Immunoglobulin E antibodies from pancreatic cancer patients mediate antibody-dependent cell-mediated cytotoxicity against pancreatic cancer cells

In addition to allergy and parasitic infections, immunoglobulin E (IgE) has been shown recently to possess anti-viral and anti-cancer effects. We investigated serum levels of IgE, its low-affinity receptor, soluble CD23 (sCD23) in patients with pancreatic cancer and the effect of IgE against pancreatic cancer cells. Twelve patients were evaluated for pancreatic cancer by imaging and confirmed by biopsy. Fifteen healthy volunteers served as controls. Serum Igs (IgG, IgM, IgA, IgE) and sCD23 levels were determined (enzyme-linked immunosorbent assay, nephelometry) and the presence of cancer-specific IgE was assessed (fluorescence microscopy, Western blot). IgE anti-cancer activity was determined by antibody-dependent cell-mediated cytotoxicity (ADCC). Serum levels of IgE and sCD23 were elevated significantly in patients with pancreatic cancer versus controls, whereas no differences were observed in other Ig isotypes (IgG, IgM, IgA). Flow cytometry and immunofluorescence microscopy demonstrated similar presence of IgG and IgE pancreatic cancer Igs. However, Western blot analysis indicated differences in IgG and IgE antigen-specific antibodies; IgE antibody recognized a 50 kD protein. ADCC studies demonstrated that serum and purified IgE-mediated cytotoxicity against pancreatic cancer cells, effects which were reversed with anti-IgE neutralizing antibody and IgE depletion (immunoaffinity); greater cytotoxicity was observed in patient serum when compared with healthy controls. These data suggest that IgE and sCD23 may serve as useful biomarkers for patients with pancreatic cancer and may be important in the immune response to this disease in that IgE-directed therapy may help to direct treatment.

Comparison of reg I and reg III levels during acute pancreatitis in the rat

OBJECTIVE

To study alterations of serum levels of the pancreatic reg family of proteins in two models of acute pancreatitis.

SUMMARY BACKGROUND DATA

The pancreatic reg family of proteins is expressed in the acinar pancreas. Reg I (pancreatic stone protein, PSP) and reg III (pancreatitis-associated protein, PAP) are induced after the onset of acute pancreatitis, and both have been proposed as potential markers of pancreatitis.

METHODS

Pancreatitis was induced in rats by either retrograde infusion of sodium taurocholate or by direct trauma. Serum samples were obtained daily for 4 days after the procedure, and the animals were then killed. Twelve animals underwent sham procedure and six underwent daily analysis without surgery. Levels of reg I/PSP and reg III/PAP were estimated by enzyme-linked immunosorbent assay.

RESULTS

Reg III/PAP levels increased significantly the first day after induction of both types of pancreatitis and rapidly returned to baseline in all survivors. Even animals who received retrograde infusion of saline showed a mild increase in reg III/PAP on the first day, whereas control animals that did not undergo surgery showed no variations. Reg I/PSP serum levels remained unchanged throughout all experimental periods. Postinjury reg III/PAP levels significantly correlated with severity of the pancreatic injury and animal survival; reg I/PSP levels did not.

CONCLUSION

After induction of pancreatitis, serum levels of reg I and III protein differ significantly. Reg III/PAP levels are a sensitive marker of pancreatic injury and early in the disease may be a useful prognostic indicator for disease severity.

Use of pancreaticogastrostomy for pancreatic reconstruction after pancreaticoduodenectomy

After resection of the head of the pancreas, the distal remnant is typically telescoped into the jejunum. Recently, pancreaticogastrostomy has re-emerged as a useful alternative, as the anastomosis is easy and without tension. The results of pancreaticogastrostomy in 10 consecutive patients is reviewed, as is the literature of both the technique and the physiology of the procedure. In the current series, mean +/- SEM age was 65 +/- 2.3 years. Extended pancreaticoduodenectomy was performed in two patients, pylorus-preserving in eight. Mean tumor size was 3.9 +/- 1.1 cm (range, 1.5-7.5 cm), mean operative time was 6.5 +/- 0.5 hours. Intraoperatively, 7.6 +/- 0.8 L of fluid was given, only two patients were transfused. The mean length of stay was 9.4 +/- 1.8 days. There were no anastomotic leaks, no deaths, and two patients developed temporary gastric ileus. There are now 841 pancreaticogastrostomies reported in the literature, with a leak rate of 3.1% and a death rate of 2.6%. Pancreaticogastrostomy is easy to perform, safe, and useful even after extended Whipple.

A recombinant rat regenerating protein is mitogenic to pancreatic derived cells

Pancreatic regenerating protein (reg I) is expressed in acinar cells and is mitogenic to beta- and ductal cells. Isolation of large amounts of endogenous reg I for in vivo and in vitro experiments has been difficult. The aim of this study was to develop a recombinant protein and determine its bioactivity on rat pancreatic derived cells. cDNA of the rat reg I coding region was created with unique BamHI flanking sequences using reverse transcriptase PCR. The coding region was then cloned into a bacterial expression vector in which expression is controlled by a T7 promoter. After transformation into the Escherichia coli strain B21(DE3) and induction by isopropyl-beta-d-thiogalactopyranoside, a fusion protein of 24 kDa in size, named reg-PET, was noted in the bacterial lysate. This protein contained a polyhistidine and S-peptide sequence to facilitate isolation and identification, respectively. This protein was purified using affinity chromatography, and identity was confirmed with gel electrophoresis and Western analysis. The reg-PET protein was mitogenic to both ARIP and RIN cells, rat pancreatic ductal and beta-cell lines, respectively. Antibodies raised to the protein reacted against rat reg I in pancreas. The purified recombinant reg I fusion protein, like endogenous reg I, is mitogenic to pancreatic derived cells. It is more potent than reg I isolated from pancreatic tissue. This protein can be isolated rapidly, easily, and with a high amount of purity.

