Multi-disciplinary Orthopaedics Rehabilitation Empowerment (MORE) program: A new standard of care for injured workers in Hong Kong

BACKGROUND

The objective of this study is to evaluate the effects of the Multi-disciplinary Orthopaedics Rehabilitation Empowerment (MORE) Program on reducing chronic disability among injured workers and improving efficiency of work rehabilitation process.

METHODS

A cohort of patients with workplace injuries in the lower back were recruited from orthopaedics clinics and assigned to either MORE group (n= 139) or control group (n= 106). Patients in MORE group received an early MRI screening and a coordinated multi-disciplinary management, while patients in the control group received conventional care. Outcome variables are time to return-to-work (RTW) from date of injury, waiting time for MRI screening and time to medical assessment board (MAB).

RESULTS

Patients in the MORE Program had significantly shorter duration for RTW (MORE: 6.1 months,

CONTROL

12.8 months, p< 0.01), and more RTW cases (n= 64, 46.0%) compared to CONTROL group (n= 29, 27.4%). The MORE group also had much shorter waiting time for MRI scans (91.85 vs. 309.2 days, p< 0.001) and MAB referral after MRI scans (97.2 vs. 178.9 days, p= 0.001) compared to CONTROL group.

CONCLUSIONS

The MORE Program which emphasizes early intervention and early MRI screening, is shown to be effective in shortening sick leave and improving RTW outcomes of injured workers.

Calreticulin expression in neuroblastoma--a novel independent prognostic factor

BACKGROUND

Calreticulin (CRT), an endoplasmic reticulum protein, has been reported to be essential for the differentiation of neuroblastoma (NB) cells, suggesting that CRT may affect the tumor behavior of neuroblastoma. The aim of this study was to evaluate the association of clinicopathologic factors and patient survival with the expression of CRT in patients with NB.

PATIENTS AND METHODS

Sixty-eight NBs were investigated by immunohistochemical staining against CRT, and were divided into positive and negative immunostaining groups. Correlations between calreticulin expression, various clinicopathologic and biologic factors, and patient survival were studied. In seven tumor samples, CRT mRNAs and proteins were evaluated with real-time PCR and western blot, respectively, and correlated with immunohistochemical findings.

RESULTS

Among 68 NBs, 32 (47.1%) showed positive CRT expression. Positive CRT immunostaining strongly correlated with differentiated histologies, as well as known favorable prognostic factors such as detected from mass screening, younger age (< or =1 year) at diagnosis and early clinical stages, but inversely correlated with MYCN amplification. Kaplan-Meier analysis revealed that NB patients with CRT expression did have better survival. Multivariate analysis demonstrated CRT expression to be an independent prognostic factor. Moreover, CRT expression also predicted better survival in patients with advanced-stage NBs, and its absence predicted poorer survival in patients whose tumor had no MYCN amplification. The amount of CRT mRNAs and proteins in NB tumor samples tested correlated well with the immunohistochemical expressions.

CONCLUSIONS

CRT expression correlates with the differentiation of NB and predicts favorable survival, thereby suggesting CRT to be a useful indicator for planning treatment of NB.

Prediction of the outcome of pull-through surgery for Hirschsprung's disease using acetylcholinesterase activity

BACKGROUND AND PURPOSE

Advances in surgical procedures for the treatment of Hirschsprung's disease have afforded the majority of patients a satisfactory outcome after definitive corrective surgery. However, some patients continue to have signs of persistent bowel dysfunction despite adequate resection of the aganglionic bowel segment. The definite etiology of persistent bowel dysfunction in these patients remains controversial.

MATERIALS AND METHODS

The acetylcholinesterase activity in the proximal resection margin of pull-through surgical specimens collected from September 1992 to June 1998 was evaluated and correlated with clinical outcome.

RESULTS

A total of 24 patients were studied, 15 males and 9 females. The follow-up period ranged from 1 year 7 months to 7 years 6 months. The Soave procedure was performed in 17 cases and the Duhamel in 7. Twenty cases had a good or fair clinical outcome and four (16.7%) had a poor outcome. There was no mortality. Among the 20 patients with a good or fair outcome, the acetylcholinesterase activity in the proximal section margins was not increased in 12, mildly increased in seven, and moderately increased in one. The four cases with poor outcome all had moderately increased acetylcholinesterase activity in at least one specimen. The association between moderately increased acetylcholinesterase activity and poor surgical outcome was significant (p = 0.0005). In contrast, there was no association between the surgical method (Soave or Duhamel) used and clinical outcome (p = 0.55).

CONCLUSION

Acetylcholinesterase activity in the proximal resection margins of pull-through surgical specimens is a useful indicator for predicting the postoperative outcome in Hirschsprung's disease.

Magnetic resonance cholangiopancreatography diagnosed pancreatitis associated choledochal cyst: report of one case

This report describes a 6-year-old girl with a choledochal cyst associated with recurrent pancreatitis. A cystic dilatation of the common bile duct was detected by abdominal ultrasound and magnetic resonance cholangiopancreatography (MRCP). She displayed only one of the classic triads: abdominal pain plus pancreatitis. Cyst excision and Roux-en-Y hepaticojejunostomy was indicated in this case. MRCP can be considered as a unique non-invasive tool and the first choice in evaluation of choledochal cyst in pediatric group.

