T cell subsets in chronic hepatitis B and the effect of prednisolone withdrawal and interferon alpha-2b

OBJECTIVES

The evaluations of the pathogenetic roles of cell mediated immunity and of the preventive effect for disease progression with interferon(IFN) treatment in patients with chronic active hepatitis-B(CAH-B) are the objectives of this study.

METHODS

Thirty-two patients with CAH-B were treated with interferon alpha-2b(IFN alpha-2b) with prednisolone withdrawal and 30 control patients were treated with conventional hepatotonics for 6 months. Peripheral total T cell fractions and T cell subsets of the patients with CAH-B, treated with IFN alpha-2b with prednisolone withdrawal, were examined 1 month before administration of prednisolone, and compared with 12 normal controls for assessing the potential role of cellular immunity in the development of CAH-B. To estimate the effectiveness of IFN therapy for the patients with CAH-B, levels of various liver function tests, HBsAg, anti-HBs, HBeAg, anti-HBe, HBV DNA, anti-HCV and others were assessed for the treatment group and compared with control patients at pre- and post-treatment period each.

RESULTS

The value of CD4 was significantly lower in patients with CAH-B than normal controls (36.3 +/- 7.7% vs 42.1 +/- 5.7%, p < 0.05) and the value of CD8 was significantly higher in patients with CAH-B than normal controls (30.6 +/- 10.3% vs 24.3 +/- 5.2%, p < 0.05) before prednisolone administration. The patients in responder group (n = 26) had significantly lower CD4 cells compared with normal controls, but non-responders (n = 6) did not have. The levels of liver function test(LFT) in the patients with IFN alpha-2b treatment with prednisolone withdrawal were not different from the control patient group at pretreatment, but significantly lower than control patient group's after treatment, regardless of response to IFN alpha-2b treatment with prednisolone withdrawal.

CONCLUSIONS

The cellular immunity of the host may have a potential role in the pathogenesis of chronicity of hepatitis B infection. IFN alpha-2b treatment with prednisolone withdrawal may be regarded as one of the effective treatment modalities for the inhibition of disease progression in patients with CAH-B.

Growth inhibitory activities of kalopanaxsaponins A and I against human pathogenic fungi

Antifungal activities of the compounds isolated from Kalopanax pictus against representative fungi of dermatomycosis were investigated using paper disc diffusion method. It was found that kalopanaxsaponins A and I were effective in inhibiting the growth of Candida albicans KCTC 1940 and Cryptococcus neoformans KCTC 7224 with minimum inhibitory concentration (MIC) of 25 micrograms/ml. It showed that antifungal activity of both compounds have strong selectivity against the fungi of dermatomycosis.

Histomorphometric evaluation of mucin content in stone-containing intrahepatic bile ducts

Although histologic studies of mucin distribution in the peribiliary glands have been conducted, a quantitative study of mucin content in intrahepatic bile ducts has yet to be reported. In an attempt to evaluate the mucin content in stone-containing intrahepatic bile ducts, we conducted a study on 25 surgically resected livers with hepatolithiasis. Specimens from 10 livers without stones served as controls. All specimens were fixed in 10% formalin and sectioned for periodic acid Schiffalcian blue double-stain (PAS-AB; pH 2.5) to evaluate the epithelial mucin content of the intrahepatic bile ducts. The PAS-AB positive area and the total epithelial area were measured with a computerized image analyzer and the PAS-AB index was calculated as the proportion of the PAS-AB positive to the total epithelial area. The histochemical study showed that epithelial cells in both the intramural glands and extramural glands of stone-containing intrahepatic bile ducts stained heavily and homogeneously with PAS-AB, while those of controls stained weakly. The PAS-AB indexes in stone-containing intrahepatic bile ducts were 51.8 +/- 15.88% for mucous cells of intramural glands, 52.86 +/- 9.85% for mucous cells of extramural glands, and 77.29 +/- 21.59% for serous cells of extramural glands. These values were all significantly higher than those of control specimens. However, the PAS-AB index of the epithelial lining in both hepatolithiasis and control specimens were similarly low, indicating the epithelial lining does not secrete much mucous glycoprotein. The results of this study led us to conclude that stone-containing intrahepatic bile ducts contain an abundant amount of mucous glycoprotein, and mucin is secreted from the peribiliary glands, not from the epithelial lining of the bile ducts.