Characteristics of rat pancreatic regenerating protein

BACKGROUND

The pancreatic regenerating (reg) gene is an acinar cell product involved in islet formation and maintenance. Human reg protein is mitogenic to pancreatic beta and ductular cells, and its amino acid sequence predicts it to be a calcium-dependent lectin.

METHODS

We studied the biologic activity and cellular localization of rat reg I isolated from the acinar cell line AR42J and the lectin properties of reg from AR42J and pancreatic juice. Bioactivity was assayed by mitogenesis on the ductular cell line ARIP. Cellular localization was determined by differential centrifugation. Lectin properties were assessed by affinity chromatography.

RESULTS

Reg protein from crude AR42J cellular lysate and purified reg protein from AR42J induced thymidine incorporation to ARIP. Conditioned medium from AR42J and co-culture of AR42J with morphologically distinguishable ARIP, however, failed to induce mitogenesis. Reg protein was localized within the vesicle fraction of the cell and was not membrane bound. Affinity chromatography revealed that reg protein did not bind to mannose or galactose in the presence or absence of calcium. In pancreatic juice a previously undescribed mannose-binding protein was discovered at 25,000 to 30,000 daltons.

CONCLUSIONS

We conclude that reg produced in the acinar cell line AR42J is biologically active but not efficiently secreted, even though it localized within the cellular vesicles. Despite predictions based on its amino acid sequence, it does not appear to be a calcium-dependent lectin.

Effect of reg protein on rat pancreatic ductal cells

The pancreatic regenerating gene (reg I) is expressed in the exocrine pancreas and is involved in islet regeneration. Reg I protein has been shown to be mitogenic to beta- and ductal cell lines, but not mature islets. In this study, we tested the effect of two isolates of reg I on primary cultures of ductal cells. Rat pancreatic ductal cells were isolated by collagenase digestion and isolated colonies were maintained in culture. The cells were proven to be ductal in origin by their morphology and by immunofluorescent staining with epithelial markers. Reg I was isolated from human pancreatic extracts or from the rat acinar cell line AR42J by sequential ammonium sulfate precipitation and acid precipitation. Cells were cultured with doses of reg I for 72 h, pulsed with 10 microM bromodeoxyuridine (BrdU) for 2 h. After fixation, nuclei were double-stained with propidium iodide and BrdU monoclonal antibody. The percentages of nuclei positive for BrdU were calculated from at least five colonies per group. A 10-nM concentration of human reg I increased BrdU incorporation by 2.3-fold over controls, rat reg I increased it by 1.4-fold (p < 0.05). When compared to their effects on the ductal cell line ARIP, both human and rat reg I were 100 times more potent on the primary cultures of ductal cells. We conclude that human and rat reg I proteins are mitogenic to primary cultures of ductal cells. Although principally a product of the acinar cell, reg I appears to be a stimulus of ductal cell growth and, in this fashion, may modulate the expansion of the pancreatic ductal population during islet regeneration.

Pancreatic reg gene expression is inhibited during cellular differentiation

BACKGROUND AND OBJECTIVE

Factors that control pancreatic regenerating (reg I) gene expression are unknown, but it is believed that its expression may correspond with cellular differentiation. The authors recently demonstrated that reg I is expressed in AR42J, a rat acinar cell line whose state of differentiation can be modulated by dexamethasone. They used this line to study reg I expression during cellular proliferation and differentiation.

METHODS

After treatment of cells with 10 nmol/L dexamethasone, proliferation was assayed by thymidine incorporation; differentiation by expression of elastase I mRNA. Reg I mRNA levels were measured using a rat reg I cDNA probe, and reg I protein levels assayed by enzyme-linked immunosorbent assay of cellular lysates with a polyclonal antibody. The effect of gastrin, cholecystokinin and glucagon on reg I expression was also studied.

RESULTS

When compared with controls, treatment with dexamethasone caused thymidine incorporation to decrease and elastase mRNA levels to increase. Reg I mRNA decreased from controls of 100 +/- 16% to 40 +/- 18% (p < 0.05), and reg I protein levels decreased as well. Gastrointestinal hormones had no significant effect on either elastase or reg I gene expression.

CONCLUSIONS

Expression of reg I inversely correlates with the level of cellular differentiation, can be modulated via the glucocorticoid receptor, and is a potential marker of gastrointestinal epithelial differentiation. Despite its presence within a pancreatic acinar cell line, reg I gene expression is not modulated by gastrointestinal hormones.

Ectopic expression of reg protein: A marker of colorectal mucosa at risk for neoplasia

Pancreatic regenerating gene (reg I) messenger RNA is overexpressed within the pancreas following injury and resection. Its level of expression corresponds to the level of cellular dedifferentiation. Human reg I has been localized to chromosome 2p12, and ectopic expression of its mRNA has been found within colorectal tumors. We postulated that colorectal production of reg I might either be a marker for the presence of cancer or define mucosa at risk for development of neoplasia. Using a monoclonal antibody to reg I, regenerating gene protein was histochemically mapped in 56 cases of documented colorectal adenocarcinoma. In sections of colon from normal control subjects no reg I protein was noted, whereas 58.9% of the specimens from cancer patients stained positive for reg I. Although a correlation was noted between reg I staining and Dukes' stage, there was no correlation with histologic grade or 5-year patient survival. In 39 of 55 cancer specimens the transition zone (interface) between the neoplasm and normal mucosa was visualized; 100% of the transition zones contained cells that stained strongly positive for reg I. We conclude that reg I protein is ectopically expressed in colorectal mucosa at the transition zone of colorectal cancer, and occasionally within the tumor itself. Although ectopic reg I expression in colorectal epithelia is not a marker for the presence of carcinoma, it may be a sensitive marker for mucosa at risk for development of neoplasia.

