[Progress in surgical treatment of hepatocellular carcinoma with tumor thrombus in the inferior vena cava]

Hepatocellular carcinoma(HCC) is one of the most common malignancies of the digestive system,which is prone to be associated with microvascular or macrovascular invasion. Among them,HCC with inferior vena cava tumor thrombus(IVCTT) or right atrium tumor thrombus(RATT) is rare and has a poor prognosis. However,surgical treatment of HCC with IVCTT and (or) RATT is rarely reported and summarized. The review described the classification of HCC tumor thrombus with IVCTT and (or) RATT, summarized the progress of surgical approaches and surgical operations,and introduced a case of thrombectomy after pushing from the outer surface of the atrium,rendering the RATT to the inferior vena cava under non-cardiopulmonary bypass. The review also proposed the prospective treatments for HCC with IVCTT or RATT,providing clinical guidance to hepatobiliary surgeons.

Effect of the age and sex on growth performance and feather quality of 13 to 25-weeks-old White Roman geese

This study aimed to determine the effect of age and sex in weeks on growth, carcass performances, and feather quality of White Roman geese and analyze the relative effect of age and sex in weeks on feather characteristics in geese. In animal experiments, 120 White Roman geese aged 13 wk were randomly distributed among 12 pens and fed grower diet ad libitum during the growing period, with each pen containing 10 males or 10 females, depending on a completely random design. Ten geese each in their 13, 15, 17, 19, 21, 23, and 25 wk of age were sacrificed. The results showed that the age had no significant effect on the body weight (BW) of geese (P > 0.05). The chest girth was significantly longer in 21 to 25 wk old than in 13- to 19-wk-old geese (P < 0.05). The results reveal no significant change in carcass weight of grower geese among 13- to 25-wk age groups (P > 0.05). The down percentage of the 25-wk-old age group was significantly higher than that of the 13-, 15-, and 17-wk age groups (P < 0.05). The male geese had a higher dry feather weight than the females (P < 0.05). Similarly, the 18-h feed-deprived body weight (18-h FDBW) and 4 to 10 cm feather weight were significantly negatively correlated in grower geese (-0.42). This provides the feather industry an opportunity for the better utilization of grower geese by-products. In conclusion, the age has no influence on BW among 13- to 25-wk-old geese, and a good down percentage and dry weight were observed at 25 wk of age. The 18-h FDBW and down percentage had a significantly negative correlation (-0.55) in grower geese.

[The clinical value of radical resection of retroperitoneal lipo-lymphatic layer for pancreatic head cancer]

Objective: To investigate the clinical value of the novel approach,radical resection of the retroperitoneal lipo-lymphatic layer (RRRLLL),in the surgical treatment of resectable pancreatic head cancer. Methods: Between June 2020 and June 2022,a total of 221 patients with pancreatic head cancer underwent surgical treatment using the RRRLLL approach(RRRLLL group),while 107 patients received traditional surgical treatment(traditional group) in five high-volume pancreatic centers in China. Data from surgical technique and clinical perioperative outcomes,including lymph node harvested,surgical time,and complications,were analyzed. The RRRLLL group consisted of 144 males and 77 females with an age of (67.5±9.0) years(range:41.3 to 81.1 years). The traditional group included 71 males and 36 females,with an age of (66.3±8.1) years(range:45.1 to 79.2 years). Statistical analysis was performed using the K-S test,Z test,or χ2 test. Results: Pancreaticoduodenectomy was performed successfully in all patients,achieving R0 resection. RRRLLL group surgery required mobilization of retroperitoneal adipose and lymphatic tissues starting from the right edge of the inferior vena cava and extending to the left side,up to the superior mesenteric artery,down to the inferior mesenteric artery,and left to the left side of the aorta,including the perineural and lymphatic tissues around the superior mesenteric artery and the sheath of the mesenteric artery. However,the traditional group did not include the areas mentioned above in the scope of clearance. There were no statistically significant differences between the RRRLLL group and the traditional group in terms of age,sex,tumor size,T stage,and vascular invasion (all P>0.05). However,the number of lymph nodes harvested in the RRRLLL group was significantly higher at 28.7±9.0 (range: 18 to 39) compared to 18.2±8.0 (range: 12 to 21) in the traditional group (Z=-10.691,P<0.05). There were no statistically significant differences in the number of positive lymph nodes,N staging,and postoperative complications between the two groups. Conclusion: The RRRLLL approach improved lymph node dissection compared to the traditional approach,potentially leading to reduced recurrence rates.

[Prevalence and treatment of anemia in chronic kidney disease patients based on regional medical big data]

Objective: To assess the prevalence, risk factors and treatment of anemia in patients with chronic kidney disease (CKD). Methods: A descriptive method was used to analyze the prevalence and treatment of anemia in CKD patients based on regional health data in Yinzhou District of Ningbo during 2012-2018. The multivariate logistic regression analysis was used to identify independent influence factors of anemia in the CKD patients. Results: In 52 619 CKD patients, 15 639 suffered from by anemia (29.72%), in whom 5 461 were men (26.41%) and 10 178 were women (31.87%), and anemia prevalence was higher in women than in men, the difference was significant (P<0.001). The prevalence of anemia increased with stage of CKD (24.77% in stage 1 vs. 69.42% in stage 5, trend χ2 test P<0.001). Multivariate logistic regression analysis revealed that being women (aOR=1.57, 95%CI: 1.50-1.63), CKD stage (stage 2: aOR=1.10, 95%CI: 1.04-1.16;stage 3: aOR=2.28,95%CI: 2.12-2.44;stage 4: aOR=4.49,95%CI :3.79-5.32;stage 5: aOR=6.31,95%CI: 4.74-8.39), age (18-30 years old: aOR=2.40,95%CI: 2.24-2.57, 61-75 years old: aOR=1.35,95%CI:1.28-1.42, ≥76 years old: aOR=2.37,95%CI:2.20-2.55), BMI (<18.5 kg/m2:aOR=1.29,95%CI: 1.18-1.41;23.0-24.9 kg/m2:aOR=0.79,95%CI: 0.75-0.83;≥25.0 kg/m2:aOR=0.70,95%CI: 0.66-0.74), abdominal obesity (aOR=0.91, 95%CI: 0.86-0.96), chronic obstructive pulmonary disease (aOR=1.15, 95%CI: 1.09-1.22), cancer (aOR=3.03, 95%CI: 2.84-3.23), heart failure (aOR=1.44, 95%CI: 1.35-1.54) and myocardial infarction (aOR=1.54, 95%CI:1.16-2.04) were independent risk factors of anemia in CKD patients. Among stage 3-5 CKD patients with anemia, 12.03% received iron therapy, and 4.78% received treatment with erythropoiesis-stimulating agent (ESA) within 12 months after anemia was diagnosed. Conclusions: The prevalence of anemia in CKD patients was high in Yinzhou. However, the treatment rate of iron therapy and ESA were low. More attention should be paid to the anemia management and treatment in CKD patients.

[Application of membrane anatomy in hepatopancreatobiliary and splenic surgery]

Understanding of a variety of membranous structures throughout the body,such as the fascia,the serous membrane,is of great importance to surgeons. This is especially valuable in abdominal surgery. With the rise of membrane theory in recent years,membrane anatomy has been widely recognized in the treatment of abdominal tumors,especially of gastrointestinal tumors. In clinical practice. The appropriate choice of intramembranous or extramembranous anatomy is appropriate to achieve precision surgery. Based on the current research results,this article described the application of membrane anatomy in the field of hepatobiliary surgery,pancreatic surgery,and splenic surgery,with the aim of blazed the path from modest beginnings.