Mucin content in gallbladders with brown pigment stones or combination stones with a brown periphery

BACKGROUND/AIMS

Gallbladder mucus itself has been recognized to play an important role in gallstone development. Despite the diverse mechanisms of stone induction and the differences in stone composition, there is a quantitative increase in the epithelial mucus production period before stone formation. As brown pigment stones are found frequently in gallstone disease, we conducted a study on gallbladders with brown pigment stones or combination stones with a brown periphery to evaluate the mucin content in the gallbladder epithelium in comparison to gallbladders with cholesterol stones and those without stones.

METHODS

Gallbladder specimens were fixed in 10% formalin immediately after cholecystectomy and then embedded in paraffin. The specimens were sectioned for periodic acid-Schiff-alcian blue (PAS-AB, pH 2.5) double stain to evaluate the intra-epithelial mucin content. The PAS-AB index was calculated as a proportion of the PAS-AB-positive mucin area to the total epithelial area, using a computerized image analyzer.

RESULTS

Evaluation of the PAS-AB index on the lining epithelia of gallbladders showed that it was 32.43 +/- 9.96% in gallbladders with brown stones, which is significantly (p < 0.001) higher than in gallbladders with cholesterol stones (15.63 +/- 6. 75%) and gallbladders without stones (9.55 +/- 4.77%).

CONCLUSION

The results show that gallbladders with brown stones contain more abundant mucin than gallbladders with cholesterol stones or those without stones. They also suggest that the gallbladder epithelium per se might play a more important role in stone formation in those with brown stones than in those with cholesterol stones.

Pancreatic pseudocyst involving the spleen

The pseudocyst of the pancreas is a frequent complication of acute pancreatitis. The splenic involvement from the pancreatic pseudocyst is an uncommon entity. A 40-year-old man, who had a five-year history of alcohol consumption, was referred to our hospital for treatment of throbbing pain over left upper quadrant (LUQ) of the abdomen. Except for LUQ tenderness, physical examination was essentially normal. MRI showed two cystic lesions in splenic hilum and pancreatic tail, and prominent vessels in left infrasplenic area and gastrosplenic ligament. Angiography revealed splenic vein thrombosis. Because of persistent LUQ pain, he underwent laparotomy. During the operation, we found the cysts in pancreatic tail and splenic hilum. The cystic content was aspirated to check amylase, which showed the level of amylase being as high as 20,000 IU/L. The diagnosis of a pancreatic pseudocyst involving the spleen was established. Splenectomy and distal pancreatectomy were performed to remove both cysts. The pathologic examination of the resected spleen showed splenic infarction with cyst formation and pancreatic pseudocyst. The patient recovered uneventfully after operation.

The impact of a modified ileal neobladder on the lifestyle and voiding patterns in Asian patients

OBJECTIVE

To evaluate the impact of the modified ileal neobladder reconstruction on lifestyle, voiding habits and functional outcome in Asian patients.

PATIENTS AND METHODS

Twenty-seven Asian patients (25 men and two women, mean age 59 years, range 41-76) underwent modified ileal neobladder reconstruction after radical cystectomy for carcinoma of the bladder. The mean (range) follow-up was 21 (3-75) months. All patients were evaluated retrospectively using case notes, reviews, interviews and voiding charts; 18 patients underwent urodynamic studies.

RESULT

Twenty-five patients (93%) achieved diurnal and 23 (85%) nocturnal continence within 6 months. Of the 19 patients who were in employment before surgery, 15 continued to be economically active afterward; 26 patients (96%) reported no change in their daily living activities. Of 16 men who reported being potent pre-operatively only four retained some residual erectile function. Twenty-three patients were interviewed about their voiding habits and satisfaction with the outcome of surgery. Fourteen patients had no sensation of reservoir fullness and of the 21 men, 13 had to squat or sit to void effectively. The mean (range) voiding frequency was 5 (4-8) during the day and 2 (0-4) during sleep. Twenty-two patients were satisfied with the overall outcome.

CONCLUSIONS

The modified ileal bladder provides a high urinary continence rate with minimal changes in daily living activities and occupational status. The functional outcome was very satisfactory and accepted well, despite some changes in reservoir sensation, voiding posture and erectile function. The method is a viable option for reconstruction after cystectomy in Asian patients.