Laparoscopic cholecystectomy: applicability in the geriatric population

Elderly patients with cholelithiasis are more likely than nonelderly patients to present with an acute complication of gallstone disease such as acute cholecystitis (AC), gallstone pancreatitis (GSP), or common bile duct stones (CBDS). These acute complications may make laparoscopic cholecystectomy (LC) more hazardous, with a potential increase in perioperative morbidity or need for open conversion. The applicability of LC in the geriatric population is, therefore, unclear. We reviewed 283 consecutive patients undergoing attempted LC. Patients were classified as presenting with complicated (AC, GSP, or CBDS) or uncomplicated gallstone disease. Elderly patients were significantly more likely than younger patients to present with AC (40% versus 18%), GSP (19% versus 6%), and CBDS (21% versus 5%) (all P < 0.05). Elderly patients with chronic, uncomplicated gallstone disease (n = 20) and nonelderly patients with uncomplicated disease (n = 159) had similar open conversion rates (5% and 7%, respectively). In contrast, the open conversion rate in elderly patients with complicated gallstone disease (n = 42) was significantly higher (50%) compared to nonelderly patients with complicated disease (n = 62; rate, 16%; P < 0.05). Perioperative morbidity and length of stay were also significantly increased in the elderly group, primarily due to the high percentage of elderly patients with complicated disease. These results suggest that elderly patients with uncomplicated gallstone disease appear to be excellent candidates for LC, and this should be considered before complicated disease develops. Conversely, early conversion or planned open cholecystectomy may be warranted in the elderly presenting with acute complications of cholelithiasis.

Insulin-like growth factor I receptor messenger RNA in the colon is unchanged during neoplasia

The expression of growth factor receptor messenger RNA is difficult to quantitate due to low copy number. We describe a quantitative polymerase chain reaction that rapidly, reproducibly assays expression of human insulin-like growth factor I (IGF-I) receptor mRNA from small, biopsy-sized, specimens of tissue. This was then clinically applied to surgically resected specimens of colon. Total RNA was isolated from normal colonic mucosa and documented tumors from 4 patients undergoing resection. The mRNA was first reverse-transcribed with an oligomer bearing a complementary sequence specific for the mRNA at its 3' end, and a sequence complementary to an intervening intron of the IGF-I receptor gene at the 5' end. Competitive PCR was then performed in the presence of the cDNA product and exogenously added genomic DNA, with an upstream primer complementary to the exon sequence of the gene of interest and a downstream primer complementary to the intron sequence that was tagged to the cDNA. The genomic DNA was used as the internal standard. To calculate the number of copies of mRNA per microgram total RNA, a standard curve was used. No difference was noted in IGF-I receptor expression between neoplastic and normal colonic mucosa. This quantitative PCR is accurate, rapid, and requires very small amounts of tissue. Potential uses are in determining genetic expression of growth factor receptors or putative tumor markers preoperatively from small samples obtained during diagnostic colonoscopy or from samples obtained at surgery.

General surgical care in the nursing home patient: results of a dedicated geriatric surgery consult service

BACKGROUND

Although recent interest has centered on diseases that require operation in the elderly, few data are available about the effects of surgical intervention on the frail nursing home patient.

STUDY DESIGN

A longitudinal study was conducted of the nature of illness requiring operation and intervention in residents of a geriatric center associated with a tertiary care medical center. A unique consult service for the patients was established and all referrals were prospectively followed up.

RESULTS

The actuarial 18-month survival of patients referred was 35 percent. Although maintenance care (e.g., decubitus ulcer, stoma, and enteral tube care) made up a substantial number of referrals (32.5 percent), common surgical diseases of the abdomen, breast, and vascular system were routinely encountered (55 percent). In patients undergoing surgery, the 30-day mortality rate was 8.5 percent, and the complication rate 9.4 percent. Although patients undergoing major abdominal and vascular procedures had a higher complication rate (17.6) percent than those undergoing lesser procedures (6.3 percent, p = 0.05), there was no difference in the 30-day mortality (9.8 compared with 6.3 percent, respectively) or 18-month actuarial survival (33 compared with 32 percent, respectively) rates. The overall actuarial survival was adversely affected by the presence of coronary artery disease (relative risk [RR], 3.27) and dementia (Mini-Mental State Examination score less than 24; RR, 2.39) and age older than 70 years (RR, 2.03). The overall survival was unaffected by the actual need for operation, the magnitude of the procedure performed, gender, the number of comorbid conditions, and the preoperative code (resuscitative) status.

CONCLUSIONS

Although nursing home patients referred for surgical intervention have poor survival rates, the use of surgical procedures does not adversely affect overall survival. This supports the idea that care for this patient population is not futile, and quality of life, patient dignity, and relief of suffering can provide a alternative to curative therapy.

Differential expression of reg-I and reg-II genes during aging in the normal mouse

A cDNA termed reg (for regenerating gene) has been isolated from a rat pancreatic DNA library. Reg expression has been shown to correlate with changes in beta cell mass and function. This finding has been recently challenged by studies showing a non-beta-cell-dependent regulation of reg expression. All studies to date, however, have neglected the fact that two nonallelic reg genes (reg-I and reg-II) exist in several species. In studying the regulation of each individual copy gene, we investigated reg-I and -II gene expression in a naturally occurring modification of beta-cell physiology: normal aging. RNA was isolated from individual pancreata of 1-, 3-, 9-, 20-, and 30-month-old C57BL/6J mice (n > or = 3 per group) and subjected to slot-blot analysis using homologous probes for reg-I, reg-II, insulin, and elastase-I. A progressive age-dependent decrease in total reg mRNA levels (reg-I and -II) was detected. At 30 months of age, total reg mRNA levels were approximately 45% of the level detected in 1-month-old mice (p = .01). This paralleled the decrease in insulin mRNA levels (p = .01), which fell below 50%; by contrast, mRNA levels for elastase-I increased with age (p = .05). Analysis of RNA isolated from purified islets did not reveal any mRNA for reg, suggesting that in the normal mouse, reg is primarily a product of the exocrine pancreas. Reg mRNA were detectable in RNA extracts from stomach, duodenum, and small intestine. By hybridization of total pancreatic RNA with oligonucleotide probes which specifically recognize reg-I or reg-II sequences, we show that reg-I mRNA levels declined with age (p = .001) while reg-II mRNA levels remained unchanged. These data demonstrate that in mouse pancreas the two nonallelic reg genes are differentially expressed during aging and that the decrease in reg-I mRNA levels parallels the decrease in insulin gene expression. Differential regulation of reg-I and reg-II genes may explain the presence of conflicting data in the current literature.