Bacterial cholangitis in patients with biliary atresia: impact on short-term outcome

Bacterial cholangitis (BC) is a common complication in patients with biliary atresia (BA) and is characterized by fever, acholic stools and positive blood cultures. The diagnosis is often empirical because the yield of blood cultures is low. It is difficult to differentiate BC from other febrile episodes. In order to characterize the clinical and laboratory features of BC in patients with BA, identify risk factors, and correlate cholangitis with outcome, 37 patients with BA from 1993 to 1998 who underwent a Kasai operation in our hospital were studied. The follow-up period ranged from 6 to 59 months. A total of 107 febrile episodes were documented in these patients. The diagnostic criteria for cholangitis were fever, increased jaundice, or acholic stools. The clinical features, laboratory data, results of bacterial cultures, and outcomes were analyzed retrospectively. A total of 107 febrile episodes, including 78 bouts of cholangitis and 29 non-cholangitis infections, were found in 34 patients. Patients with BC had higher postoperative bilirubin levels (P = 0.02) and less frequent use of prophylactic antibiotics (P = 0.05) than those with non-cholangitis infections. Abnormal white blood cell counts (> 12,000 or <4,000 mm3) tended to be present in patients with BC (P = 0.08). There were no statistical differences in the risk factors and laboratory data between culture-positive (n = 16) and -negative (n = 62) cholangitis cases. The occurrence of cholangitis significantly reduced survival in both patients with good (P = 0.03) and inadequate bile flow (P = 0.03). All 9 patients who had never had cholangitis survived during the follow-up period. Repeated attacks of BC further decreased survival probability. The responsive organisms were mainly enteric bacteria, including Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumanni, and Salmonella typhi. The sensitivity tests justified empirical therapy with ceftriaxone. The effectiveness of prophylactic trimethoprim-sulfamethoxazole or neomycin warrants further studies. BC was a highly prevalent postoperative complication in patients with BA, especially those with inadequate bile drainage. It significantly affected early mortality. Aggressive and complete treatment with empirical ceftriaxone was appropriate.

Complete genome sequence of an M1 strain of Streptococcus pyogenes

The 1,852,442-bp sequence of an M1 strain of Streptococcus pyogenes, a Gram-positive pathogen, has been determined and contains 1,752 predicted protein-encoding genes. Approximately one-third of these genes have no identifiable function, with the remainder falling into previously characterized categories of known microbial function. Consistent with the observation that S. pyogenes is responsible for a wider variety of human disease than any other bacterial species, more than 40 putative virulence-associated genes have been identified. Additional genes have been identified that encode proteins likely associated with microbial "molecular mimicry" of host characteristics and involved in rheumatic fever or acute glomerulonephritis. The complete or partial sequence of four different bacteriophage genomes is also present, with each containing genes for one or more previously undiscovered superantigen-like proteins. These prophage-associated genes encode at least six potential virulence factors, emphasizing the importance of bacteriophages in horizontal gene transfer and a possible mechanism for generating new strains with increased pathogenic potential.

Prognostic indicators of survival in infants with congenital diaphragmatic hernia

PURPOSE

This study sought to identify the factors predictive of the short-term outcome in infants with congenital diaphragmatic hernia (CDH).

METHODS

We retrospectively reviewed medical records from September 1985 to December 1998 for all infants born with CDH and managed at National Taiwan University Hospital (NTUH). Coexisting pathology and measures of respiratory function were analyzed to determine the prognostic factors.

RESULTS

A total of 32 infants with CDH were managed at NTUH over the past 13 years. The investigated factors associated with poor prognosis in CDH included congenital heart disease, chromosomal abnormality, pneumothorax, and preoperative parameters including arterial partial carbon dioxide pressure greater than 40 mmHg, arterial partial oxygen pressure less than 100 mmHg, alveolo-arterial partial oxygen pressure greater than 610 mmHg, and oxygen index (OI) greater than 0.4. Multiple logistic regression analyses indicated that only an OI greater than 0.4 and pneumothorax were significant indicators of poor prognosis. When the incidence of pneumothorax was compared between patients who received ventilation using a conventional mechanical ventilator or high-frequency oscillatory ventilator (HFOV), a trend toward a lower incidence of pneumothorax in those using HFOV for initial stabilization was found (p = 0.08).

CONCLUSIONS

An OI greater than 0.4 before surgery and pneumothorax are poor prognostic indicators in infants with CDH. A high OI is reflective of the severity of pulmonary dysfunction in infants. Pneumothorax further compromises the dysfunction of a hypoplastic lung in infants with CDH. The results of this study show the importance of avoiding iatrogenic pneumothorax during management of infants with CDH.

Focal nodular hyperplasia of the liver in a child

We present a case of focal nodular hyperplasia (FNH) of the liver in a 7-year-old girl. The hepatic tumor was found incidentally on physical examination at school. During surgery, a hypervascular mass with a nodular surface was found to be confined to the right lobe of the liver (mainly in segments 5 and 6). The brownish tumor and the gallbladder were completely removed. Pathologic examination revealed a 10 x 9 x 5-cm mass with a central scar and radiating septa, consistent with the diagnosis of FNH. The postoperative course was complicated by subhepatic effusion, which was resolved by percutaneous computed tomography-guided drainage. She remained well 2 years after surgery.

Role of thermography in the diagnosis of undescended testes

OBJECTIVES

The location of an undescended testis is important for the choice of therapy. Ultrasonography cannot serve as a stand-alone screening method in the management of the undescended testis because of its limited sensitivity and accuracy. The aim of this study was to clarify the diagnostic value of thermography in the patients with undescended testes.

METHODS

We evaluated prospectively 28 patients with 36 undescended testes from January 1995 to December 1996. The patients' ages ranged from 16 to 39 months with a mean age of 26.3 +/- 8.2 months. In addition to physical palpation by a pediatric surgeon, ultrasonography and thermography were performed for screening the locations of retained testes.

RESULTS

The diagnostic rates were 63.9% (23/36) by palpation, 65.7% (23/35) by ultrasonography and 54.5% (18/33) by thermography. The results of the three diagnostic methods showed no significant difference by Fisher's exact test. Of the 17 higher located testes (inguinal canal and above external ring) 7 were palpable, 8 were identified by ultrasonography, 10 were detected by thermography. Of the 7 nonpalpable testes and testes not detected by ultrasonography, 5, including 2 intra-abdominal testes, were identified by thermography.

CONCLUSION

It is suggested that thermography can play a role in locating high undescended testes which are nonpalpable and not detected by ultrasonography.