Relationship between the abdominal sagging index and the reproductive performance of the Roman goose

OBJECTIVE

This research aimed to explore the changes in the observed abdominal sagging index (ASI) and reproductive performance of Roman male and female geese during the breeding period.

METHODS

The 339 six-month-old breeding geese (109 male; 230 female) were used in this study, in which five male and five female geese were slaughtered on a monthly basis to record the ASI.

RESULTS

The short diameter of the testes of the male goose when the female goose lays eggs and in the second, third, and fourth months was significantly wider than in the fifth months (19.0, 20.8, 21.4, and 19.6 vs 12.7 and 14.0 mm/bird; p = 0.0105). On the other hand, the testicular weight of the male goose in the second and third months after the female goose lays eggs was significantly higher than that in the second and fifth months after laying (0.33% and 0.37% vs 0.11% and 0.19%; p = 0.0212). During the exploring period, the length and weight of the fallopian tube, the weight of the ovary, the number of follicles in 2 to 3 cm, the number of follicles in 3 to 4 cm, the fallopian tube weight in the carcass weight percentage, and the ovary weight in the carcass weight percentage all demonstrated a significant curve response. Further, female ASI was positively correlated with reproductive tract length (r = 0.815; p<0.05) and egg production per female (r = 0.790; p<0.05).

CONCLUSION

The ASI classification method is more objective and easy to distinguish. This scoring method has a high correlation with the number of eggs laid by each goose and the length of the reproductive tract, inferring that the goose observation could take advantage of ASI during egg-laying and can predict the reproductive system development during the laying period and determine when the breeding goose begins to lay eggs.

[The clinical value of classification of hilar cholangiocarcinoma based on actual anatomy]

Objective: To examine the significance and prognostic value of the classification of hilar cholangiocarcinoma based on actual anatomical location. Methods: A retrospective study was conducted including 120 patients of hilar cholangiocarcinoma treated at the Second Affiliated Hospital,Zhejiang University School of Medicine and Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2019 to December 2021. Patients with hilar cholangiocarcinoma were classified for seven types according to the site of tumor location. The clinicopathological and prognostic data of 120 patients were retrospectively analyzed(There were 57 males and 63 females,the age (M(IQR)) was 61(22)years(range:42 to 85 years)). All patients received radical resection without visible intraoperative tumor residue and negative bile duct resection margin according to intraoperative pathological biopsy. The classification variables were analyzed by Pearson χ² test or Fisher's exact probability test,one-way ANOVA or Kruskal-Wallis rank sum test.Kaplan-Meier method was used for survival analysis. Cox proportional risk model was used for prognostic factors. Results: The coincidence rate of preoperative surgical planning and actual operational styles was verified in 33 cases. Twenty-six cases were consistent,and 7 cases were inconsistent,with a coincidence rate of 78.8%. According to the actual anatomical location,patients in type of secondary branch experienced a significantly longer operation duration,a higher portal vein resection rate,margin positive rate and more advanced T stage(all P<0.05). The median overall survival time of the unilateral main trunck group was 27.0 months,and the bilateral group was 17.0 months. Survival analysis based on the tumor classification of the actual anatomical location showed that the unilateral or main trunck group predicted less aggressive clinical features and favorable outcomes(HR=1.931,95%CI:1.066 to 3.499,P<0.05). Multivariate analysis demonstrated that the actual anatomical location of the tumor type(HR=2.269,95%CI:1.333 to 3.861,P=0.003),combined liver resection(HR=0.464,95%CI:0.253 to 0.848,P=0.013) and N stage(HR=6.317,95%CI:3.083 to 12.944,P<0.01) were independent factors affecting the prognosis of patients. Conclusion: The classification based on the actual anatomy can be used as a promising scheme in refining patient stratification and predicting survival in hilar cholangiocarcinoma,and it can guide the selection of surgical methods,and predict operative safety and radical resection rate.

[Clinical application of bipolar tweezers-clamp for hepatic parenchymal transection]

Objective: To investigate the clinical value of the bipolar tweezers-clamp for the hepatic parenchymal transection in the resection of hepatocellular carcinoma. Methods: From January 2020 to January 2021,63 patients with the hepatocellular carcinoma for hepatectomy at Department of Hepatopancreatobiliary Surgery,Yuebei People's Hospital Affiliated to Shantou University Medical College were analyzed retrospectively.According to the different instruments used in the hepatic parenchymal transection,the patients were divided into bipolar tweezers-clamp group and ultrasonic scalpel group.There were 32 patients in bipolar tweezers-clamp group,with age of (55.5±10.5)years(range:37 to 78 years),including 22 males and 10 females,tumor size was (6.0±3.4)cm(range:2.4 to 13.4 cm). There were 6 patients with portal vein tumor thrombus and 5 patients with portal hypertension. There were 31 patients in ultrasonic scalpel group,with aged(57.8±10.1)years(range:37 to 79 years),including 27males and 4 females,tumor size was(7.9±5.1)cm(range: 2.4 to 21.3 cm),3 patients with portal vein tumor thrombus and 2 patients with portal hypertension. The preoperative baseline data,operation time,blood loss,postoperative liver function and the complications were compared between two groups using t test,χ² test and Fisher exact probabilityrespectively. Results: The operation was successfully completed in both groups.Compared with the ultrasonic scalpel group,the operation time was significantly shorter((219.3±76.4)minutes vs.(294.0±100.8)minutes,t=-3.322,P=0.002),the blood loss was less((250(475)ml vs. 500(1 050)ml,t=-2.307,P=0.026),the concentrate red blood cells transfusion volume was less(0.92(0.88)U vs. 2.32(4.00)U,Z=-1.987,P=0.047) in the bipolar tweezers-clamp group.The postoperative serum ALB level was higher in the bipolar tweezers-clamp group than that in the ultrasonic scalpel group((33.5±6.1)g/L vs. (29.5±4.2)g/L,t=3.226,P=0.020) on postoperative day 1;((35.7±4.5)g/L vs.(30.1±3.2)g/L,t=5.575,P<0.01) on postoperative day 3;((33.2±3.7)g/L vs. (31.0±4.4)g/L,t=3.020,P=0.004) on postoperative day 7. There was no significant difference in serum ALT,TBIL and PT level between the two groups(all P>0.05).No postoperative bile leakage occurred in both groups.The postoperative complications occurred in 8 cases(25.0%)in the bipolar tweezers-clamp group,including liver failure in one,and in 11 cases(35.5%)in the ultrasonic scalpel group,including liver failure in two(P>0.05). Conclusion: The bipolar tweezers-clamp is a safe and reliable method for the hepatic parenchymal transaction,which is quick and less bleeding during the hepatic resection.

[Ten-year retrospect of ALPPS in the treatment of hepatocellular carcinoma:an eternal concept with cautious technologic choice]

Clinical practice using associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) or its modified procedures in treatment of primary hepatocellular carcinoma(HCC) with insufficient future liver remnant(FLR) in the past 10 years has failed to meet our expectations both in achieving decreased perioperative complications and mortality.The efficacy of ALPPS in improving long-term survival outcome of HCC still remains poor.Due to the trauma of two surgery within a short period,and patients with inadequate FLR are all diagnosed at advanced disease stages,ALPPS can only achieve surgical rather than biological tumor-curability.Previous studies have demonstrated comparable 5-year survival rates between early and advanced stages of HCC who underwent regional treatments.Therefore,tumor biological conversion is the key strategy prior to liver remnant volume conversion in improving treatment outcomes for HCC patients with insufficient FLR.Target therapy,immunotherapy together with locally treatment were expected to improve the conversion efficacy.Looking back at the development of ALPPS for the last decade,the rapid proliferation of FLR should be passed on,while the technology costs high risks and result in poor long-term outcome must be cautiously selected.