Regenerating (reg) and insulin genes are expressed in prepancreatic mouse embryos

The pancreatic regenerating (reg) gene is proposed to be involved in pancreatic beta-cell growth. Up- or down-regulation of reg gene expression has been shown to parallel variations in beta-cell mass and function in the adult pancreas. In several species at least two nonallelic reg genes have been identified. In this study we investigated the expression of each individual reg gene (reg-I and reg-II) during embryogenesis in the mouse. Single mouse embryos were harvested at 8.5, 9, 10, and 12 days of development, homogenized and subjected individually to reverse transcription (RT)-PCR, with a single primer pair to amplify both reg-I and -II mRNAs. Southern blot analysis of the RT-PCR products revealed the presence of reg mRNA at day 9 of embryogenesis, just before the beginning of pancreatic organogenesis. Slot-blot analysis with internal oligonucleotide probes that specifically recognize reg-I or -II sequences demonstrated that only reg-I mRNA was present in day 9 and day 10 prepancreatic embryos. Reg-II mRNA was not detected until day 12, a stage corresponding to late organogenesis. RT-PCR for insulin mRNA from the same samples used for the amplification of reg mRNA showed that the earliest insulin expression occurred at day 8.5, and coincided with the onset of reg-I expression. Hybridization with gene-specific oligonucleotide probes revealed that only insulin-II mRNA was detectable at this time. Insulin-I mRNA was not detectable until day 12 and coincided with early reg-II expression. These results suggest that the two nonallelic reg genes and the two insulin genes are expressed differentially during early embryogenesis. Differential expression of reg-I and -II suggests that they may be induced by different and independent stimuli and have distinct functions.

Pancreatic regeneration (reg) gene expression in a rat model of islet hyperplasia

BACKGROUND

After pancreatectomy, regeneration of acinar and islet elements occurs. Recent data from a model of islet hyperplasia in the hamster suggested that induction of a local pancreatic factor stimulates islet formation. We postulate that the reg gene may be this factor.

METHODS

We studied reg expression during induction of islet growth by using a similar model in the rat. Rats underwent surgical wrapping of the splenic lobe of the pancreas or sham operation.

RESULTS

At 2 days ductular proliferation and immunohistochemical evidence of insulin within ductular epithelia were evident in the wrapped lobe. By 14 and 56 days islet number per square millimeter increased 63% and 43%, respectively. Reg mRNA levels, measured by Northern blot analysis with a rat reg cDNA probe (n = 5), increased 300% at 2 days in the wrapped lobe and decreased to that of unwrapped controls by 14 days. In situ hybridization showed localization of reg to the acinar cells. In unwrapped gastric lobes of animals who underwent surgical wrapping of the splenic lobe, no change in islet number per square millimeter or reg gene expression was noted.

CONCLUSIONS

Surgical wrapping of the pancreatic splenic lobe induces local reg gene expression that is temporally associated with duct cell hyperplasia. This is followed by islet formation within the wrapped lobe. Reg may play a role in the induction of new islets from ductular precursors and in maintenance of normal islet function.

Altered insulin receptor messenger ribonucleic acid splicing in liver is associated with deterioration of glucose tolerance in the spontaneously obese and diabetic rhesus monkey: analysis of controversy between monkey and human studies

There are two insulin receptor (IR) isoforms (designated type A and type B), derived from alternative splicing of exon 11 of the IR gene. Recently, we reported (Huang Z., Bodkin N.L., Ortmeyer H.K., Hansen B.C., Shuldiner A. R., 1994, J Clin Invest, 94:1289-1296) that an increase in the exon 11- (i.e. lacking exon 11) (type A) IR messenger RNA (mRNA) variant in muscle is associated with hyperinsulinemia, an early risk factor for noninsulin-dependent diabetes mellitus (NIDDM), in the spontaneously obese, diabetic rhesus monkey. To explore further the role of IR mRNA splicing in insulin resistance of NIDDM, we studied liver, another target organ that is resistant to insulin action in NIDDM. The relative amounts of the two IR mRNA-splicing variants in liver were quantitated by RT-PCR in normal, prediabetic, and diabetic (NIDDM) monkeys. The percentage of the exon 11- mRNA variant in liver (n = 24) was significantly correlated with fasting plasma glucose (r = 0.55, P < 0.01) and intravenous glucose disappearance rate (r = -0.45, P < 0.05). The exon 11- mRNA variant was increased significantly from 29.8 +/- 1.6% in monkeys with normal fasting glucose to 39.2 +/- 2.9% in monkeys with elevated fasting glucose (P < 0.01). These studies provide the first direct evidence in vivo that the relative expression of the two IR mRNA-splicing variants is altered in liver and suggest that increased expression of the exon 11- IR isoform may contribute to hepatic insulin resistance and NIDDM or may compensate for some yet unidentified defect.