Free radical scavenging activity of fullerenol on the ischemia-reperfusion intestine in dogs

Fullerenol, a water-soluble C(60)-fullerene derivative, has been demonstrated to have the capability to scavenge free radicals in vitro and in vivo. The purpose of this study was to investigate whether fullerenol can scavenge the free radicals that are massively induced during ischemia-reperfusion (I/R) injury of the small intestine, either preventively or therapeutically. Clamping the superior mesenteric artery and vein for 60 minutes to induce I/R injury was performed on male mongrel dogs. Thirty dogs were divided into three groups (10 in each): The control (C) group received no medication; the preventive (P) group received fullerenol (1 mg/kg) intravenously 30 minutes before ischemia; the therapeutic (T) group received the same dose of fullerenol immediately after reperfusion. This study was an experimental randomized trial. Intestinal segments were obtained 10, 20, 30, and 60 minutes after reperfusion; and blood samples and specimens of major organs were taken 60 minutes after reperfusion. Concentrations of lipid peroxidation products, including conjugated diene (CD) and malondialdehyde (MDA), and the level of glutathione (GSH) in intestinal tissue were determined. Serum indicators of liver and renal function were measured. Histologic examination of the small intestine and major organs were also performed. A significant increase in intestinal MDA and CD contents was detected at 30 and 60 minutes after reperfusion. The tissue GSH content, in contrast, was decreased 60 minutes after reperfusion. Administration of fullerenol diminished these changes both preventively and therapeutically. Liver and renal functions were within normal limits in all groups. Moreover no obvious histopathologic additional damage could be found in either the P or the T group. It is suggested that fullerenol can be considered a powerful scavenger for the free radicals induced by I/R injury of the small intestine.

Choledochal cyst in infancy: a follow-up study

From January 1980 to February 1997, 19 cases, 8 males and 11 females, of choledochal cyst were diagnosed before one year old. The majority of patients were diagnosed by ultrasonography before 6 months old (15/19; 79%), including two diagnosed prenatally. According to Todani's classification, type Ia was the most common (74%), followed by type Ic (26%). Fourteen patients underwent Roux-en-Y choledocho- or hepatico-jejunostomy and cyst excision, 3 patients underwent Kasai operation, and I patient underwent external biliary drainage only. The remaining one patient with Trisomy 18 anomaly refused operation. Four of the 10 patients in whom liver histologic examinations were performed, had liver cirrhosis. The follow-up period of these patients ranged from 6 months to 9 years, with a mean of 4.1 years. We divided these 19 cases into 2 groups, according to the presence or absence of biliary atresia. In the 7 infants with biliary atresia (37%), all presented with jaundice and alcoholic stool. Two patients died due to delayed presentation and surgery, both had liver cirrhosis. One patient is living with liver cirrhosis. Another patient was lost to follow-up, but frequent cholangitis was noted till 8 months old. The remaining 3 patients are living and well. In the 12 without biliary atresia, 9 patients are living and well. Two patients died, one due to Trisomy 18 anomaly and the other with delayed surgery and liver cirrhosis. One case was lost to follow-up. In summary: 1-) a possibility of the association of biliary atresia in infants with choledochal cyst should be carefully searched and considered as a unique group; 2) ultrasonography is a good diagnostic tool in choledochal cyst during prenatal or infancy period; 3) the mortality cases were characterized by prolonged bile stasis, biliary cirrhosis, delayed surgery, or multiple anomalies; 4) surgery should be performed as early as possible for those with persistent jaundice and light colored stools.

Changes of serum and urinary neopterin concentrations in rats after partial hepatectomy

OBJECTIVE

To investigate the changes in serum and urinary neopterin concentrations over time after partial hepatectomy in rats, and to find out if neopterin can be used as a marker of immunological response during the regulation of liver regeneration.

DESIGN

Randomised experiment.

SETTING

University hospital, Taiwan, R.O.C.

SUBJECTS

84 male Wistar rats weighing about 200g.

INTERVENTIONS

Partial hepatectomy (67%) or sham operation (n = 42 in each group).

MAIN OUTCOME MEASURES

Serum and urinary neopterin concentrations measured by radioimmunoassay preoperatively and on days 1, 2, 3, 5, 7, and 10 postoperatively.

RESULTS

Serum neopterin concentrations increased and reached their peak on days 5 and 7 after partial hepatectomy. The urinary neopterin concentration showed a similar trend, but with a more pronounced increase on days 5 and 7.

CONCLUSIONS

Serum and urinary neopterin concentrations can be used as markers of activated cell-mediated immunity in rats after partial hepatectomy.

Viral etiology of intussusception in Taiwanese childhood

BACKGROUND

Adenovirus infection and lymphoid hyperplasia have been associated with childhood intussusception. However, the extent of other viruses involved in this condition remains unclear. This prospective study investigates the relationship between some lymphotropic viruses and current childhood intussusception.

METHODS

Patients with intussusception encountered in a pediatric emergency department in a recent 3-year period were studied. Healthy infants and toddlers of comparable age served as controls. Throat and rectal viral cultures were performed in patients and controls. Viral antibodies against adenovirus, cytomegalovirus, human herpesvirus (HHV)-6, HHV-7 and Epstein-Barr virus (EBV) were tested in paired sera from the patients. Acute stage serum from each patient and mesenteric lymph nodes from patients requiring surgery were studied for the presence of adenovirus genome by PCR.

RESULTS

Twenty-seven of 61 (44.3%) intussusception patients, but only 2 of 52 (3.8%) healthy controls shed nonenteric adenovirus in throat and rectal specimens (P < 0.001). Of the 27 (74.1%) patients who shed adenovirus, 20 were older than 1 year old, whereas only 1 of 15 (6.7%) similarly aged patients in a previous study from the same area three decades ago did so (P = 0.001). Among 43 patients with available paired sera, acute primary viral infection was found in 17 (39.5%) by adenovirus, 4 (9.3%) by HHV-6, 5 (11.6%) by HHV-7, 2 (4.7%) by EBV and none by cytomegalovirus. Multiple viral infections occurred in 6 patients. Adenovirus genome was detected in 4 of 9 mesenteric lymph nodes and in only 3 of 60 (5%) acute phase sera.

CONCLUSIONS

Primary nonenteric adenovirus infection contributes to current childhood intussusception. Acute primary HHV-6, HHV-7 and EBV infections also play etiologic roles.