Evidence for accelerated generation of hydroxyl radicals in experimental obstructive jaundice of rats

We present evidence herein of the accelerated generation of hydroxyl radical (.OH) in the plasma and the liver tissue of common bile duct ligated (CBDL) rats, a model for experimental obstructive jaundice. .OH production in the plasma was monitored in vivo by the identification of dihydroxybenzoates in plasma [2,3-dihydroxybenzoate (2,3-DHB) and 2,5-dihydroxybenzoate (2,5-DHB)] using high performance liquid chromatography (HPLC). The average concentrations of 2,3-DHB and 2,5-DHB produced in the plasma of the controls were 33+/-3 microM and 232+/-34 microM (n = 15), respectively, whereas their respective concentrations increased to 149+/-28 microM and 604+/-88 microM in the CBDL rats (n = 19). Furthermore, we also observed a time-dependent decreasing trend of 2,3-DHB and 2,5-DHB production after surgical removal of the ligation of the experimental animals. In addition, the generation of .OH in the liver tissue was studied by using dimethyl sulfoxide (DMSO) as a molecular probe and measuring the amount of methanesulfinic acid (MSA), the product of the trapping reaction. The net production of MSA in the liver tissue of the control rats was 1.22+/-0.05 O.D. unit/g protein (n = 5), whereas its respective concentration of MSA in the liver tissue of CBDL rats increased to 2.05+/-0.15 O.D. unit/g protein (n = 5). In addition, we showed that CBDL rats receiving a pretreatment of mannitol, an .OH scavenger, resulted in the decreased production of MSA. Electron micrographic study indicated that the most prominent change observed in CBDL rats was the alteration of mitochondria, which were swollen with distorted cristae. Meanwhile, the bile canaliculi were moderately more dilated than that of the controls, and an increased neutrophil peripheral blood count was found in CBDL rats when compared to the controls. Taken together, our data suggest that accelerated generation of .OH in the CBDL rats is obvious and may play a key role in the pathogenesis of liver damage associated with obstructive jaundice.

Induction of differentiation of the human histocytic lymphoma cell line U-937 by hypericin

Hypericin, a photosensitizing plant pigment, was found to be a potent inducer of differentiation of human myeloid leukemia U-937 cells. At a concentration of 0.2 microM, hypericin exhibited 50% growth inhibition. An effect on cell differentiation by hypericin was assessed by its ability to induce phagocytosis of latex particles, and to reduce nitroblue tetrazolium (NBT). Approximately 51% of 0.2 microM hypericin-treated cells were stained with NBT and 63% showed phagocytic activity. In order to establish whether hypericin induces differentiation of U-937 cells to macrophage or granulocyte, esterase activities and cell sizes were measured. When U-937 cells were treated with 0.2 microM and 0.15 microM of hypericin, the alpha-naphthyl acetate esterase activity was increased by 38.4% and 48.1%, respectively, but naphthol AS-D chloroacetate esterase activity was not influenced. The size of hypericin-treated cells in terms of cell mass was larger than that observed in untreated cells as determined by flow cytometry. Protein kinase C (PKC) inhibitor, NA-382, decreased the NBT reducing activity of hypericin, whereas a cAMP-dependent protein kinase A (PKA) inhibitor, H-89, did not show any influence on the differentiation. These results indicate that hypericin triggers differentiation toward monocyte/macrophage lineage by PKC stimulation.

Role of hyperinsulinemia and glucose intolerance in the pathogenesis of nonalcoholic fatty liver in patients with normal body weight

OBJECTIVES

The pathogenesis of nonalcoholic fatty liver in non-obese persons is poorly understood. We aimed to elucidate whether hyperinsulinemia and glucose intolerance are associated with development of fatty liver in patients with normal body weight.

METHODS

Forty-seven patients with fatty liver were divided into non-obese (n = 25) and obese groups (n = 22) according to age adjusted body mass index. Inclusion criteria were as follows: (1) elevated transaminase levels during more than 3 months of follow up period, (2) no detectable HBsAg or anti-HCV in the serum, (3) alcohol consumption less than 40 gm/week, (4) no use of potential hepatotoxic drugs within 3 months and (4) sonographic evidence of fatty liver(moderate to severe degree). Baseline insulin levels and oral glucose tolerance test using 75gm of glucose were performed and the results were compared in each group of patients.