[A new classification of intrahepatic cholangiocarcinoma based on actual anatomy:a series of 135 cases]

Objective: To explore the feasibility and clinical value of a new classification for resectable intrahepatic cholangiocarcinoma (IHCC) according to the actual anatomy. Methods: The data of 135 patients with IHCC who were admitted to the Department of Hepatopancreatobiliary Surgery,Second Affiliated Hospital of Zhejiang University School of Medicine from November 2011 to November 2020 after discussion by a multidisciplinary team and planned to undergo radical resection were analyzed retrospectively. There were 77 males and 58 females,with a median age of 61 years (range:26 to 86 years),of which 38 cases had vascular invasion. This new classification was carried out independently by two hepatobiliary surgeons. First,a preliminary classification was made based on the location of the tumor,and then the final classification was based on vascular invasion. All patients were followed up by telephone,and the follow-up was as of November 2020. Survival time is defined as the time after surgery to follow-up or death. Log-rank test was used to compare patients' median recurrence-free survival and overall survival time. The Cox proportional hazard model was used to analyze the prognosis factors of the overall survival time of patients with IHCC. Results: Among the 135 patients,129 underwent R0 resection and 6 underwent R1 resection. According to the actual anatomy,28 cases (20.7%) belonged to segmental type, 43 cases (31.9%) belonged to branch type, 64 cases (47.4%). The median survival time of all patients was 35.2 months(95%CI:21.3 to 70.5 months),the 1-year cumulative survival rate was 75.1%,the 3-year cumulative survival rate was 45.8%,and the 5-year cumulative survival rate was 39.0%. After grouping according to the classification,the median survival time of segmental patients was 36.9 months (more than 50% of patients reached the median survival time),and the median survival time of branched patients was 33.8 months (95%CI:16.8 to 38.5);The median survival time of lobe patients was 25.0 months (95%CI:13.6 to 58.7). The result of Log-rank test between groups indicated that the median survival time of patients with segmental type was better than that of patients with branch and lobe type(HR=2.03,95%CI:1.24 to 3.64,P=0.006);There was no significant difference in survival time between patients with branch type and lobe type (P=0.685). The results of the multivariate analysis of the Cox risk ratio model suggested that the actual anatomical location classification (HR=2.32,95%CI:1.10 to 4.92,P=0.028) and the postoperative lymph node metastasis rate (HR=2.06,95%CI:1.24 to 3.45,P=0.005) were independent factors related to survival after radical resection of IHCC patients. Conclusion: It is simple and convenient to classify resectable IHCC by actual anatomy,which can be used to preliminarily judge the prognosis of patients and provide a feasible classification scheme for the clinic.

[Analysis of treatment modalities and prognosis of patients with gallbladder cancer in China from 2010 to 2017]

Objective: To evaluate the clinical characteristics and prognosis of gallbladder cancer (GBC) patients in China. Methods: This retrospective multicenter cohort study enrolled 3 528 consecutive GBC patients diagnosed between January 2010 to December 2017 in 15 hospitals from 10 provinces. There were 1 345 (38.12%) males and 2 183 (61.88%) females.The age of diagnosis was (63.7±10.8) years old (range: 26 to 99 years old) .There were 213 patients (6.04%) in stage 0 to Ⅰ, whereas 1 059 (30.02%) in stage Ⅱ to Ⅲ, 1 874 (53.12%) in stage Ⅳ, and 382 (10.83%) unavailable. Surgery was performed on 2 255 patients (63.92%) . Three hundred and thirty-six patients received chemotherapy or radiotherapy (9.52%; of which 172 were palliative); 1 101 (31.21%) received only supportive treatment.The patient source, treatment and surgery, pathology, concomitant gallstone, and prognosis were analyzed. Results: Among the 3 528 GBC patients, 959 (27.18%) were from East China, 603 (17.09%) from East-North China, 1 533 (43.45%) from Central China, and 433(12.27%) from West China. Among the 1 578 resectable tumor, 665 (42.14%) underwent radical surgery, 913 (57.86%) underwent surgery that failed to follow the guidelines.Eight hundred and ninety-one (56.46%) patients were diagnosed before surgery, 254 (16.10%) during surgery, and 381 (24.14%) after surgery (time point of diagnosis couldn't be determined in 52 patients) .Among the 1 578 patients with resectable tumor, 759 (48.10%) had concomitant gallstone.Among the 665 patients underwent radical surgery, 69 (10.4%) showed positive resection margin, 510 (76.7%) showed negative resection margin, and 86 (12.9%) unreported margin status.The 5-year overall survival rate (5yOS) for the 3 528-patient cohort was 23.0%.The 5yOS for patients with resectable tumor was 39.6%, for patients with stage ⅣB tumor without surgery was 5.4%, and for patients with stage ⅣB tumor underwent palliative surgery was 4.7%. Conclusions: More than half GBC patients in China are diagnosed in stage Ⅳ.Curative intent surgery is valuable in improving prognosis of resectable GBC.The treatment of GBC needs further standardization.Effective comprehensive treatment for GBC is in urgent need.

Surgical indication and strategy for liver hemangioma in the caudate lobe: a multi-institutional retrospective analysis with 137 patients

Objective

To investigate the surgical indication and tactics for liver hemangioma in the caudate lobe

Methods

From January 1994 to July 2019, 137 patients, including 51 males and 86 females with the average age of 49.2 years old were diagnosed with liver hemangioma in caudate lobe and received treatment at five tertiary referral hospitals. Clinical features, correlations between tumor size and clinical manifestations, treatments, and prognosis were analyzed.

Results

Of the 137 patients identified, 40 (29.20%) patients were asymptomatic, whereas other 94 patients had clinical symptoms mainly presented as upper abdominal discomfort, epigastric distention, upper abdominal dull pain, nausea, and vomiting. Fifteen (93.75%), 18 (39.13%), and 7 (10.45%) patients presented no clinical symptoms among those tumor size was less than 3 cm (D ≤ 3 cm, n = 16), 3 cm < D ≤ 6 cm (n = 46), and 6 cm < D ≤ 9 cm (n = 67), respectively, while all 8 patients with tumor larger than 9 cm were symptomatic. Tumor diameter was obviously associated with the presence of clinical symptoms. In follow-up period, 7 patients in the conservative group (n = 39) received surgery because of tumor growth or symptom appearance. Totally 105 patients received operation including partial resection or isolated complete resection of caudate lobe and caudate lobe resection combined with liver segment resection, right liver resection, or left liver resection. All operations went smoothly, and no severe complications appeared.

Conclusion

Tumor diameter was obviously associated with the presence of clinical symptoms in patients with hemangioma in caudate lobe. Surgical therapy is not recommended for asymptomatic patients and available for patient who has symptoms. Effective surgical strategies should be put into use to reduce operative bleeding.

Decreased expression of SorCS1 in colorectal cancer: An independent predictor of poor prognosis

Previously, we identified that sortilin related VPS10 domain containing receptor 1 (SorCS1) was hypermethylated in colorectal cancer (CRC) tissues. Here, we aimed to investigate the association between CRC and SorCS1. DNA methylation was determined by methylation-specific polymerase chain reaction (MSP) or quantitative real-time methylation analysis (MethyLight). Colorectal cancer tissue specimens from 239 patients that had undergone surgical treatment were evaluated using immunohistochemistry (IHC) analysis for the expression of SorCS1 and correlated with clinicopathological variables and prognosis. We found that SorCS1 was hypermethylated in CRC cell lines and 67.5% (27/40) CRC tumor tissues. The loss of SorCS1 mRNA (p<0.001) and protein expression (p=0.033) were highly correlated with promoter methylation. In addition, SorCS1 expression was significantly increased in younger patients (p=0.006), low CEA level (p<0.001) and pT1-2 stage (p=0.005). Survival analysis revealed that decreased expression of SorCS1 was an independent factor for predicting the increased risk of recurrence (p=0.024) and poor overall survival (p=0.006). Subgroup analysis for CEA level, pT and pN classifications showed that SorCS1 retained its stratified significance only in patients with low CEA level, pT3-4 tumors and pN1-2 lymph node status. Our findings suggest that SorCS1 is epigenetically inactivated in a substantial fraction of CRC, and its expression may be a promising prognostic factor in CRC patients.