Hepatocellular carcinoma in children: clinical review and comparison with adult cases

BACKGROUND

Hepatocellular carcinoma (HCC) in children was rarely reported and usually included with hepatoblastoma in most studies of pediatric liver malignancies despite different clinical behaviors. The authors report their experience in pediatric HCC and discuss its differences from adult HCC.

METHODS

A retrospective review of radiographic, laboratory, pathological, and therapeutic data in 55 children with HCC was performed. The liver function was graded by modified Child's classification. Kaplan-Meier survival curves in various therapeutic and Child's groups were plotted, and log-rank test was used to detect differences among survival curves.

RESULTS

Although children with HCC mostly presented with advanced disease at diagnosis, disturbances of liver function were unremarkable. Sixty-eight percent of cases concurred with liver cirrhosis. The median survivals for resectable, chemotherapeutic, and untreated HCCs were 23, 3, and 2 months, respectively. Resectable HCC significantly posed a much better prognosis. However, the resectability was unsatisfactory (18.2%). Resection was limited because of anatomic unfeasibility including bilateral involvement (62.5%), portal vein thrombi (41.7%), distant metastasis (29.1%), para-aortic lymphadenopathy (18.8%), inferior vena cava thrombi (16.7%), and hilar invasion (6.3%). Distant metastasis was the most ominous for survival in children with unresectable HCC.

CONCLUSIONS

HCC behaved somewhat differently between children and adults. Surgical resection represented the best hope of long-term survival. The outcome in children could not keep up with that in adults because of a diagnostic delay. Hence, alpha-fetoprotein and sonography screening in carrier children should be worthwhile.

Fifteen years' experience with gastric partitioning for obesity treatment

Most reports derived from experiences in Western countries indicate that surgery offers the best hope for morbidly obese patients. We report our experience with gastric partitioning in 63 Chinese patients (17 men and 46 women) aged 14 to 42 years, whose preoperative excess weights ranged from 62.3% to 166.7% above their ideal body weight. Transverse stapling was performed in 30 patients treated before April 1983, while vertical stapling gastric partitioning with a window and a Marlex band to encircle the outlet tract was done in 33 patients after that. No patient died, but one had leakage at the anastomosis. Success was defined as a return to within 50% of the ideal body weight. Vertical-windowed gastric partitioning with a Marlex-banded outlet resulted in a significantly higher success rate than transverse stapling--70% vs 37%. Our experience suggests that vertical-windowed gastric partitioning with a Marlex-banded outlet is a safe and effective surgical treatment for morbidly obese Chinese people.

Tissue plasminogen activator reduces intraperitoneal adhesion after intestinal resection in rats

We investigated whether tissue plasminogen activator (tPA), a plasma serine protease that catalyzes the initial and rate-limiting step in fibrinolysis, inhibits postoperative intraperitoneal adhesion formation in rats. Male Wistar rats weighing 200 to 250 g underwent laparotomy with a 15-cm intestinal resection and reanastomosis; the intestinal serosa was scratched to induce adhesion formation. The rats were divided into three groups: the control group received no medication; the normal saline group received peritoneal irrigation with 6 mL normal saline intraoperatively; and the tPA group received peritoneal irrigation with 6 mL tPA solution (5 mg/L) intraoperatively. The rats were killed 7 or 14 days later. The scores (severity of adhesion, 0-3 point scale), strength, and extent of fibrous bands were recorded on the day the rats were killed. Wound strength was measured using an Instron tensionmeter immediately after the rats were killed. The concentrations of plasma tPA and plasminogen activator inhibitor (PAI)-1 and -2 were measured. The scores and strength of fibrous bands in the tPA group were lower than those in the control and saline groups whereas wound strength was similar in all groups. The plasma tPA concentration was significantly higher and the plasma PAI-1 and PAI-2 concentrations were significantly lower in the tPA group than in the control and saline groups on the 7th and 14th postoperative days. Our findings suggest that tPA can reduce the incidence of postoperative intraperitoneal adhesions without impairing wound healing.

A follow-up study of annular pancreas in infants and children

Fifteen pediatric patients undergoing surgery for annular pancreas from 1984 to 1996 were analyzed. Vomiting was the most common presenting symptom. Twelve patients (80%) had associated anomalies including malrotation (40%), intrinsic duodenal obstruction (33%), Down syndrome (27%) and duodenal bands (27%). Their ages at operation were between 5 hours and 8.5 years, with a median of 4 days. Surgical treatment included duodenojejunostomy in nine, duodenoduodenostomy in five and duodenotomy with duodenoplasty in one. The mean duration for reestablishment of bowel transit was 17.9 days, with 22.8 days for duodenojejunostomy and 12.3 days for duodenoduodenostomy. All cases received postoperative follow-up, but only 11 of them were long-term followed until April 1997, with a duration ranging from 1 year and 2 months to 11 years, with a median of 7 years and 5 months. The survival was 100%, but 12 cases (80%) developed postoperative complications including cholestatic jaundice (53%), upper gastrointestinal motility disorder (47%), failure to thrive (40%) and chronic diarrhea (33%). Annular pancreas divisum was noted in one case with chronic relapsing pancreatitis. At the end of follow-up (April 1997), when final ages ranged from 1 year and 2 months to 18 years and 9 months with a median of 7 years and 5 months, there were still problems: steatorrhea in 1, diarrhea after fatty diet in 3, malnutrition in 4, failure to thrive in 3 and lower concentration of stool trypsin in 3 cases. In conclusion, close long-term follow-up is essential for infants treated for annular pancreas because many of them can be expected to develop complications, even if the initial postoperative period is uncomplicated and survival is excellent.