RESULTS

Mean baseline insulin levels were elevated in both groups above the reference value, 9.3 +/- 3.5 microU/L in non-obese group and 9.9 +/- 3.5 microU/L in obese group (p = 0.26). Seventeen of non-obese patients (68%) had elevated basal insulin level and 16 of obese patients (73%) had elevated basal insulin level (p = 0.39). In oral glucose tolerance test, there was no difference in glucose level between non-obese and obese groups from O minute to 180 minutes (p > 0.05). Eleven patients from the non-obese group (44%) and 8 patients from the obese group (36%) had either impaired glucose tolerance or diabetes (p = 0.29).

CONCLUSION

Our data suggest that hyperinsulinemia and glucose intolerance may play a role in the pathogenesis of fatty liver in patients with normal body weight as well as in patients with obesity.

Effect of vitamin E, topical hypothermia and steroid on ischemic liver in rats

Major hepatic surgery often requires temporary occlusion of the porta hepatis in order to minimize intraoperative bleeding. Occlusion of porta hepatis induces hepatic ischemia and may cause liver damage. This study was conducted to evaluate the effects of vitamin E, topical hypothermia and administration of steroids on ischemic liver by assessing the hepatic levels of lipid peroxides and examining the ultrastructural change of mitochondria. One hundred and twenty male wistar rats were divided into four groups, each of 30. All rats underwent laparotomy and the liver ischemia experiment was conducted by clamping the porta hepatis for 15 minutes. Group A received no further treatment, group B received vitamin E (30IU/Kg/B.W) supplementation for one week before experiment, group C was topically cooled and group D received preocclusion intravenous methylprednisolone (2mg/Kg/B.W). Hepatic lipid peroxides, expressed as nmol MDA/g wet wt were assessed by spectrofluorometric methods, and were measured immediately before occlusion, 15 min after occlusion, and 15 min after reperfusion. The results showed that the concentration of lipid peroxides increased markedly after occlusion of porta hepatis in group A, which received no treatment in ischemic liver (8.76 +/- 3.19 vs. 10.49 +/- 3.35 MDA nmol/g wet wt, p < 0.05, paired t-test), while the concentrations of hepatic lipid peroxides were not found to increase in groups B, C or D. In the meantime, the ultrastructural study showed marked swelling of mitochondria in ischemic liver of group A rats only. This suggests that vitamin E supplementation, topical hypothermia and administration of steroids will inhibit the propagation of lipid, peroxidation and provide protective effects on liver parenchyma during ischemia.

Ultrasound-guided percutaneous transhepatic drainage of gallbladder followed by cholecystectomy for acute cholecystitis--10 years' experience

Acute cholecystitis is a common disease which may carry the risk of complications, including empyema, perforation, abscess, peritonitis and sepsis. Percutaneous transhepatic drainage of the gallbladder (PTGBD) with antibiotics can provide prompt decompression of gallbladder in acute cholecystitis and interrupt the natural history of the disease effectively. From July 1986 to June 1996, 154 patients with acute cholecystitis were reviewed retrospectively in Kaohsiung Medical College Hospital. The chief symptoms and signs were pain (98.1%), fever (57.1%) and jaundice (37.7%). WBC count more than 10,000 was noted in 116 (75.3%) patients. Associated diseases included empyema: 42 (27.3%), septic shock: 14 (9.1%), diabetes mellitus: 13 (8.4%), pancreatitis: 10 (6.5%), perforation: 7 (4.5%), liver cirrhosis: 6 (3.9%) and respiratory failure: 1 (0.6%). All of them underwent ultrasound-guided PTGBD immediately after the diagnosis was established. The symptoms and signs disappeared soon after this procedure. Bacterial culture was found positive in 104 (67.5%) of 154 patients in which Escherichia coli (51.9%) was the most common organism, followed by Klebsiella pneumonia (20.2%). After acute stage, 138 patients obtained the cholangiography via PTGBD tube. Gallbladder stones were only noted in 56 (40.6%) patients, gallbladder stone concomitant with common bile duct stone in 26 (18.8%), cystic duct obstruction in 25 (18.1%), acalculous cholecystitis in 21 (15.2%), gallbladder perforation in 1 (0.7%), choledochocyst in 1 (0.7%), and cholecystocolonic fistula in 1 (0.7%). There were 135 patients to undergo surgery after the clinical condition was stable. The operative findings included gallbladder stones only in 88 (65.2%), gallbladder stone concomitant with common bile duct stone in 34 (25.2%), acalculous cholecystitis in 13 (9.6%), choledochocyst in 1 (0.7%), and cholecysto-colonic fistula in 1 (0.7%). The postoperative complications included wound infection 8 (5.9%), UGI bleeding 3 (2.2%), acute renal failure 1 (0.7%) and acute respiratory failure 1 (0.7%). The postoperative mortality rate was 0.7% (1/135), which was much lower than those of previous reports, which not undergoing PTGBD initially. It led us to conclude that PTGBD, as an initial preoperative modality to treat acute cholecystitis, is effective in decreasing postoperative morbidity and mortality.