Pancreatic thread protein is mitogenic to pancreatic-derived cells in culture

BACKGROUND & AIMS

Pancreatic thread proteins (PTPs) are acinar cell products and members of the regenerating gene (reg) family. reg expression increases during islet regeneration, is depressed during aging-related islet dysfunction, and may be important in beta-cell growth and maintenance. The aim of this study was to examine the genetic expression of reg in pancreatic-derived cells in vitro and the mitogenic effect of PTP/reg protein on these cells.

METHODS

reg gene expression was measured by Northern analysis in three rat pancreatic cell lines: ARIP (ductal), AR42J (acinar), and RIN (beta-cell). PTP/reg protein was isolated from bovine and human pancreas. Cells were cultured with PTP/reg for 72 hours, and thymidine incorporation was measured.

RESULTS

reg messenger RNA was detected in AR42J but not in ARIP or RIN. PTP/reg protein was mitogenic to RIN and ARIP in a dose-related fashion but not to AR42J. It was not mitogenic to cultured mature rat islets.

CONCLUSIONS

reg messenger RNA is expressed in acinar but not in beta-cell or ductal pancreatic cell lines. PTP/reg protein was mitogenic to both beta-cell and ductal cell lines but not to mature, nondividing islets. This supports the hypothesis that PTP/reg protein is an acinar cell-derived mediator of beta-cell growth and may be involved in modulating the duct-to-islet axis.

Outcome following colon surgery in the octagenarian

The results of colon surgery in all individuals aged 80 years or greater at one teaching institution during the 1987-1993 time period were reviewed. Sixty patients, ranging in age from 80 to 92 years, underwent 41 elective operations and 21 emergency procedures. Emergency procedures resulted in death or a major complication in over one-half of patients, and only six were ultimately able to return home. Conversely, elective procedures were relatively well tolerated, and 31 of 37 survivors returned immediately to independent living (P = 0.006). Mortality was 33.3 per cent in emergency cases versus 9.8 per cent in elective operations (P < 0.03). The occurrence of a postoperative complication increased the length of stay by an average of 12 days. These data suggest that elective colon surgery in the elderly produces results little different from the population at large. Conversely, emergency operations are associated with a high morbidity and mortality rate. Age alone should not be a determining factor in who undergoes an elective colon operation. Greater efforts should be made to screen elderly individuals to limit emergency surgery.

Immediate laparoscopic cholecystectomy as definitive therapy for acute cholecystitis

The objective of this study was to determine the safety and efficacy of immediate laparoscopic cholecystectomy in the management of acute calculous cholecystitis. A prospective data collection was performed on all patients admitted to one surgical service over a 2-year period. The patients were managed by a uniform protocol consisting of (1) preoperative ERCP when common duct stones were suspected; (2) operation within 24 h of diagnosis; and (3) selective operative cholangiography. Previous surgery was not a contraindication to inclusion. The setting was an urban teaching hospital. There were 52 patients, 34 females and 18 males. Nineteen had undergone previous abdominal surgery. Five patients had preoperative ERCP and five had intraoperative cholangiography. The patients underwent laparoscopic cholecystectomy 0.8 +/- 0.4 days postadmission. Four (7.7%) were converted to open cholecystectomy. Fifty-eight percent had spillage of bile and/or stones. Patients went home 2.3 +/- 1.6 days postoperatively. There were no deaths and two complications: a subhepatic biloma and a superficial wound infection. Follow-up of all patients has revealed no late complications. We conclude: (1) Immediate laparoscopic cholecystectomy is safe and effective for acute cholecystitis even when complicated by previous surgery, inflammatory adhesions, and gangrene. (2) Intraoperative spillage of bile and stones does not lead to an increase in early complications. (3) Cholangiography is needed only when clinically indicated. (4) Laparoscopic cholecystectomy should be the treatment of choice for patients admitted for acute cholecystitis.

Acute abdomen in the hemodialysis patient population

BACKGROUND

The cause and frequency of the acute abdomen in patients undergoing hemodialysis are not well reported. Previous studies associate bowel infarction with hemodialysis, but dialysis generally is not implicated as a risk factor for mesenteric ischemia.

METHODS

The records of 567 patients undergoing long-term hemodialysis during the period from July 1988 to June 1993 were retrospectively reviewed.

RESULTS

Twelve patients (2.1% of the hemodialysis population) were admitted with acute abdominal pain or sepsis. They were demographically no different than their counterparts who did not have an acute abdomen. The final diagnoses were bowel infarction in 11 patients and acute pancreatitis in one. Principal areas of involvement were equally divided between large and small intestine and were due to nonocclusive mesenteric ischemia in all cases. Six patients had an occluded hemodialysis fistula on admission, suggesting hypotension and/or hypovolemia as a possible etiologic factor. Overall, mortality and major morbidity rates were 50% and 25%, respectively.

CONCLUSIONS

An acute abdomen is a relatively uncommon problem in the hemodialysis population but is associated with a high mortality. Mesenteric infarction is the most common cause and should be the presumptive diagnosis until proven otherwise.

Competitive reverse-transcriptase polymerase chain reaction without an artificial internal standard

Advances in our understanding of molecular and cellular physiology necessitate that mRNA levels for specific growth factors and other rare transcripts be measured quantitatively in small samples. Conventional methods such as Northern blot analysis and solution hybridization/ribonuclease protection are not sufficiently sensitive. We now report the theory, development, and validation of a rapid and highly sensitive assay, the RNA/DNA quantitative polymerase chain reaction (RD-PCR), which uses a competitive PCR approach to measure the number of copies of a specific mRNA per cell. Total nucleic acid (RNA and genomic DNA) is isolated from cells in culture. The mRNA of interest is first reverse-transcribed with an oligomer bearing a complementary sequence specific for the mRNA at its 3'-end, and a sequence complementary to an intron of the desired gene at the 5'-end. Competitive PCR is then performed in the presence of the cDNA product and endogenous genomic DNA, with an upstream primer complementary to the exon sequence of the gene of interest, and a downstream primer complementary to the intron sequence that was tagged to the cDNA. The cell's own genomic DNA is thereby used as the internal standard. To control for the efficiency of reverse transcription, a standard curve is used in each assay. The technique was validated by comparing the quantitation of insulin-like growth factor I (IGF-I) mRNA in two human cell lines by RD-PCR and by RNase protection analysis. Both methods gave similar numbers of copies of IGF-I mRNA per cell. For accurate analysis, RNase protection required at least 10(7) cells; RD-PCR required as little as 10(2) cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Telerobotic assisted laparoscopic surgery: initial laboratory and clinical experience

OBJECTIVES

To assess the feasibility of telerobotic assisted surgery.