[The new classifications of biliary tract diseases based on actual anatomy]

In order to facilitate the treatment strategies for biliary tract injury, hilar cholangiocarcinoma, bile duct tumor thrombus, cholangiocellular carcinoma and bile duct cystic dilatation, many classifications have been made, even more than 10 types for one disease. Each type is represented by numbers or English alphabet, which are not only confusing but also difficult to remember. The Academician Mengchao Wu divided the liver into five sections and four segments base on its anatomy, this classification is very direct and visual, thus had been using till now. In order to overcome those complicated problems, it is considered to develop a new classification based on actual anatomic location similar to that for liver cancer, which is easy to remember and to directly determine the treatment strategy. All kinds of classifications have their own characteristics and advantages and disadvantages. This practical classifications avoid the complexity and may be useful for clinicians.

[The role of anatomical hepatectomy in the treatment of intrahepatic cholangiocarcinoma]

Objective: To evaluate the role of anatomical hepatectomy in the treatment of intrahepatic cholangiocarcinoma. Methods: The cases of intrahepatic cholangiocarcinoma who received curative surgery in two hospitals from 2010 to 2015 were analyzed retrospectively. Among the 98 patients enrolled in this study, 55 were male and 43 were female. The median age was 61 years. According to receiving anatomical hepatectomy or not, the 98 cases were divided into two groups: non-anatomical hepatectomy(n=30) and anatomical hepatectomy(n=68). The surgical results were compared between the two groups.Survival curves were plotted by the Kaplan-Meier method and compared by the log-rank test. The influence of each prognostic factor identified by univariate analysis was multivariate analysis by Cox's proportional hazard regression. Results: The duration of surgery was significantly prolonged in the anatomical hepatectomy group((196.4±94.9)minutes vs. (166.2±65.7)minutes, P=0.027), while there was no significant difference in terms of other surgical results such as intraoperative blood transfusion, postoperative morbidity and mortality rate. Compared to non-anatomical hepatectomy, anatomical hepatectomy significantly improved long-term survival results(14 months vs. 11 months)(χ²=4.641, P=0.031). Single variable analysis indicated that tumor differentiation, tumor numbers, T stage, N stage, anatomical hepatectomy and adjuvant therapy significantly affected overall survival. Multivariate analysis demonstrated that tumor numbers(HR=0.522, 95% CI: 0.259-0.974, P=0.042) and anatomical hepatectomy(HR=1.858, 95%CI: 1.092-3.161, P=0.022) were two independent prognostic factors for overall survival. Conclusion: Compared to non-anatomical hepatectomy, anatomical hepatectomy performed for intrahepatic cholangiocarcinoma is not only safe but also beneficial for long-term survival.

Synergistic O2-/Li+ Dual Ion Transportation at Atomic Scale

The ion migration during electrochemical process is a fundamental scientific issue for phase transition behavior and of technical importance for various functional devices, where cations or anions are active under electrical bias. Usually only one type of functional ion, O^2- or Li⁺, is activated due to their different migration energy barriers, cooperated by the valence change of other immobile ions in the host lattice matrix, e.g., Co²⁺/Co³⁺ and Mn³⁺/Mn⁴⁺ redox couples, owing to the charge neutralization. Here we select spinel Li₄Ti₅O₁₂ as anode and construct an all-solid-state battery under a transmission electron microscope; a synergistic transportation of O^2- and Li⁺ driven by an electrical bias was directly observed at the atomic scale. A small amount of oxygen anions was extracted firstly as a result of its lowest vacancy formation energy under 2.2 V, leading to the vertical displacement of oxygen. Up to 2.7 V, an ordered phase with both Li- and O- deficiency formed. The Li⁺ and O^2- ions are simultaneously extracted out from the [LiO₄] tetrahedra due to the electroneutrality principle. The migration paths of O and Li have been proposed and verified by first-principles calculations. These results reveal a brand new synergistic ion migration manner and may provide up-to-date insights on the transportation process of lithium ion conductors.

Identification and characterization of probiotic yeast isolated from digestive tract of ducks

The objective of this study was to isolate and identify yeast strains from the digestive tract of ducks, and evaluate in vitro their potential as probiotics in poultry. The yeast strains were isolated using malt extract agar medium, and identified through morphological, physiological, and biochemical tests as well as sequence homology analyses of 26S rDNA D1/D2 region. A total of 35 yeast strains were isolated from the guts of Cherry Valley meat ducks, including seven strains of Saccharomyces cerevisiae (S. cerevisiae). These seven strains of S. cerevisiae were further screened for their use as alternative yeast probiotics strains for poultry feed. The yeast strains were characterized for their cell surface hydrophobicity, autoaggregation ability, and resistance to high temperature (30°C, 37°C, and 42°C), low pH (2.0, 3.0, and 4.0), bile salts (0.3% and 0.6%), and nutrition starvation (2, 4, 6, 8, 10, and 12 days). The isolates of WHY-2 and WHY-7 had a higher survival percentage at 37°C, pH 2.0, 0.60% poultry bile salts, and 10 days of nutrition starvation, with higher cell surface hydrophobicity and autoaggregation, when compared with the other isolates, suggesting that the isolates WHY-2 and WHY-7, could be used as probiotic candidates. The data obtained in this study could help in selecting probiotic yeast candidates for use in poultry industry.

[The impact of resection of skull base tumor via an endoscopic endonasal approach on the visual function of vision impaired patients and the analysis of factors affecting their visual recovery]

Objective: To evaluate the visual outcomes of patients with visual impairment after resecting skull base tumor via an endoscopic endonasal approach, and to analyze the factors affecting visual recovery. Methods: One hundred and fifty-three patients with skull base tumor who suffered from preoperative visual impairment from Skull Base Surgery Center of Xuanwu Hospital were operated through an endoscopic endonasal approach. Both preoperative and postoperative visual function outcomes as well as factors that might have affected their visual recovery were analyzed retrospectively by Chi square test and Logistic regression analysis. Results: Complete resection was achieved in 85.6% of the patients using this technique. The rate of postoperative visual recovery in the female group (86.1%) was higher than that in the male group (73.9%), the benign group (90.2%) higher than the malignant group (20.0%), the group without optic atrophy (97.1%) higher than the one with (51.2%), and the acute group (96.6%) higher than the chronic group (80.0%). Significant differences were found between the abovementioned groups (χ(2) value was 5.849, 87.860, 79.757, 4.745, respectively, all P<0.05). The degree of optic atrophy and the property of tumors were significantly associated with visual improvement after treatment (Wold χ(2) value was 18.597 and 35.623, all P<0.001). Conclusions: Our results indicate that endoscopic endonasal surgery shows its ability both to resect skull base tumors and to improve visual function in the majority of patients. The timing of treatment for patients suffered from preoperative visual impairment should be selected in early stage before optic atrophy occurs.

[Terminal branches portal vein embolization for planed hepatectomy]

OBJECTIVE

To explore the application of the technique of terminal branches portal vein embolization(TBPVE)for planed hepatectomy.