Changes of insulin and somatostatin and their relationship to liver regeneration in experimental obstructive jaundice

The liver is a parenchymal organ that has a substantial capacity to regenerate after damage. Obstructive jaundice is a common surgical disease and potentially risky. A successful outcome of operations depends upon the hepatic regeneration reserve. Insulin is one of factors responsible for hepatotrophic regeneration and somatostatin has a reversal suppressive action. Experimental obstructive jaundice was introduced and relieved. In addition, serum insulin and somatostatin concentrations were measured. We used immuno-histochemical study of pancreatic tissue by immunogold to express the tissue relative insulin and somatostatin concentrations. Nucleolar organizer regions (NORs) were used to predict the nucleolar activity of liver cells. In our studies, we observed the serum concentrations of insulin and somatostatin were similar to the relative tissue concentration in pancreatic tissues. The relative tissue gold-particle score of insulin in group A (rats with common bile duct tied), was CONT: T4: T7: T14 = 100%: 90.5%: 68.3%: 46.2%; of somatostatin was 100%: 120%: 118.2%: 115.5% respectively. In group B (common bile duct tied for 4 days then relieved), the gold-particle score of insulin was T4: T4R4: T4R7: T4R14 = 90.5%: 62.8%: 72.2%: 95.4%; of somatostatin was 120.2%: 114.3%: 108.1%: 106.2% respectively. In group C (common bile duct tied for 7 days then relieved), the gold-particle score of insulin was T7: T7R4: T7R7: T7R14 = 68.3%: 53.3%: 73.5%; of somatostain was 118.2%: 109.4%: 104.6%: 102.1% respectively. The mean numbers of AgNORs in group A revealed CONT: T4: T7: T14 = 2.24 +/- 0.24: 3.02 +/- 0.96: 3.26 +/- 1.02:3.08 +/- 0.84, group B was T4: T4R4: T4R7: T4R14 = 3.02 +/- 0.96: 3.03 +/- 0.73: 3.36 +/- 1.12: 3.72 +/- 1.46, and group C showed T7: T7R4:T7R7: T7R14 = 3.26 +/- 1.02: 3.26 +/- 0.84: 3.31 +/- 1.24: 3.54 +/- 1.24. In conclusion, our studies suggested: (1) liver regeneration appeared promptly after obstructive jaundice developed, but prolonged cholestasis inhibited this process. (2) Insulin levels gradually fell during the process of obstructive jaundice. Those levels elevated when cholestasis was improved. Nevertheless, both insulin and hepatic regeneration power could not reflect the initial improvement of cholestasis simultaneously. It took a longer time for the improvement of cholestasis and the recovery of the liver function. (3) Patho-physiologically, somatostatin had a weak influence on hepatic regeneration during obstructive jaundice. (4) Our studies provided clues that early biliary drainage might improve hepatic regeneration capacity. Supplement of insulin during the obstructive jaundice might be helpful for the improvement of hepatic regeneration power.

Antimetastatic activity of the new platinum analog [Pt(cis-dach) (DPPE).2NO3] in a metastatic model of human bladder cancer

Surgical orthotopic implantation (SOI) of histologically intact human RT-4 bladder tumor tissue in nude mice resulted in local growth, invasion, regional extension and metastases as well as distant metastases to other organ sites and lymph nodes, thus mimicking the bladder cancer patient. This metastatic bladder tumor animal model was treated with two doses of new platinum analog ¿Pt(cis-dach)(DPPE).2NO3¿ for the evaluation of antimetastatic efficacy compared to two doses of cisplatinum. Unlike the untreated control group or the group treated with the low dose of cisplatinum, there were no metastases in either the high or low-dose platinum-analog-treated groups and the high-dose cisplatinum-treated group. The results obtained with this patient-like nude-mouse model of bladder cancer indicate that the new platinum analog appears to be a valuable lead compound with antimetastatic efficacy and clinical potential.