Carnitine contents in remnant liver, kidney, and skeletal muscle after partial hepatectomy in rats: randomized trial

Carnitine, an important carrier of free fatty acid that is transported into mitochondria for beta-oxidation, was thought to be one of the key factors in the regulation of liver regeneration. If the carnitine content is insufficient in the hepatocyte, it might impair the energy substrate's transport and the energy charge required for cell regeneration. The purpose of this study is to evaluate the changes of carnitine content in remnant liver, kidney, and skeletal muscle simultaneously after partial hepatectomy in rats. Partial hepatectomy with resection of the median and left lateral lobes was performed on male Wistar rats. Rats with a sham operation comprised a control group. This study was an experimental randomized trial. Ten rats from each group were sacrificed before the operation and at 6, 24, 48, and 72 hours after the operation. The carnitine content, as total and free forms, in remnant liver, kidney, and skeletal muscle were quantified by high-performance liquid chromatography. The carnitine contents in the remnant liver increased significantly at 6, 24, and 48 hours after partial hepatectomy (p < 0.01). The increase of total carnitine content was more obvious than that of the free form. In contrast, the decreasing concentrations of total carnitine and free carnitine in the kidney were significant (p < 0.01). In skeletal muscle the total carnitine content decreased to a small extent, and it was observed only at 6 hours after partial hepatectomy (p < 0.05). It is suggested that remnant liver promoted the generation of carnitine, whereas kidney and skeletal muscle released their stored carnitine at an early stage after partial hepatectomy. As a result, the influx of the carnitine into hepatocytes increased at the regenerative stage. The carnitine content of remnant liver is sufficient during the early posthepatectomy stage.

Manifestations and surgical treatment of choledochal cyst in different age group patients

Whether early surgery is necessary for asymptomatic choledochal cyst is still controversial. In order to evaluate the manifestations of choledochal cyst on different age group patients, we investigated 57 patients, 36 females and 21 males, who underwent surgery for choledochal cyst at National Taiwan University Hospital from July 1988 to June 1995. Of these, 93% were classified as type I according to the Alonzo-Lej or Todani classification method. Patients were divided into three groups according to their age at surgery: group I, 14 infants (< 1-yr); group II, 28 children (1-16 yr); and group III, 15 adults (> 16 yr). The most common symptom in infants was jaundice, while abdominal pain was the most frequent in children and adults. Preoperative evaluation of liver function showed that alanine aminotransferase was higher in group II (160 +/- 77 IU/L) and group III (164 +/- 75 IU/L) than group I (74 +/- 28 IU/L). A higher tendency of biliary sludge and stone formation was noticed in group III (6/15, 40%) when compared with group I (2/14, 14.3%) and group II (5/28, 17.9%). The incidence of high bile amylase concentration in the choledochal cyst was higher in groups II (16/21,76.2%) and III (9/11, 81.8%) than in group I (2/9, 22.2%). There was more inflammatory changes detected in the choledochal cyst wall and gall bladder by histologic examination in older patients (groups II and III). Therefore, an early surgery for choledochal cyst is suggested for prevention of liver injury, biliary sludge, stone formation and pancreatitis.

Accessory hepatic duct associated with a choledochal cyst

This case report describes an accessory hepatic duct (AHD) identified by intraoperative cholangiography during excisional surgery of a choledochal cyst (CC). The accessory duct was divided and reconstructed successfully to the Roux-en-Y jejunal loop. The postoperative course was uneventful, and follow-up abdominal sonography revealed neither evidence of biliary tract obstruction nor atrophic changes of the liver. It is advocated that an AHD should be meticulously reconstructed if it is divided during excisional surgery of a CC.

Anaesthetic managements for conjoined twins with complex cardiac anomalies

PURPOSE

To describe the perioperative assessment and anaesthetic management for surgical separation of three sets of conjoined twins with complex cardiac anomalies threatened with arterial desaturation and haemodynamic instability.

CLINICAL FEATURES

Three sets of conjoined twins, one omphaloischiopagus, one omphalopagus, and one thoraco-omphalopagus, were considered for separation during the perinatal or infantile period. Preoperative functional evaluation including continuous pulse oximetry, capnography, and cardiac electrophysiological studies were considered to be as important as anatomical evaluation of the cardiac anomalies and cross-circulation by angiography in assessing the feasibility of surgical separation. Ipsilateral infusion of prostaglandin E1 and phenylephrine were applied to the cyanotic and healthy twins respectively, to restore arterial oxygenation intraoperatively and to avoid profound hypoxaemia.

CONCLUSION

Surgical separation and anaesthesia should be well planned and rehearsed before clinical deterioration of the weaker twin. Aggressive pharmacological intervention and understanding of the cross-circulation pathophysiology is necessary to manage critical situations during surgical separation and in the postoperative period.

Changes in T-lymphocyte subpopulations and serum lymphokine concentrations after partial hepatectomy in rats

The relationship between liver regeneration and immunological response does exist. Extrathymic T cells and serum lymphokines are believed to be changed after partial hepatectomy, but there is still much controversy. This study evaluates the changes of peripheral blood T-lymphocyte subpopulations, natural killer (NK) cells, serum lymphokines, and NK cells in the remnant liver after partial hepatectomy. Male Wistar rats weighing around 200 g were used as subjects. Partial hepatectomies (67%) were done. Counting T-lymphocyte subpopulations (includes T3, T4, T8, T-IL2R, and NK cells) by using fluorescin isothiocyanate or phycoerythrin was performed preoperatively and on 1,2,3,5,7, and 10 d postoperatively. Serum gamma-interferon (gamma-IFN), interleukin-2 and interleukin-2 receptor concentrations were measured. Absolute number of NK cells in the remnant liver was also counted. Rats with right-side nephrectomy, sham operation, and no operation were used as control groups. Comparing the difference between all groups, we found that all T-lymphocyte subpopulations in peripheral blood, serum gamma-IFN, peripheral blood NK cells, and the absolute number of NK cells in the remnant liver of hepatectomized rats increased markedly, and were significantly higher than control groups rats, on the fifth and seventh post-hepatectomy day. It is suggested that gamma-IFN and NK cells were activated markedly and might play important roles in the regulation of liver regeneration after partial hepatectomy.

Perforated Meckel's diverticulum in a neonate

A case of Meckel's diverticulum is reported in an eight-day-old male baby, the youngest patient to have had this condition at National Taiwan University Hospital. The baby had been affected by bilious vomiting of 3 days' duration and abdominal distension before being brought to the hospital. A perforated Meckel's diverticulum was found during emergency laparotomy. The resected Meckel's diverticulum did not contain ectopic tissue. The narrow lumen and narrow base of the diverticulum was thought to be the cause of poor self-emptying and subsequent acute inflammation and perforation.