METHODS

From February 2016 to June 2016, 4 patients with hepatocellular carcinoma underwent TBPVE and liver resection in Yuebei People's Hospital (n=3) and Jiangxi Ji'an Central People's Hospital (n=1). All of them were male and were 50, 64, 39 and 47 years old respectively. All the tumors located in the right lobe. All patients had the liver function of Child-Pugh A classification and liver cirrhosis level of G2S4. The standard liver volume (SLV) were 1 291, 1 109, 1 177 and 1 242 ml and estimated future liver remnant(FLR) were 315, 347, 306 and 323 ml respectively. The puncture site of TBPVE was determined by the three-dimensional reconstruction of portal vein. Three patients were punctured in the segment Ⅵ and the other one punctured in the segment Ⅲ. CT scan was repeated 2 weeks after TBPVE and FLR and FLR/SLV were calculated. All patients underwent right hepatectomy 2 weeks after TBPVE.

RESULTS

On the 14(th) day after TBPVE, the FLR of 4 patients were 529, 462, 469 and 498 ml which increased 67.9%, 33.1%, 53.3% and 54.2% compared with that before TBPVE, and FLR/SLV were 41.0%, 41.7%, 39.8% and 40.1% respectively. No severe complication occurred. Right hepatectomy were performed 2 weeks after TBPVE. No inflow blood control applied during the liver resection. The mean blood loss was 950 ml and the mean operating time was 3.3 hours (ranging from 3 to 4 hours). One patient had respiratory infection and two had slight jaundice and ascites for a short period. No other complication occurred.

CONCLUSION

The TBPVE could induce a rapid and large FLR volume that give chances to patients with small FLR to have liver resection for hepatocellular carcinoma.

Epidemiology of Enterobius vermicularis infection among elementary school children in Hualien, Taiwan from 2007 to 2012

Enterobius vermicularis is the most common human intestinal parasite, and its control among school children is an important public health issue. The objective of this study was to document the present situation of E. vermicularis infection in school children in Hualien. The administrative divisions in Hualien county include 13 districts (3 in a mountainous area, 10 in a rural/urban area). Between 2007 and 2012, a total of 41,191 children in 13 districts in Hualien were examined using consecutive 2-day adhesive cellophane paper perianal swabs. Our results showed Enterobius egg-positive infection rates of 5.79% (452/7,089) in 2007, 6.25% (457/7,312) in 2008, 5.37% (385/7,173) in 2009, 4.98% (330/6,804) in 2010, 4.91% (301/6,133) in 2011, and 4.68% (279/5,960) in 2012. Compared to the previously reported national average in Taiwan (range, 1.53-2.23%), the prevalence of E. vermicularis in Hualien is relatively high. The infection rates were 7.55-29.10% in mountainous areas and 0.50- 12.43% in rural/urban areas. All first and fourth grade students in elementary schools in Hualien were selected as study participants. The average infection rate of the first grade students (6.71%) was higher than that of the fourth grade students (4.23%). These results indicate that enterobiasis remains an important parasitic disease among school children in Hualien, especially those in mountainous areas.

[The role of Hong's single-stitch duct to mucosa pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy]

Objective: To investigate the role of "Hong's single-stitch duct to mucosa pancreaticojejunostomy(HSDMP)" in laparoscopic pancreaticoduodenectomy (LPD). Methods: The clinical data including perioperative and short-term outcomes of 51 cases of LPD with HSDMP which performed in Zhejiang Provincial People's Hospital(33 cases) and Frist Clinical Hospital of Jilin University(18 cases) between April and October 2016 were reviewed retrospectively. There were 31 male patients and 20 female patients. The mean age was(59±11)years. Body mass index (BMI) was 18 to 28 kg/m(2) and the average BMI was (23.2±4.4)kg/m(2). Preoperative diagnosis: 18 cases with pancreatic mass, 26 cases with peri-ampullary tumor, 3 cases with intra-ductal papillary mucinous neoplasms, 2 cases with duodenal carcinoma, 2 cases with serous cystadenoma. Results: Fifty-one patients accepted LPD using HSDMP. One patient underwent LPD combined with resection of superior mesentery vein. The mean operation time was (307±69)minutes, the mean diameter of pancreatic duct for reconstruction was (3.1±1.1)mm.The mean operation time for HSDMP was (34±5) minutes, the estimated blood loss was (170±127)ml. Twelve cases(23.5%) had pancreatic fistula according to International Study Group definition, including 9 cases(17.6%) of grade A and 3 cases (5.9%) of grade B. Five cases(9.8%) had delayed gastric empty, 5 cases(9.8%) had bile leakage and 2 cases(3.9%) had pulmonary infection postoperative.All these complications were treated by non-surgical strategies. One patient(2.0%) suffered from postoperative intra-abdominal bleeding and recovered after reoperation. Pathologic results showed pancreatic ductal adenocarcinomas in 20 cases(39.2%), non-pancreatic original peri-ampullary tumors in 23 cases(45.1%), intra-ductal papillary mucinous neoplasms in 3 cases(5.9%), duodenal carcinoma in 2 cases(3.9%), serous cystadenoma in 2 cases(3.9%) and neuroendocrine tumors in one case(2.0%). Conclusions: HSDMP could not only reduce the incidence of clinical pancreatic fistula, but also save operation time. It is a feasible and safe method for pancreaticojejunostomy.

Prevalence and genotype of Giardia duodenalis from faecal samples of stray dogs in Hualien city of eastern Taiwan

Giardia duodenalis is a zoonotic protozoan parasite that causes diarrhea through waterborne transmission or fecal-oral infection. The cysts are chlorine-resistant and, therefore, can pollute drinking water and induce a pandemic disease. In this study, we aimed to detect G. duodenalis infection in stray dogs in Hualien, Taiwan. We collected faecal samples from 118 dogs and amplified DNA sequences of the β-giardin gene by nested polymerase chain reactions (nested PCR). Eleven of the 118 faecal samples tested positive for the parasite. The genotype analysis of the 11 samples indicated that 7 samples belonged to assemblage C and four samples belonged to assemblage D. Our study provided a better understanding of the infection rate and genotypes of G. duodenalis in dogs from Hualien City, and human infection could not be induced by this zoonotic infection pathway in Hualien City.

Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial

OBJECTIVE

This study compared the postoperative pancreatic anastomosis leakage rate of a new binding technique with the conventional technique of pancreaticojejunostomy after pancreaticoduodenectomy.

SUMMARY BACKGROUND DATA

Leakage from pancreatic anastomoses remains the single most important morbidity after pancreaticoduodenectomy and contributes to prolonged hospitalization and mortality. The reported incidence after conventional pancreaticojejunostomy ranged from 10% to 29%. We previously reported a new binding pancreaticojejunostomy technique with a leakage of 0%.

METHODS

We conducted a prospective randomized study on 217 patients who underwent pancreaticoduodenectomy for benign and malignant diseases of the pancreatic head and the periampullary region comparing the 2 techniques of pancreaticojejunostomy.

RESULTS

Of the 111 patients randomized to the conventional group, pancreaticojejunostomy leakage occurred in 8 patients, while no patient in the 106 patients randomized to the binding group developed leakage (chi test, P = 0.014). The overall postoperative complications developed in 41 patients (36.9%) in the conventional group compared with 26 patients (24.5%) in the binding group (chi test, P = 0.048). Seven patients (6.3%) died in the perioperative period in the conventional group compared with 3 patients (2.8%) in the binding group (chi test, P = 0.37). The postoperative hospital stay (mean +/- SD) for the conventional group was 22.4 +/- 10.9 days, which was significantly longer than the binding group (18.4 +/- 4.7 days) (Mann-Whitney U test, P < 0.001).

CONCLUSIONS

Binding pancreaticojejunostomy after panceaticoduodenectomy significantly decreased postoperative complication and pancreaticojejunostomy leakage rates and shortened hospital stay when compared with conventional pancreaticojejunostomy.