Laparoscopic fenestration for giant liver cyst

Laparoscopic fenestration for treatment of the non-parasitic cyst of the liver has been rarely reported, but sporadic cases appeared elsewhere in the literature. Here we report four cases with symptomatic giant nonparasitic liver cysts which were treated by a laparoscopic fenestration procedure that allowed the successful removal of the cyst dome. Before starting to excise the wall of the cyst, laparoscopic-quided needle aspiration of the cyst fluid was done first in order to clean the visual field for laparoscopic intervention where possible. The cyst wall was usually slightly transparent and somewhat smooth in the external and internal surface of the cysts. It was necessary to lysis the omental adhesion sometime before starting to remove the dome of the cyst. The cyst wall of the exposed part could be removed first with heat-probe instrument through laparoscopy. Those patients were discharged and revealed an uneventful post-operative course in three cases but in one case we had to convert to the traditional laparostomy to perform resection of the multiple cystic lesions. Post-operative echographic study showed that the giant cyst had collapsed. Therefore, we believe laparoscopic fenestration for the liver cyst is simple and effective, if the patient is a candidate who requires operation to remove the dome of the giant cyst.

Action of the peroneus longus tendon on the first metatarsal against metatarsus primus varus force

A medially directed force was applied to the first metatarsal in 10 cadaver feet. The peroneus longus tendon was subjected to a pull of 5 pounds. The soft tissues between the first and second metatarsals were cut sequentially, starting with the skin on the dorsal and plantar aspect, followed by the intermetatarsal ligament and adductor hallucis tendon, and, finally, the peroneus longus tendon at its distal insertion. Dorsoplantar radiographs while weightbearing were taken after each sectioning. A statistically significant varus displacement of the first metatarsal was observed only after transection of the peroneus longus tendon. It was concluded that the peroneus longus tendon is a strong retaining mechanism of the first metatarsal.

The etiology and clinical characteristics of mesenteric adenitis in Korean adults

This study is aimed at investigating the etiology and clinical characteristics of mesenteric adenitis in Korean adults, prospectively. Clinical manifestations of fifteen patients who presented with the acute onset of right lower quadrant pain and sonographically enlarged mesenteric lymph nodes and normal appendix were evaluated. For etiologic diagnosis, stool culture, serologic test for Epstein-Barr virus, and Widal test were performed. Colonoscopy with mucosal biopsies and microbial tissue cultures were performed in 12 of 15 patients. Of fifteen patients 6 were male and the average age was 29.9 (17 approximately 41) years. Associated symptoms were diarrhea (80%), fever (73%), nausea and vomiting (27%). Right lower quadrant tenderness was observed in all cases but rebound tenderness was observed only in 26.7% of the cases. Etiology was identified in 7 cases (47%): 2 Yersinia enterocolitica infection, 2 non-typhoidal Salmonella infection, 2 tuberculosis, and 1 typhoid fever. In colonoscopic examination, signs of active inflammation were observed in 9 cases (75%) and inactive or normal findings in 3 cases (25%). All of our patients, except for the patients with tuberculosis and typhoid fever who needed specific antibiotic therapy, improved spontaneously without using antibiotics. In conclusion, the etiology of mesenteric adenitis in Korean adults seems to be different from that of western countries. Furthermore, mesenteric adenitis in Korean adults is a clinical syndrome, frequently found in a relatively young age group, which improves spontaneously unless specific anti-microbial agents are indicated by microbiological tests, such as tuberculosis or typhoid fever.

Morphology of intrahepatic duct in surgical treatment of hepatolithiasis

BACKGROUND/AIMS

Surgery is the usual treatment for hepatolithiasis. However, the method of choice is based on intrahepatic duct morphology.

MATERIAL AND METHODS

Six hundred sixty-two patients with hepatolithiasis were operated on in the period between 1980-1994. Hepatolithiasis was clinically classified into primary (75.8%) and secondary (24.2%) types.

