimensional (3D) measurement devices have enabled us to make 3D images of teeth without destruction of samples. However, raw fundamental data on tooth shape requires complex equipment and techniques. An online database of 3D teeth models is therefore indispensable. We aimed to explore the basic methodology for constructing 3D teeth models, with application for data sharing. Geometric information on the human permanent upper left incisor was obtained using micro-computed tomography (micro-CT). Enamel, dentine, and pulp were segmented by thresholding of different gray-scale intensities. Segmented data were separately exported in STereo-Lithography Interface Format (STL). STL data were converted to Wavefront OBJ (OBJect), as many 3D computer graphics programs support the Wavefront OBJ format. Data were also applied to Quick Time Virtual Reality (QTVR) format, which allows the image to be viewed from any direction. In addition to Wavefront OBJ and QTVR data, the original CT series were provided as 16-bit Tag Image File Format (TIFF) images on the website. In conclusion, 3D teeth models were constructed in general-purpose data formats, using micro-CT and commercially available programs. Teeth models that can be used widely would benefit all those who study dental morphology.

Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan

Two hundred and sixty-five consecutive patients awaiting hepato-biliary-pancreatic surgery were prospectively observed for surgical site infections (SSIs). SSI rates differed according to type of hepato-biliary-pancreatic surgery. Multivariate analysis identified enteric anastomoses, poor postoperative blood glucose control and type of cancer as independent risk factors. SSI rates were directly correlated with the degree of hyperglycaemia encountered during the postoperative period. In particular, SSI rates were 5/25 (20%) among patients in whom a blood glucose level of <200mg/dL was maintained by insulin infusion therapy, which was significantly better than the rates of 49/94 (52%) among patients in whom a blood glucose level of <200mg/dL was not maintained despite insulin infusion therapy (P<0.01). It is necessary to maintain postoperative blood glucose levels of <200mg/dL in order to reduce SSI rates.

Homer1c interacts with Hippi and protects striatal neurons from apoptosis

By the two hybrid screening of mouse brain cDNA library, we identified Hppi, a cell death-promoting protein, as a binding partner of postsynaptic scaffold protein Homer1c. Hippi interacted specifically with Homer1c but not with its homologue Homer2. It was reported that Hippi, when complexed with Hip1, induces the apoptosis in striatal neurons and may cause Huntington's disease. We found that this apoptotic effect of Hippi was specific to the striatum and was not observed in hippocampal neurons. Furthermore, the apoptotic effect of Hippi was prevented when Homer1c was co-expressed in cultured striatal neurons. The protective effect of Homer1c was diminished when Hippi binding domain was deleted. These results suggest that Homer1c may play an important role in the mechanisms of neuronal death in the striatum.