Choledochal cyst in neonates

Common bile duct cyst, or choledochal cyst is known to be an uncommon cause of neonatal jaundice. It is usually associated with distal biliary tract obstruction and presents a clinical picture that is indistinguishable from biliary atresia. We report two cases of neonatal choledochal cyst encountered from 1992 to 1994. The infants were free from perinatal insult and presented with prolonged jaundice. In both cases, antenatal ultrasonography was unremarkable. Biochemical examinations revealed elevated levels of serum transaminases, alkaline phosphatase and direct bilirubin. Abdominal sonograms disclosed a cystic mass close to the gall-bladder. Intrahepatic duct dilation was noted in one patient. Hepatobiliary scintigraphy demonstrated accumulation of the radionuclide in the porta hepatis without subsequent intestinal activity. Cystic dilatation of the common bile duct with distal obstruction was noted during surgery. Both infants underwent cyst excision with Roux-en-Y hepaticojejunostomy and cholecystectomy. Liver biopsy in one infant showed mild proliferation of the interlobular bile duct and mild portal fibrosis. The postoperative course was uneventful. We conclude that early detection and treatment of choledochal cyst in neonates are important for preventing serious complications of biliary obstruction.

Pentalogy of Cantrell corrected by one-stage repair

Pentalogy of Cantrell (POC), is a rare congenital defect associated with five ventral midline abnormalities and high mortality. We report a 2,788 g female infant with partial repair of POC in the neonatal stage. This consisted of repairing the omphalocele, plicating the eventrated diaphragm and placing the heart into the thoracic cavity by fixing the pericardium to the ventral side of the diaphragm. She was well 6 months after surgery.

Effect of octreotide on postoperative intraperitoneal adhesions in rats

BACKGROUND

Octreotide, a long-acting somatostatin analogue that can inhibit glycosaminoglycan synthesis by fibroblasts in skin, may be a potent inhibitor of postoperative intraperitoneal adhesions. An animal model was developed to evaluate the effect of octreotide.

METHODS

Twenty-four male Wistar rats were divided into four groups. Laparotomy with a 15-cm intestinal resection and reanastomosis was performed on each group of rats. The intestinal serosa was also scratched to induce adhesion formation. No medication was given to group-1 rats (C). Group-2 rats received peritoneal irrigation with 6 ml normal saline intraoperatively (NS). Group-3 rats received irrigation with 6 ml octreotide solution (5 micrograms/ml) intraperitoneally (Oc). Group-4 rats received irrigation with 6 ml octreotide solution intraoperatively and 10 micrograms/kg of octreotide injection intramuscularly twice a day for 14 days (Oc + IM). All rats were killed 2 weeks later. The number of fibrous bands at and away from the anastomotic site was recorded. The strength and extent of the fibrous bands were also measured.

RESULTS

The total scores of intraperitoneal adhesion bands were significantly reduced in group Oc and group Oc + IM rats when compared with group C (p < 0.05). When the fibrous bands at the anastomotic site and away from it were distinguished, the results were the same. As to the strength and extent of intestinal adhesions, the data showed no significant difference among all four groups.

CONCLUSIONS

These data supported the suggestion that octreotide can reduce the incidence of postoperative intraperitoneal adhesions in rats.

Alimentary tract duplications

A total of 17 patients with alimentary tract duplications underwent surgery at National Taiwan University Hospital from 1978 to 1994. Fifteen patients (88%) had gastrointestinal duplication and two (12%) had esophageal duplication. Common presenting symptoms of gastrointestinal duplication were melena and abdominal pain. The ileum was the most common site of duplication. Multiple duplications were seen in three patients. All duplications were cystic, except for one single appendiceal duplication. Ectopic gastric mucosa was detected in nine of the 16 nongastric duplications. One patient with ileal duplication had ectopic pancreatic tissue. Twelve patients received resection of the duplication with a segment of bowel and primary anastomosis, three patients underwent simple excision and two patients had partial resection of the duplication and stripping of the residual mucosa. Two patients had other associated congenital anomalies: one had ventricular septal defect and the other, imperforate anus and malrotation of intestine. There was no operative mortality or morbidity in this series.

Liver laceration in premature neonate: report of a case with successful surgical treatment

Neonatal liver laceration is a relatively rare but probably fatal condition without prompt diagnosis and treatment. It should be considered in newborn infants who are presented with sudden onset of symptoms and signs of hemoperitoneum such as shock, pallor, abdominal distension, abdominal bruising, or scrotal ecchymosis. Roentgenogram may show free peritoneal fluid. Abdominal sonography is helpful in the detection of intraabdominal bleeding. Paracentesis is the most effective diagnostic procedure for the confirmation of hemoperitoneum. The rupture of the liver is the first priority to be considered, though other abdominal organs including adrenals, kidneys, and spleen are also prone to injury. Once liver laceration is highly suspected, resuscitation with blood transfusion, correction of coagulopathy, and then emergency surgical intervention must be performed if conservative treatment fails. Here we present a 1,662 gm premature male neonate who underwent successful surgical repair of the liver laceration.

Alterations of remnant liver carnitine and serum carnitine concentrations after partial hepatectomy in rats

The role of carnitine in the early phase of liver regeneration after partial hepatectomy has been a controversial issue. The purpose for this study was to evaluate the alterations of remnant liver carnitine and serum carnitine concentrations in partial-hepatectomized rats. Partial hepatectomy, with resection of the median and left lateral lobes (67%), was done in 40 male Wistar rats weighing about 200 g. Another group of 40 rats underwent a sham-operation for comparison. All the rats underwent fasting for 4 hours before surgical procedure and 2 hours after surgery. They were killed at 6, 24, 48 or 72h after the operation, ten rats for each time. The serum carnitine concentration, remnant liver carnitine content, serum free fatty acid (FFA), acetoacetate (AA) and beta-hydroxybutyrate (BB) concentrations were measured. It was found that: (1) the serum carnitine concentration increased in the early posthepatectomized stage; (2) the carnitine content in the remnant liver increased in the early posthepatectomized stage; and (3) the serum FFA and its metabolites markedly increased with a depressed ketone body ratio noted in the early post-hepatectomized stage. These results supported the theory that regenerating liver utilized free fatty acids as an immediate main substrate. The utilization then decreased. Because of a marked increase of the carnitine concentration in the remnant liver and serum, it is suggested that the carnitine contents were sufficient for liver regeneration. There must be other reasons for the decreased utilization of free fatty acids.