Orthotopic Abdominal Multivisceral Transplantation Without Venovenous Bypass in Pigs

BACKGROUND

Because venovenous bypass (VVB) can cause specific complications, a simplified orthotopic abdominal multivisceral transplantation (MVTX) technique without VVB in pigs has been evaluated in terms of morbidity and mortality.

MATERIALS AND METHODS

Outbred large-white pigs weighing 25 to 40 kg of random sex underwent MVTX operation. After in situ cold perfusion through the aorta and superior mesenteric vein, the multivisceral allograft was procured from the donor and tailored at the back table. The multivisceral allograft, including liver, pancreas, stomach, duodenum, and proximal 2 m of jejunum, was en bloc transplanted into recipient after resection of entire foregut and midgut; VVB was not used. We analyzed the hemodynamic change, arterial blood gas data, and fluid requirements intraoperatively.

RESULTS

Among 25 MVTXs, 19 (76%) animals survived after the operation. Without using an immunosuppressant, postoperative survival time was 2 to 146 hours. Ten recipient pigs died within 24 hours. Seven animals were lost between postoperative days 2 and 5. Two pigs survived for more than 5 days. The recipient pigs were mostly in a state of hypovolemic shock and metabolic acidosis during the reperfusion phase.

CONCLUSIONS

Despite a high morbidity and mortality, the simplified technique without VVB is feasible to successfully achieve MVTX in the pig.

Predicting postoperative nausea and vomiting with the application of an artificial neural network

BACKGROUND

Several medications have proved to be useful in preventing postoperative nausea and vomiting (PONV). However, routine antiemetic prophylaxis is not cost-effective. We evaluated the accuracy and discriminating power of an artificial neural network (ANN) to predict PONV.

METHODS

We analysed data from 1086 in-patients who underwent various surgical procedures under general anaesthesia without antiemetic prophylaxis. Predictors used for ANN training were selected by computing the value of chi(2) statistic and information gain with respect to PONV. The configuration of the ANN was chosen by using a software tool. Then the training of the ANN was performed based on data from a training set (n=656). Testing validation was performed with the remaining patients (n=430) whose outcome regarding PONV was unknown to the ANN. Area under the receiver operating characteristic (ROC) curves were used to quantify predictive performance. ANN performance was compared with those of the Naïve Bayesian classifier model, logistic regression model, simplified Apfel score and Koivuranta score.

RESULTS

ANN accuracy was 83.3%, sensitivity 77.9% and specificity 85.0% in predicting PONV. The areas under the ROC curve follow: ANN, 0.814 (0.774-0.850); Naïve Bayesian classifier, 0.570 (0.522-0.617); logistic regression, 0.669 (0.623-0.714); Koivuranta score, 0.626 (0.578-0.672); simplified Apfel score, 0.624 (0.576-0.670). ANN discriminatory power was superior to those of the other predicting models (P<0.05).

CONCLUSIONS

The ANN provided the best predictive performance among all tested models.

Laparoscopic hepatectomy by curettage and aspiration. Experiences of 62 cases

BACKGROUND

This article introduces a new technique for hepatectomy. Its purpose is to describe the details of laparoscopic hepatectomy by curettage and aspiration (LHCA) and develop a new instrument for this technique.

METHODS

We have performed laparoscopic hepatectomy by curettage and aspiration (LHCA) in 62 patients in our institute between 1998 and 2005: 34 men and 28 women, mean age 47.8 years (range: 26-71 years). Their diagnoses included 18 primary hepatic carcinoma, 2 metastatic carcinoma, 19 intrahepatic duct calculus, and 23 benign entities.

RESULTS

The LHCA operation was completed in 60 patients. In two, the procedure had to be converted to open operation. The mean operative time was 146 min and the mean operative blood loss was 458 ml. Complications occurred in two patients, one with bile leakage and the other with pneumothorax. All the patients were ambulatory within 24 hours of operation. The average length of hospital stay was 1 week.

CONCLUSIONS

Our experience leads us to believe that laparoscopic hepatectomy by curettage and aspiration (LHCA) is a safe and effective technique for resection of liver lesions.

Surgical treatment of hepatocellular carcinoma originating from caudate lobe--a report of 39 cases

The study objective was to study the therapeutic effect of surgical treatment for hepatocellular carcinoma (HCC) originating from the caudate lobe. From 1995 to 2003, caudate lobe resection was carried out for 97 cases; among them 39 were for HCC, who were divided into two groups. Group A consisted of 19 cases undergoing isolated caudatectomy, and group B consisted of 20 cases undergoing caudatectomy combined with other liver resections. The factors that might influence postoperative recovery were compared between the two groups. A special instrument, Peng's Multifunctional Operative Dissector, was used for surgical dissection. All tumors were resected successfully. One patient died of postoperative renal failure. Hydrothorax occurred in three patients, ascites occurred in four patients, and bile leakage occurred in one patient. Thirty cases received long-term follow-up with survival rates at 1, 3, and 5 years of 53%, 50%, and 39%, respectively. Caudate lobectomy is an effective therapeutic method for HCC originating in the caudate lobe. Isolated caudatectomy should be performed as the first choice whenever possible. Anterior transhepatic approach is appropriate in some cases. Peng's Multifunctional Operative Dissector is a very useful instrument for surgical dissection.

Diagnosis and treatment of VIPoma in China: (case report and 31 cases review) diagnosis and treatment of VIPoma

OBJECTIVES

To discuss the experience of diagnosis and treatment of VIPoma by summarizing clinical information of 31 patients with VIPoma in China.

METHODS

To analyze clinical manifestations, laboratory examinations, imaging features, operation, pathologic findings, and follow-up survey of 31 patients, among them 1 case was from our hospital and the other 30 cases were reported in Chinese literature from 1977 to 2002.

RESULTS

Periodical backache, skin rash, and polyps of colon were never reported previously, all of which except polyps disappeared after operation. Partial resection of superior mesenteric vein was also never reported. The mean serum value of VIP which had been very high before operation, decreased markedly after the operation (963.2 pg/ml Versus 131.9 pg/ml),the immunohistochemical expression of many kinds of digestive hormone including VIP presented positive. Hepatic involvement was 29.0%,nodal metastasis was 9.7%.

CONCLUSIONS

VIPoma is rare. Typical symptoms and the serum value of VIP are keys to diagnosis before operation, Surgical resection is the most effective means for cure. surgical debulking of the tumor, somatostatin analogues can be used for good palliation.

Binding pancreaticojejunostomy--a safe and reliable anastomosis procedure

BACKGROUND

Over the past one hundred years, the development of pancreaticoduodenectomy (PD) has always involved the struggle against pancreatic leakage. Until now, leakage of the pancreatic anastomosis has remained a common and serious complication after PD. Various methods of dealing with the pancreatic stump for prevention of pancreatic anastomotic leakage have been described. No matter which method is used, however, pancreatic anastomotic leakage is still most likely to occur when anastomosis involves a normal and soft pancreas.

METHODS

To perform a safe and reliable pancreaticoenteric anastomosis, we investigated the risk factors and potential mechanisms of occurrence of pancreatic leakage, including leakage from the needle hole and from the seam between two anastomosed structures, blood supply to the anastomosis and tension at the anastomosis. Based on these findings, we established a new pancreaticoenteric anastomosis procedure - binding pancreaticojejunostomy. The unique aspects of this procedure are as follows. The sero-muscular sheath of jejunum is bound to the invaginated pancreatic stump, so as to seal the gap between them; mucosa of the segment of jejunum that would eventually be in contact with the pancreatic stump is destroyed either chemically or by electric coagulation to promote healing. There is no needle hole on the jejunal surface of the anastomotic site.