RESULTS

Patients treated between 1990-1994 (35.9%), liver resection was performed in 71 patients (69 of left and 2 of the right liver). However, liver resection was chosen only in 6.7% (11/163) during the 1970s. Candidacy for liver resection increased recently due to the increase in primary type. According to the morphology of intrahepatic ducts, the location of stricture was classified into: Central type (n = 59, 30%), Segmental type (n = 101, 51%), and Subsegmental type (n = 21, 10.6%), and unclassified (n = 17, 8.4%). Liver resection was recommended for patients of segmental or subsegmental type. Choledocho-lithotomy with T-tube drainage was indicated in two third of the patients with hepatolithiasis. However, the incidence of post-operative retained stones was very high, and post-operative choledochoscopic lithotripsy was used to treat these post-operative problems easily. The mortality of this disease was 1% (2/198) in the 1990s compared with that of 4.1% (19/464) in 1980s and 10.1% (15/148) in 1970s.

CONCLUSION

We strongly recommend that liver resection for patients with adequate indications will have good results. In addition, one should pay attention to the abnormal pattern of intrahepatic ducts that are commonly found in patients with hepatolithiasis during liver resection. Liver resection is an ideal surgical method for the eradication of diseased lesions and to prevent malignant changes from bile duct with stones. Concise information concerning the anatomic structure was found to be important in determining post-operative results in the management of hepatolithiasis.

Biochemical events associated with ligation of the common bile duct in Wistar rats

Oxygen free radicals have been implicated as mediators of tissue injury in a variety of diseases. We investigated the role of oxidative injury and oxygen free radical scavengers in liver cell injury associated with obstructive jaundice in Wistar rats. Bile duct ligation for 4 or 7 days led to a decrease in both vitamin E and A in the plasma and liver of male Wistar rats, indicating the malabsorption of lipid-soluble vitamins. Serum bilirubin, alkaline phosphatase and gamma-glutamyl transpeptidase activities were increased in the bile-duct-ligated rats. Furthermore, marked increases in lipid peroxide and oxidized glutathione levels indicated cholestatic liver injury. The antioxidant defense system was impaired, as shown by decreases in reduced glutathione and in the activities of glutathione peroxidase (GSH-Px) and superoxide dismutase. Moreover, these high lipid peroxide levels and low levels of antioxidants correlated with the severity of jaundice. After releasing the bile duct ligation, levels of bilirubin, lipid peroxide and oxidized glutathione declined, while the levels of vitamin E and A, reduced glutathione, and the activities of GSH-Px increased, indicating an improvement in liver function. These findings suggest that lipid peroxidation is associated with the pathogenesis of liver damage in animals with bile duct ligation. Meanwhile, free oxygen radical scavengers are reduced in the bile-duct-ligated rats, thereby increasing the susceptibility of the liver to injury by oxygen-derived free radicals.

Transuretero-ureterostomy: a review of 253 cases

OBJECTIVES

To review our experience of transuretero-ureterostomy (TUU), which can be a dangerous procedure if a problem arises with the anastomosis, because both upper urinary tracts are put at risk to deal with a problem that initially affected only one side.

PATIENTS AND METHODS

TUU was performed in 253 patients following undiversion, trauma or strictures of the distal ureter, with a Mitrofanoff-type of continent urinary diversion, or otherwise during reconstructive urological surgery, mainly in association with cystectomy and substitution cystoplasty. The patients were followed and complications or problems reviewed.

RESULTS

Five patients had problems with the distal ureter below the TUU and one had problems as a result of stone disease in the transposed ureter some distance proximal to the TUU, but there were no long-term complications as a direct result of the TUU.

CONCLUSIONS

Providing the anastomosis is stented until there is radiological evidence of healing of the TUU, then TUU is a safe and reliable procedure.

Conservative hepatic resection for hepatocellular carcinoma of cirrhotic patients

We evaluated in retrospect the applicability of conservative hepatic resection for hepatocellular carcinoma (HCC) of cirrhotic patients. Eighty (14.6%) of 548 patients with HCC underwent liver resection over a period of 10 years in this hospital. They were divided into two groups according to surgical procedures. In group I, 22 patients underwent major hepatic resection, and in group II, 58 patients underwent conservative liver resection. The operative mortality for patients in group I was 13.6% while it was 3.5% for those in group II. The difference was significant (p<0.05). The five-year survival rate was 22% for patients in group I, while it was 21% for group II patients. The rate of HCC recurrence was 47.4% for group I patients while it was 57.1% for group II patients. The difference was not significant. The tumor-free survival rates at 6-, 12-, 24- and 36-months were 80%, 75%, 55% and 55% respectively for patients in group I, while they were 50%, 42.5%, 42.5% and 42.5% for patients in group II. It suggested that conservative liver resection was associated with early recurrence of HCC. But the difference of mean tumor-free survival time is not significant (35.82+/-5.47 vs 38.63+/-8.05 months, p>0.05). Using Cox's regression analysis, the presence of Child's B was identified as an independent adverse prognostic factor (p=0.000) for long-term survival. The factors associated with poor tumor-free survival rate were Child's classification (p=0.008), metastasis (p=0.021), liver cirrhosis (p=0.039) and tumor size (p=0.054). By evaluating the operative mortality, long-term survival rate, prognostic factors for cumulative survival time and tumor-free survival time, it suggests that conservative liver resection can be selectively used to treat HCC associated with liver cirrhosis.