Alterations of remnant liver carnitine palmitoyltransferase I activity and serum carnitine concentration after partial hepatectomy in rats

Many authors agree that alteration of the energy substrate from glucose to free fatty acid occurs during the early stage after partial hepatectomy. An accelerative effect of carnitine on the early phase of liver regeneration was suggested in several reports, but much controversy prevails. Using male Wistar rats weighing about 200 g as subjects, we undertook partial hepatectomy with resection of the median and left lateral lobes (67%). Another group of rats undergoing a sham operation was compared. Rats were killed at 6, 24, 48, or 72 hr after the operation. The rate of synthesis of DNA and content of DNA in remnant liver were chosen as regenerative indicators. Serum carnitine, free fatty acid and its metabolites, remnant liver carnitine palmitoyltransferase I (CPT-I) activity, high-energy phosphate (HEP), including adenosine triphosphate (ATP), and creatine phosphate (CP) were measured. The results showed a marked decrease of HEP, ATP, and CP with suddenly increased free fatty acid and total ketone body in serum that occurred during the early regenerating phase after partial hepatectomy. Serum L-carnitine also increased markedly in this early stage. The mitochondrial CPT-I activity in the remnant liver decreased significantly 24 hr after partial hepatectomy. Our data show that regenerating liver utilizes free fatty acids as an immediate main substrate. Mitochondrial respiration with a CPT-I effect could be an important reaction in this utilization.

Colon perforation in a patient with hyperimmunoglobulin E (Job's) syndrome

A Taiwanese boy was diagnosed as having hyperimmunoglobulin E syndrome at the age of 4 years. At age 18 he was admitted to the hospital because of pneumonia in the left lower lobe. Abdominal pain developed 9 days later, and his condition progressed to peritonitis. Colon perforation, 10 cm distal to the ileocecal valve, was found. Double-barrel ileostomy was performed, and reanastomosis was done 1 1/2 months later. Afterward, he was fine, and he had no significant gastrointestinal problems after being discharged. To the author's knowledge, this is the first reported case of hyperimmunoglobulin E syndrome complicated by colon perforation.

Effects of lipids on intestinal adaptation following 60% resection in rats

The effects of long-chain triglycerides (LCT) and of medium-chain triglycerides (MCT) on intestinal adaptation in rats were compared following a 60% resection of intestine. Sixty Long-Evans rats were divided into four groups: control (sham-operated) rats fed an MCT-enriched diet, control rats fed an LCT-enriched diet, experimental rats fed an MCT-enriched diet, and experimental rats fed an LCT-enriched diet. In the MCT-enriched diet, 90% of the fat was MCT; in the LCT diet, 90% was LCT. In each diet, 31-32% of daily caloric intake came from fat. All diets were isocaloric and isonitrogenous. Following the 60% intestinal resection from the mid-portion of the small intestine, there were significant increases in mucosal height, villous height, villous width, and crypt depth (P < 0.05). Gut weight, mucosal weight, protein and DNA content, and DNA synthetic rate also increased. In the ileum, rats receiving the LCT diet showed greater increases in gut weight, mucosal weight, crypt depth, protein and DNA content, and DNA synthetic rate than the MCT rats did (P < 0.05). In the jejunum, however, the differences were not statistically significant. In both the jejunum and the ileum, the response of the intestine was greater closer to the anastomotic site (P < 0.05). Results of these studies demonstrated that LCT had a better effect than MCT on intestinal response both structurally and functionally.

Effect of pentoxifylline on intraperitoneal adhesions after intestinal resection in rats

Pentoxifylline, an analogue of the methylxanthine theobromine, inhibits glycosaminoglycan and collagen synthesis by dermal fibroblasts in vitro and also inhibits the proliferation of dermal fibroblasts. It may have the same effect on fibroblasts derived from postoperative adhesion bands, thus preventing postoperative adhesion formation. An animal model was developed to evaluate the effect of pentoxifylline. Twenty-four male Wistar rats were divided into four groups, and all underwent laparotomy with a 15 cm intestinal resection and reanastomosis. The intestinal serosa was scratched to induce adhesion formation. No medication was given in group 1 rats, group 2 rats received 6 mL normal saline by intraoperative peritoneal irrigation, group 3 rats received 6 mL pentoxifylline solution (1 mg/mL) by intraperitoneal irrigation and group 4 rats received both 6 mL intraoperative pentoxifylline solution (1 mg/mL) irrigation and 50 mg/kg pentoxifylline by intramuscular injection, twice a day for 14 days. All rats were sacrificed 2 weeks later. The numbers of fibrous bands at and away from the anastomotic site were recorded and scored. The score for each rat was calculated as the sum of the scores for each band. The strength and the extent of the fibrous bands were also measured and compared. The scores of adhesion bands at the anastomotic site were significantly reduced in group 3 and group 4 rats when compared with group 1 rats. However, there were no significant differences among the 4 groups in the extent and strength of adhesions at sites other than the anastomosis site.

Separation of ischiopagus tripus conjoined twins

The authors report on their second experience of a successful separation of ischiopagus tripus conjoined twins. Particular emphasis is placed on the painful decision of sacrificing the only available leg to cover the infected wound after an unexpected complication in twin A. The twins' preoperative evaluation, separation surgery, and subsequent 16-month course are described.