RESULTS

From 1996 to 2003, a total of 227 consecutive patients were treated with this type of pancreaticojejunostomy in this institution. None of the patients developed a pancreatic anastomotic leak.

DISCUSSION

Binding pancreaticojejunostomy is a safe and reliable anastomotic procedure to effectively minimize leakage even when the texture of the pancreas is soft and normal.

Surgical intervention for obstructive jaundice due to biliary tumor thrombus in hepatocellular carcinoma

This retrospective study in eight surgically treated patients with obstructive jaundice due to biliary tumor thrombus in a patient with hepatocellular carcinoma (HCC) was performed to evaluate the role of surgical intervention. All biliary tumor thrombi were confirmed preoperatively or intraoperatively. Only two manifested intraluminal biliary obstructions due to a primary tumor that had not been found preoperatively. The operative procedures included hepatectomy with removal of the biliary tumor thrombus (n=3), hepatectomy combined with extrahepatic bile duct resection (n=1), thrombectomy through a choledochotomy (n=3), and piggyback orthotopic liver transplantation (n=1). The 1- and 3-year survival rates were 62.5% and 37.5%, respectively. Two patients survived more than 5 years. Surgical intervention was effective in patients with obstructive jaundice due to a biliary tumor thrombus in an HCC. Thus surgery for a recurrence can prolong survival, and liver transplantation is a treatment worthy of further investigation.

Binding pancreaticojejunostomy: 150 consecutive cases without leakage

The objective of this study was to verify the safety of a new technique termed "binding pancreaticojejunostomy" in a prospective cohort study. Pancreaticojejunal anastomostic leakage is a major cause of morbidity and mortality after pancreaticoduodenectomy. To prevent the development of pancreatic fistulas, we designed a special technique that we termed binding pancreaticojejunostomy. Binding pancreaticojejunostomy entails binding 3 cm of the serosamuscular sheath of the jejunum to the intussuscepted pancreatic stump. From January 1996 to May 2001, a total of 150 consecutive patients were treated with this type of pancreaticojejunostomy, including typical pancreaticoduodenectomy in 120, hepatopancreaticoduodenectomy in 17, pylorus-preserving pancreaticoduodenectomy in 10, and duodenal-preserving resection of the head of the pancreas in three. None of the patients developed pancreatic fistulas. The overall morbidity was 31.3%. The following complications occurred: gastrointestinal bleeding in six, pulmonary infection in 12, wound infection in 20, delayed gastric emptying in three, incision dehiscence in four, and hepatic insufficiency in two. The mean postoperative hospital stay was 19.8 +/- 5 days. Binding pancreaticojejunostomy is a safe, simple, and effective technique.

Diagnosis and treatment of congenital choledochal cyst: 20 years' experience in China

AIM

To summarize the experience of diagnosis and treatment of congenital choledochal cyst in the past 20 years (1980-2000).

METHODS

The clinical data of 108 patients admitted from 1980 to 2000 were analyzed retrospectively.

RESULTS

Abdominal pain,jaundice and abdominal mass were presented in most child cases. Clinical symptoms in adult cases were non-specific, resulting in delayed diagnosis frequently. Fifty-seven patients (52.7%) had coexistent pancreatiobiliary disease. Carcinoma of the biliary duct occurred in 18 patients (16.6%). Ultrasonic examination was undertaken in 94 cases, ERCP performed in 46 cases and CT in 71 cases. All of the cases were correctly diagnosed before operation. Abnormal pancreatobiliary duct junction was found in 39 patients. Before 1985 the diagnosis and classification of congenital choledochal cyst were established by ultrasonography preoperatively and confirmed during operation, the main procedures were internal drainage by cyst enterostomy. After 1985, the diagnosis was established by ERCP and CT, and cystectomy with Roux-en-Y hepaticojejunostomy was the conventional procedures.In 1994, we reported a new and simplified operative procedure in order to reduce the risk of choledochal cyst malignancy. Postoperative complication was mainly retrograde infection of biliary tract, which could be controlled by the administration of antibiotics, there was no perioperative mortality.

CONCLUSION

The concept in diagnosis and treatment of congenital choledochal cyst has obviously been changed greatly.CT and ERCP were of great help in the classification of the disease.Currently, cystectomy with Roux-en-Y hepaticojejunostomy is strongly recommended as the choice for patients with type I and type IV cysts. Piggyback orthotopic liver transplantation is indicated in type V cysts (Caroli's disease) with frequently recurrent cholangitis.

Safe upper limit of intermittent hepatic inflow occlusion for liver resection in cirrhotic rats

AIM: To evaluate the effects of varying ischemic durations on cirrhotic liver and to determine the safe upper limit of repeated intermittent hepatic inflow occlusion.

METHODS: Hepatic ischemia in cirrhotic rats was induced by clamping the common pedicle of left and median lobes after non-ischemic lobes resection. The cirrhotic rats were divided into six groups according to the duration and form of vascular clamping: sham occlusion (SO), intermittent occlusion for 10 (IO-10), 15 (IO-15), 20 (IO-20) and 30 (IO-30) minutes with 5 minutes of reflow and continuous occlusion for 60 minutes (CO-60). All animals received a total duration of 60 minutes of hepatic inflow occlusion. Liver viability was investigated in relation of hepatic adenylate energy charge (EC). Triphenyltetrazollum chloride (TTC) reduction activities were assayed to qualitatively evaluate the degree of irreversible hepatocellular injury. The biochemical and morphological changes were also assessed and a 7-day mortality was observed.

RESULTS: At 60 min after reperfusion following a total of 60 min of hepatic inflow occlusion, EC values in IO-10 (0.749 ± 0.012) and IO-15 (0.699 ± 0.002) groups were rapidly restored to that in SO group (0.748 ± 0.016), TTC reduction activities remained in high levels (0.144 ± 0.002 mg/mg protein, 0.139 ± 0.003 mg/mg protein and 0.121 ± 0.003 mg/mg protein in SO, IO-10 and IO-15 groups, respectively). But in IO-20 and IO-30 groups, EC levels were partly restored (0.457 ± 0.023 and 0.534 ± 0.027) accompanying with a significantly decreased TTC reduction activities (0.070 ± 0.005 mg/mg protein and 0.061 ± 0.003 mg/mg protein). No recovery in EC values (0.228 ± 0.004) and a progressive decrease in TTC reduction activities (0.033 ± 0.002 mg/mg protein) were shown in CO-60 group. Although not significantly different, the activities of the serum aspartate aminotransferase (AST) on the third postoperative day (POD₃) and P OD₇ and of the serum alanine aminotransferase (ALT) on POD₃ in CO-60 group remained higher than that in intermittent occlusion groups. Moreover, a 60% animal mortality rate and more severe morphological alterations were also shown in CO-60 group.

CONCLUSION: Hepatic inflow occlusion during 60 min for liver resection in cirrhotic rats resulted in less hepatocellular injury when occlusion was intermittent rather than continuous. Each period of 15 minutes was the safe upper limit of repeated intermittent vascular occlusion that the cirrhotic liver could tolerate without undergoing irreversible hepatocellular injury.

Diagnosis and treatment of congenital choledochal cyst: 20 years′ experience in China

AIM: To summarize the experience of diagnosis and treatment of congenital choledochal cyst in the past 20 years (1980-2000).

METHODS: The clinical data of 108 patients admitted from 1980 to 2000 were analyzed retrospectively.