The ultrastructural study on epithelium of gallbladder with gallstones

To investigate the fine structures of epithelium, 30 patients bearing gallstones were subjects for this study: ten for gallbladders with cholesterol stones, 10 for pigment stones and 10 for the control. The electron microscopic examination of these specimens revealed that all the epithelial cells from three gallbladder models had similar ultrastructural features. The most striking feature was the presence of numerous mucous droplets in the apical portion of the all epithelial cells. Another prominent finding was multivesicular bodies predominantly in gallbladders with pigment stone. Golgi apparatus, rough endoplasmic reticulum and mitochondria were apparent and well-developed. Crescent and semi-circular structures were found exclusively in gallbladders with cholesterol gallstones. According to the well-developed Golgi apparatus, rough endoplasmic reticulum and abundant mucous droplets, these epithelial cells are presumably mucus secretory cells. The gallbladder epithelium may play an important role in regulating the stone formation.

Lateral column lengthening with calcaneocuboid fusion: range of motion in the triple joint complex

Lengthening the lateral column of the foot has been shown to correct flatfoot deformity. In adults, however, lengthening leads to calcaneocuboid arthritis. Lateral column lengthening with calcaneocuboid fusion, which lengthens the lateral column of the foot and prevents calcaneocuboid arthritis, was investigated in a cadaver model to determine the remaining range of motion in the talonavicular and subtalar joints. Inversion/eversion motion was produced by tendon pulls and the range of motion was measured in three dimensions using a magnetic space tracker. After lateral column lengthening with calcaneocuboid fusion, 48% of talonavicular and 70% of subtalar joint range of motion were preserved. Analysis of the inversion and eversion ranges of motion suggests that the lengthening fusion limits eversion more than inversion. These findings demonstrate the need for clinical investigation of this procedure, which could preserve motion in the talonavicular and subtalar joints, correct deformity, and obviate calcaneocuboid arthritis.

Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint

The plantar plate is a rarely seen, yet central structure to the lesser metatarsal phalangeal (MP) joint. Thirty cadaver lesser MP joints were studied to obtain a detailed description of the plate, including its dimensions, connections, and histology. The plate was found to be made of fibrocartilage with fiber orientation which suggests that it withstands tensile loads in line with the plantar fascia as well as the compressive loads from the metatarsal head. The plantar plate was the most substantial distal insertion of the plantar fascia. Impressive plantar plate attachments were noted to the proximal phalanx, the major longitudinal bands of the plantar fascia, and the collateral ligaments. The plate and collateral ligaments formed a substantial soft tissue box connected to the sides of the metatarsal head. From the dissections, it is apparent that malposition of the toe at the MP joint is likely over time to be associated with pathology in both the collateral ligaments and the plate. Because of these attachments and a close association with the flexor tendons to the lesser toe, the plate can be compared with the sesamoid mechanism of the first MP joint.

Selective hindfoot arthrodesis for the treatment of adult acquired flatfoot deformity: an in vitro study

An acquired flatfoot deformity with significant laxity at the transverse tarsal joint was created experimentally and the amount of correction that was obtained with selective hindfoot fusions was measured radiographically. Results showed that the talonavicular, double (talonavicular and calcaneocuboid), and triple arthrodeses were able to fully correct the deformity, including correction of hindfoot valgus with just a talonavicular fusion. Subtalar and calcaneocuboid fusions failed to completely correct the deformity. This study provides experimental evidence that although the triple joints are interconnected, they differ with respect to their ability to malalignment. We conclude that talonavicular or double arthrodesis will correct deformity in a flatfoot with considerable laxity through the transverse tarsal joint, but that a subtalar fusion will not provide consistent correction.