METHODS

In a laboratory model, a cholecystectomy, splenectomy, and nephrectomy were performed by an inexperienced surgeon who was being mentored by an experienced surgeon stationed at a remote site. The remote surgeon controlled the laparoscopic camera by utilizing a telerobotic system. In patients, laparoscopic cholecystectomy, varix ligation, and bladder suspension were performed by an experienced team utilizing a robotic system controlled by an experienced surgeon from a remote site.

RESULTS

In both the laboratory and clinical setting, all procedures were successfully completed without complications.

CONCLUSIONS

Current technology is available to successfully allow for telerobotic assisted surgery.

Assignment of the human pancreatic regenerating (REG) gene to chromosome 2p12

A cDNA termed reg (for regenerating gene) has been isolated and characterized from a rat pancreatic library. Expression of reg is markedly increased in regenerating islets and decreased when insulin gene expression is inhibited. These findings have led to the hypothesis that reg may be involved in the expansion of beta-cell mass during regeneration as well as in the maintenance of normal beta-cell function. The human reg gene has a high degree of similarity to the rat reg gene. To determine the chromosomal location of the human reg gene, we analyzed two panels of mouse- or hamster-human hybrid cell lines containing a single human chromosome or several different human chromosomes. DNA extracts from these cell lines were analyzed for the presence of the human reg gene by polymerase chain reaction. In addition, human metaphase chromosomes were used for fluorescence in situ hybridization to further confirm the chromosomal assignment and to determine the subchromosomal localization. With these approaches, we show that the human reg gene is located on the short arm of chromosome 2 near the centromere at band 2p12.

Surgery in the nursing home patient

Will a Geriatric Surgical Consult Service eventually develop into yet another surgical subspecialty? Precedent has been set in surgical fields such as pediatric and plastic surgery, and surely the expanding patient population will demand that some surgeons take care of the geriatric surgical patient full time. Those surgeons doing so will therefore become recognized experts and will be frequently consulted. The surgical problems faced by this unique patient population observed in our small series are most often straightforward. More complicated issues related to wound and intravenous line care, breast disease, and alimentary tract disease should be easily handled by an aggressive, conscientious, well-trained general surgeon.

Origin and control of gastrointestinal motility

As a result of improved understanding of the origin and control of motility at both the whole organ and the cellular level, a scientific approach to the diagnosis and treatment (both medical and surgical) of motility disorders has evolved. Examples are present for all levels of the gastrointestinal tract. Manometric, myoelectric, and pharmacologic studies have elucidated the role of the lower esophageal sphincter and stomach in the pathogenesis of gastroesophageal reflux and determined the mechanism of successful medical and surgical treatment. Better evaluation of colorectal motility using colonic transit studies, pelvic floor radiography, and rectoanal manometrics has led to a better identification of both the etiology of severe constipation and patients who will have a successful surgical outcome. Studies of normal and abnormal gallbladder motility and responsiveness to hormonal stimulation have shed light on the cellular abnormalities in gallbladder myocytes that predispose to gallstone formation. Finally, since we have learned that certain surgical procedures affect motility in an adverse manner, a better basic understanding of gastrointestinal physiology has led to a better clinical understanding of the mechanism by which the changes occur and to the development of more directed physiologic operations. The classic example is seen in ulcer surgery, where the introduction of highly selective vagotomy instead of truncal vagotomy preserved antral innervation and decreased the incidence of postvagotomy complications. All these concepts and more are addressed in more detail in subsequent articles in this issue.

Groin lymphorrhea complicating revascularization involving the femoral vessels

Seven (4%) of 193 patients developed lymphoceles in 8 (2%) of 316 groin wounds after 211 arterial reconstructive procedures. Included were 91 aortic, 15 extra-anatomic, and 105 infrainguinal revascularizations. Lymphoceles developed in otherwise uncomplicated wounds in 6 (8%) of 73 patients with oblique incisions and bilaterally in 1 (1%) of 120 patients with vertical incisions (p = 0.01). This difference may be related to the surgical technique, with increased lymphatic damage and inadequate wound closure in the oblique approach. No increased incidence of lymphorrhea was noted in those patients undergoing aortic reconstruction regardless of the type of incision used (p = 0.15), or when compared with patients who had undergone extra-anatomic or infrainguinal bypass (p = 0.14). Each lymphocele was persistent, and external fistulas spontaneously occurred in three. Diagnosis was based upon clinical awareness and the appearance of the groin mass. Conservative management was uniformly unsuccessful, and operative ablation of the lymph fistula and lymphocele proved to be definitive therapy.