Separation of thoracopagus conjoined twins. A case report

A pair of thoracopagus conjoined twins with a connection at the atrioventricular groove of both hearts and a huge conjoined liver were surgically separated. An aortopulmonary shunt was created for Twin B, a victim of complex congenital heart disease with hypoplastic right heart syndrome, who died 5 hours later. However, Twin A survived after prolonged endotracheal intubation and parenteral nutrition. He survived for 7 months, and went home, but finally died of sepsis. In reviewing 47 pairs of surgically separated thoracopagus conjoined twins, in 30 pairs of type A (Leachman's classification, completely separate hearts), 42 patients survived (70%); in 5 pairs of type B (atrial connection only), one patient survived (10%); in 9 pairs of type C (both atrial and ventricular interconnections), none survived; in 3 pairs of unknown type, 2 survived. Total survival rate of surgically separated thoracopagus conjoined twins was 47.9%. The survival rate was 38.2% in those operated in the neonatal period (n = 34) and 63.6% in those operated over 1 month of age (n = 44) (p = 0.016). In conclusion, thoracopagus conjoined twins are rare. Although its separation carries a high risk, especially in those with cardiac connection, this report confirmed that separation is still feasible under proper preparation and planning.

Hyperammonemic encephalopathy due to essential amino acid hyperalimentation

Hyperammonemic encephalopathy has occasionally been reported in uremic patients receiving hyperalimentation with essential amino acid (EAA) as a source of nitrogen as one of the remaining treatment options when the enteric routes were prohibited. We encountered this complication in a patient with normal renal function. A rat animal model was designed to elucidate the mechanism of hyperammonemia resulting from hyperalimentation with EAA as a source of nitrogen. Sixty-four male Long-Evan rats were divided into eight groups receiving feeds ad libitum or different formula of hyperalimentation. Hyperammonemia was found in every rat given hyperalimentation with EAA as the only nitrogen source. Using the Tukey honestly significant difference test, the results were significantly higher (p < 0.001) than that of the control group which were given feeds ad libitum and those groups given hyperalimentation for the same number of days but with mixed amino acid (MAA) as the nitrogen source. Adding arginine to EAA for a further four days after initial administration of EAA hyperalimentation for three days only slightly lowered the mean serum ammonia level. When compared to that of the three-day EAA hyperalimentation group, the difference was not statistically significant. Adding arginine, citrulline, and ornithine to EAA for a further four days significantly lowered the mean serum ammonia level. When we changed EAA hyperalimentation to MAA hyperalimentation for a further four days, the mean serum ammonia level decreased dramatically to nearly normal. Hyperalimentation using EAA as the exclusive source of nitrogen resulted in hyperammonemia. A deficiency of arginine or other amino acids of the urea cycle failed to account completely for the hyperammonemia observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reduced-size liver transplantation in mini pigs]

Liver transplantation as therapy for end stage hepatic disease has developed rapidly since the 1980s. Pediatric candidates, however, have suffered the greatest delay in receiving suitable organs, with 20% to 50% of deaths occurring in patients on the waiting list. To overcome the shortage of young donors, surgeons are currently experimenting with the technique of partial liver transplantation. In this study, 10 pairs of mini pigs were used for partial liver transplantation. UW (University Wisconsin) solution was used for liver preservation after the liver was procured. The left lobe was separated using the intact vascular branches method. The raw surface was covered with histoacryl orthotopically in the smaller pig in a position of 60 degrees-90 degrees counter clockwise rotation. The results were: (1) six of the ten transplanted pigs survived for more then one week without any immunosuppressive drugs; (2) the mean operation time was 5h 18 mins; (3) the mean ischemic time of the donor liver was 6h 25 mins; (4) the liver functions tests were acceptable until the day before death. Based on this experiment, we suggest that partial liver transplantation is feasible, both technically functionally.

[Ultrastructure changes of the remnant regenerating hepatocytes after partial hepatectomy in rats]

In spite of its highly functionally differentiated characteristics, the remnant liver has the capability of regeneration after massive hepatectomy either in human beings or in experimental animals. This experiment was performed to study the ultrastructural changes of the regenerated hepatocytes after massive hepatectomy. Male Wistar rats weighing around 200g were used in this study. Partial hepatectomy with resection of the median and left lateral lobes (67.31%) was performed. The rats were sacrificed at 6, 24, 48 and 72 hours after the operation. The remnant liver was inspected under a light and electron microscope. We found that: (1) the glycogen in the cytoplasm of hepatocyte nearly disappeared 6 hours after hepatectomy, with a decrease of rough endoplasmic reticulum (RER) and an increase of smooth endoplasmic reticulum (SER) and lysosomes were noted; (2) 24 hours after hepatectomy, (the nuclear membrane became zigzag shaped and the reappearance of glycogen and an increase of RER, autophagosome and lipid droplets were noted. (3) the number of mitosis increased markedly at 48 hours postoperatively; and (4) 72 hours after hepatectomy, the lysosome and RER returned to preoperative condition with some RER became dilated; SER was hardly found and lipid droplets became bigger and increased; and the nuclear membrane shape was still a zigzag at this time.

Rat liver regeneration after partial hepatectomy: effects of insulin, glucagon and epidermal growth factor

This study evaluated the role of insulin, glucagon and the epidermal growth factor (EGF) on liver regeneration after partial hepatectomy. Male Wistar rats, weighing approximately 200 g, were used. A partial hepatectomy, with resection of the medial and left lateral lobes (67.31%), was performed on the control group and seven hormone-treated groups: insulin, glucagon, EGF, insulin plus glucagon, insulin plus EGF, glucagon plus EGF, and a combination of the three hormones. The hormones were administered subcutaneously two days prior to the partial hepatectomy. The groups administered insulin were allowed to drink 20% glucose in water. Another group of rats received simulated operations, i.e., only a laparotomy was performed. The rats were killed at six, 24, 48 and 72 hours after the operation. Remnant liver weight, deoxyribonucleic acid (DNA) content, rate of DNA synthesis, mitotic index, blood glucose and serum insulin levels were measured. The results showed that: 1) the effects of single hormone administration on posthepatectomy liver regeneration were not obvious; 2) combined administration of insulin and glucagon increased the weight of the remnant liver, the DNA content, and the rate of DNA synthesis; 3) the combined administration of insulin, glucagon, and EGF increased the regeneration based on the remnant liver weight and mitotic index; and 4) there was no concordance between the change in blood glucose levels and the effect of hormones during liver regeneration.