A rapid and versatile method to synthesize internal standards for competitive PCR

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Preservation and propagation of cyclic myoelectric activity after feeding in rat small intestine

The cyclic nature and distal propagation of the fasting migrating motor complex (MMC) of the small intestine have been well described. The fate of the MMC after feeding, however, has not been elucidated. We used time series analysis with fast Fourier transforms (FFT) to study myoelectric cycling before and after feeding. Ten rats were chronically prepared with bipolar electrodes secured to the duodenum and proximal jejunum. Spikeburst frequency was recorded before and after feeding simple nutrients. During fasting, cyclic activity occurred at the MMC frequency. Although after feeding this periodicity appeared disrupted, FFT analysis showed persistent cycling at the fasted (MMC) rate. Digital filtering of data at the MMC frequency isolated cycling from background noise during both fasted and fed states and showed a depression in the amplitude of the waveform after feeding. Root-mean-square analysis of the waveform confirmed statistically significant depression of amplitude by 47-57%. The waveform propagated from the duodenum to the jejunum during both the fasted and fed state at an unchanged rate. We conclude that factors controlling myoelectric cycling during the fasted state persist after feeding, allowing continued net abroad propulsion of food.

Previous abdominal colectomy affects functional results after ileal pouch-anal anastomosis

We assessed the effect of previous abdominal colectomy on functional results after ileal "J" pouch-anal anastomosis (IPAA) in patients with ulcerative colitis. Twenty-five patients with colectomy prior to IPAA were compared with 22 patients who underwent noncolonic abdominal operations prior to IPAA. No differences were observed in pre- or postoperative resting anal sphincter pressure, squeeze pressure, or rectal inhibitory reflex. Previous colectomy was associated with a greater incidence of postoperative small bowel obstruction. Mean +/- SEM daily stool frequency at 1 and 12 months postoperatively, respectively, was 8.9 +/- 0.8 and 5.7 +/- 0.3 for patients who had undergone previous colectomy, and 8.2 +/- 0.7 and 6.0 +/- 0.5 for the no-previous colectomy group (p = not significant). At the same postoperative intervals, nocturnal stool frequency was 1.9 +/- 0.3 and 1.1 +/- 0.2 for the colectomy group and 1.5 +/- 0.3 and 0.6 +/- 0.1 for the no colectomy group (p = 0.05 at 1 year). More patients in the previous colectomy group had greater than or equal to 1 nocturnal stool after 1 year (71% versus 33%, p = 0.03). Although pouch capacity at 1 year was not different in the 2 groups, pouch capacity was directly related to stool frequency in the no colectomy group (r2 = 0.48, p = 0.01), but not in the previous colectomy group (r2 = 0.08, p = not significant). We conclude that previous abdominal colectomy may be associated with a higher overall incidence of small bowel obstruction. Moreover, previous colectomy is a determinant of postoperative nocturnal stool frequency after IPAA, most likely due to altered ileal pouch function.(ABSTRACT TRUNCATED AT 250 WORDS)

Time-series analysis of myoelectric cycling of sphincter of Oddi: evidence of cycling during fed state

The sphincter of Oddi (SO) in the fasted opossum exhibits spontaneous cyclic spikeburst activity that is temporally related to the interdigestive migrating myoelectric complex (MMC) of the small intestine. After feeding, the cyclic activity is apparently disrupted. Our aim was to use time-series analysis to mathematically describe the periodic behavior of the fasted state and to determine whether this periodicity is present after feeding. Five opossums were chronically prepared with bipolar electrodes secured to the SO. With the animals fasted and conscious, myoelectric activity was recorded for at least two MMC cycles after which they were fed 170 kcal of cream. Spikeburst frequency data were analyzed by fast Fourier transform (FFT) and by digital band-pass filtering. Results from FFT analysis showed an intense low-frequency peak during the fasted state which persisted but was markedly depressed during the fed state. Analysis of the data after filtering also showed persistent sinusoidal activity at the MMC frequency after feeding, although the waveform was significantly depressed by both peak-to-peak amplitude and root mean square amplitude analysis. Recovery to normal fasting cyclic behavior with recovery of both FFT and filtered data was observed. We conclude that in the opossum the cyclic nature of the SO myoelectric activity observed during the fasted state persists after feeding, but is inhibited and masked by an increase in overall spikeburst activity.

Substance P stimulates the opossum sphincter of Oddi in vitro

We have previously shown that substance P (SP) regulates sphincter of Oddi (SO) motility in vivo. However, its mechanism of action remains unclear. Our aim was to develop an in vitro model to measure spikeburst (SB) an contractile frequency (CMC) of the SO and to characterize further SP effects. In 16 opossums, SO rings were excised, mounted within a Kreb's tissue bath with bipolar electrodes and force transducers, allowed to equilibrate, and exposed to increasing SP concentrations with washout between each test solution. Spikeburst and CMC frequencies were recorded on a polygraph, quantitated, expressed as differences before and during SP, and statistically analyzed with Student's test. Although SP induced a significant concentration-dependent increase in phasic SB frequency and CMC, the amplitude of concentrations was not affected by SP. A close correlation was found between basal and SP-stimulated SB and CMC, suggesting myoelectric and mechanical coupling. Previous exposure of SO to SP antagonist [D-Arg1, D-Pro2, D-Trp7,9, Leu11]-SP significantly decreased the response to SP. Tetrodotoxin (TTX), did not affect the delta CMC response to SP. In conclusion an in vitro preparation was developed to study the effect of SP on the SO. Substance P increased SB and CMC of the SO in a concentration-dependent fashion, thus acting as a stimulatory peptide. Perfusion of SO rings with SP antagonist had no effect on basal CMC but significantly inhibited the action of SP in a competitive manner. The effect of SP was not altered by TTX. These data suggest that the action of SP on the SO is primarily myogenic.

Successful surgical treatment of idiopathic colonic dysmotility. The role of preoperative evaluation of coloanal motor function

Identification of patients with severe idiopathic colonic dysmotility who would benefit from surgery can be difficult. Colonic transit studies and anorectal manometry were applied to 12 women with severe constipation before subtotal colectomy. Delayed transit was noted in all patients with most exhibiting left-sided colonic arrest. Mean anal resting pressure and rectal capacity were similar to that in healthy controls. Pathologic examination results revealed decreased argyrophilic neurons in the colonic myenteric plexus. At 24 months postoperatively, all patients were satisfied with their results and mean (+/- SEM) weekly bowel movement frequency was 17 +/- 3 (compared with 0.8 +/- 0.2 preoperatively). Preoperative coloanal function studies therefore aid in the selection of patients who will be successfully treated by surgery. Subtotal colectomy with ileorectal anastomosis is the preferred operation because dysmotility can originate from either side of the colon.

Characterization of substance P effects on sphincter of Oddi myoelectric activity

We examined the effects of substance P (SP) on the myoelectric activity of the opossum sphincter of Oddi (SO). Myoelectric data from the SO in five adult opossums were recorded using thin stainless steel electrodes and computer-assisted analog-to-digital conversion. In fully awake and conscious animals, baseline spikeburst activity during phase I of the MMC occurred at a frequency of 28.6 +/- 3.1 spikebursts (SB) per 20-min period. Intravenous infusion of graded doses of substance P (from 0.5 to 8.0 micrograms/kg) stimulated SO myoelectric activity in a dose-related manner (from 80 +/- 8 to 235 +/- 11 SB/20 min, respectively, P less than 0.05 when compared to baseline). The effect of substance P on SO myoelectric activity was antagonized by administration of the H2-blocker, cimetidine (92.0 +/- 6.1 vs 48.2 +/- 7.0, n = 5, P less than 0.05). Administration of the antimuscarinic drug atropine only slightly affected the SO spikeburst frequency when infused prior to SP (73.0 +/- 10.4 vs 70.8 +/- 8.2, P greater than 0.05). We conclude that SP stimulated the SO spikeburst frequency in a dose-dependent fashion. Cimetidine markedly inhibited the response of the SO to SP but atropine did not. The excitatory effect of substance P on the opossum SO is mediated at least in part by a histaminergic, noncholinergic pathway.

Graded effect of protein on regional myoelectric activity of the opossum sphincter of Oddi

Although it is known that the sphincter of Oddi exhibits a myoelectric response to intraluminal nutrients, the effect of specific dietary components has not been well characterized. The aim of this study was to determine the effect of intragastric instillation of a protein meal on regional myoelectric activity of the opossum sphincter of Oddi. Seven adult opossums were chronically prepared with self-retaining bipolar electrodes secured to the proximal and distal parts of the sphincter. After a 2-week recovery period, and with the animals fasted and conscious, myoelectric activity was recorded for two cycles of the migrating myoelectric complex. The animals then received graded calories of protein through an orogastric tube and recordings were continued until return of the fasted cyclic activity. Doses of 60, 120, and 240 kcal of protein elicited increases in myoelectric spike activity of the proximal sphincter of 18.7%, 41.9%, and 66.6%, respectively. Similarly, the length of the fed state was prolonged by increasing caloric loads, with mean (plus or minus standard error of the mean) times of 266 +/- 25, 292 +/- 15, and 375 +/- 42 minutes for each dose. A similar relationship was noted in the distal part of the sphincter. Regression analysis between the proximal and distal parts of the sphincter during the fasted and fed states showed a strong and persistent correlation of gradient of spikeburst frequency. We conclude that myoelectric spike frequency of the opossum sphincter of Oddi exhibits a dose-related response to intragastric protein calories. Furthermore, the proximal and distal parts of the sphincter remain electrically coupled, with the proximal region pacing the distal region during the fasted state and after protein administration.

Use of ricin A-chain to selectively deplete Kupffer cells

We used the A-chain of the toxin ricin (RTA) as a toxin specific to Kupffer cells in mice. RTA is specifically taken up by the mannose receptor present exclusively in macrophages. Kupffer cells were quantitated by shifts in beta-glucuronidase clearance and microscopic counts of cells which phagocytosed India ink. When compared to saline controls, 20 mg/kg of RTA intraperitoneally (divided over 4 days) or intraportally (single doses) significantly prolonged the t 1/2 half-life of beta-glucuronidase by 270 +/- 37 and 210 +/- 8%, respectively. Kupffer cell numbers were significantly decreased by 27 +/- 8 and 33 +/- 16%. This effect persisted for at least 3 days after toxin administration. Despite effects on Kupffer cell number, minimal histological damage to liver, spleen, lung, and heart was noted. Higher doses of RTA or doses potentiated by ureteral ligation to prevent renal clearance resulted in prohibitive mortalities and histologic liver damage. Doses of Hura crepitans inhibitor, a toxin similar to RTA but not mannose-receptor specific, did not affect Kupffer cell numbers. We conclude that RTA given both intraperitoneally and intraportally at low doses is toxic specifically to Kupffer cells. Kupffer cell numbers can be indirectly measured by beta-glucuronidase clearance.

Emergencies in inflammatory bowel disease

A review of acute emergencies in inflammatory bowel disease is presented. Caveats include prompt surgical drainage of loculated abscesses and aggressive management of bleeding or perforation. Adequate nutritional and immunologic assessment of all patients prior to surgery is paramount and has resulted in the widespread use of total parenteral nutrition. Aggressive medical therapy, particularly steroids, may be useful in "cooling down" cases of acute inflammation prior to surgery. This is particularly useful in Crohn's disease, in which recurrences abound and surgery has a significant degree of complication and recurrence. When urgent operation is necessary for acute ulcerative colitis, abdominal colectomy with ileostomy and preservation of the rectum is generally indicated. This will allow subsequent mucosal proctectomy and ileoanal anastomosis. When urgent colectomy is indicated for Crohn's colitis without rectal involvement, ileorectal anastomosis can be considered either as a primary or secondary procedure. If toxic megacolon is present, an initial trial of medical therapy is warranted in order to allow a single-staged operation to be performed electively.