RESULTS: Abdominal pain, jaundice and abdominal mass were presented in most child cases. Clinical symptoms in adult cases were non-specific, resulting in delayed diagnosis frequently. Fifty-seven patients (52.7%) had coexistent pancreatiobiliary disease. Carcinoma of the biliary duct occurred in 18 patients (16.6%). Ultrasonic examination was undertaken in 94 cases, ERCP performed in 46 cases and CT in 71 cases. All of the cases were correctly diagnosed before operation. Abnormal pancreatobiliary duct junction was found in 39 patients. Before 1985 the diagnosis and classification of congenital choledochal cyst were established by ultrasonography preoperatively and confirmed during operation, the main procedures were internal drainage by cyst enterostomy. After 1985, the diagnosis was established by ERCP and CT, and cystectomy with Roux-en-Y hepaticojejunostomy was the conventional procedures. In 1994, we reported a new and simplified operative procedure in order to reduce the risk of choledochal cyst malignancy. Postoperative complication was mainly retrograde infection of biliary tract, which could be controlled by the administration of antibiotics, there was no perioperative mortality.

CONCLUSION: The concept in diagnosis and treatment of congenital choledochal cyst has obviously been changed greatly. CT and ERCP were of great help in the classification of the disease. Currently, cystectomy with Roux-en-Y hepaticojejunostomy is strongly recommended as the choice for patients with type I and type IV cysts. Piggyback orthotopic liver transplantation is indicated in type V cysts (Caroli’s disease) with frequently recurrent cholangitis.

Beta-catenin mutations are associated with a subset of low-stage hepatocellular carcinoma negative for hepatitis B virus and with favorable prognosis

To better understand the role of beta-catenin mutation in hepatocellular carcinoma (HCC), we correlated the gene mutation with hepatitis virus B (HBV) and hepatitis virus C (HCV) status and the clinicopathological features in 366 patients with resected primary unifocal HCC. beta-Catenin mutations were also analyzed in 55 patients with multifocal HCC (68 tumors). Of the whole series, 57 (13.1%) of 434 tumors examined had beta-catenin mutations, 34 occurred at the serine/threonine residues of the GSK-3beta region of beta-catenin. Outside the GSK-3beta phosphorylation site, codons 32 and 34 were two mutational hot spots (17 tumors). The non-HBV-related HCC that was predominantly HCV related had a higher frequency of mutation (P: < 0.00001) and more frequent mutations at codon 45 than HBV-related HCC. HBV-related HCC had a younger mean age (P: < 0.00001), and higher male-to-female ratio (P: < 0.003) and positive familial history of HCC (P: < 0.014). Among 366 unifocal HCCs selected for clinicopathological analysis, beta-catenin mutations were associated with grade I (P: = 0.005) and stage I and II HCC (P: < 0.0001), and a better 5-year survival rate (P: = 0. 00003). These findings suggest mechanisms for beta-catenin mutations differ between HBV-related and non-HBV-related HCCs, and that beta-catenin mutation is a favorable prognostic factor related to low stage. beta-Catenin mutation was associated with nuclear expression of the protein (P: < 0.00001), but we failed to detect point or large fragment deletion mutation in 39 HCCs with nuclear beta-catenin expression, presumably wild-type protein. HCCs expressing mutant nuclear beta-catenin had a better 5-year survival rate (P: < 0.007), suggesting that mutant and wild-type nuclear beta-catenin proteins are not functionally equivalent and deserve more studies for further clarification.

Preoperative transcatheter arterial chemoembolization and prognosis of patients with hepatocellular carcinomas: retrospective analysis of 120 cases

To clarify whether preoperative transcatheter arterial chemoembolization (TAE) improves the prognosis of patients with hepatocellular carcinoma (HCC) after surgery, 120 patients who had undergone hepatectomy for HCC from 1988 to 1994 and satisfied the criteria of stages II and III were enrolled in this study. Forty-four patients underwent preoperative TAE (group A) and 76 patients did not (group B). No significant differences in the outcomes were observed between these two groups. To rectify the comparison, patients with tumors 2 to 8 cm were assigned to groups A1 (n = 24) and B1 (n = 57), and those with tumors > 8 cm were assigned to groups A2 (n = 20) and B2 (n = 19), respectively. Although no significant differences in survival between groups A1 and B1 were found, group A2 presented superior 1-, 2-, and 3-year tumor-free survival rates of 80%, 55%, and 32% and 1-, 3-, and 5-year cumulative survival rates of 90%, 53%, and 42%. These figures are in comparison with the tumor-free survival rates of 50%, 22%, and 11% (p = 0.06), and the cumulative survival rates of 72%, 33%, and 11% (p = 0.01) during the same periods for group B2, respectively. The Cox regression model revealed that for patients with tumors > 8 cm, the relative risk of preoperative TAE for overall survival was 0.38 (p = 0.017), indicating that preoperative TAE might benefit patients with tumors > 8 cm but not those with tumors 2 to 8 cm.

Thioredoxin fusion/HIV-1 protease coexpression system for production of soluble human IL6 in E. coli cytoplasm

In this paper, thioredoxin (TRX) fusion expression system has been modified to produce soluble human IL6 (hIL6) without TRX moiety in E. coli cytoplasm. A novel TRX gene fusion vector was developed that contained at the 3'-end of TRX gene a short DNA sequences encoding a linker peptide '-GSGSGVSQNYPIVQHHHHHH-', serving not only as a specific HIV-1 protease site but also providing six contiguous histidine (His) residues to foreign proteins. The cDNA for hIL6 was cloned into this vector resulting in plasmid pTRX@HISIL6. The cDNA for the HIV-1 protease has been cloned into another compatible plasmid pHMM2, resulting in plasmid pHMM2-PR. Both plasmids were transformed into E. coli strain GI724, and when induced for expression of both proteins, the correct processing of TRX@HISIL6 was obtained, producing hIL6 with His6-tag at the N terminus named HISIL6. A fraction of HISIL6 was found in soluble form and could be purified to homogeneity by Ni-NTA Superflow and ion-exchange chromatography. The biological activity of purified HISIL6 was measured by MTT method in an IL-6-dependent cell line 7TD1 to be 2.1 x 10(8) unit/mg.

Association of downregulation of cyclin D1 and of overexpression of cyclin E with p53 mutation, high tumor grade and poor prognosis in hepatocellular carcinoma

BACKGROUND/AIMS

The major regulatory events leading to cell proliferation occur in the G1 phase of cell cycle, and the deranged expression of G1 cyclins is related to oncogenesis. In this study, we analyzed the aberrant expressions of cyclins D1 and E, and their role in hepatocellular carcinoma.

METHODS

We examined paired hepatocellular carcinoma and liver RNAs taken from 71 patients who had been followed for more than 4 years after tumor resection, using reverse transcription-polymerase chain reaction supplemented with Northern blotting and immunohistochemistry. The genetic alterations of the p53 gene were also studied.

RESULTS

Downregulation of cyclin D1 mRNA was detected in 29 hepatocellular carcinomas (40.8%), while overexpression was detected in only 4 hepatocellular carcinomas (5.6%). Downregulation of cyclin D1 was associated significantly with large hepatocellular carcinomas (p=0.0006) and poorly differentiated (grades III-IV) hepatocellular carcinoma (p=0.057), but not seen in any of 15 minute hepatocellular carcinomas (< or =2.5 cm in size). Cyclin E mRNA was overexpressed in 40 hepatocellular carcinomas, regardless of tumor size. Overexpression of cyclin E was significantly associated with poorly differentiated and invasive hepatocellular carcinoma (p=0.001 and p=0.015, respectively). Downregulation of cyclin D1 and overexpression of cyclin E were significantly associated with the p53 mutation (p=0.023 and p=0.005, respectively). Hepatocellular carcinomas expressing both downregulation of cyclin D1 and overexpression of cyclin E had the worst 4-year survival (p<0.03), and higher frequencies of the p53 mutation (p<0.001), large hepatocellular carcinoma (p<0.001), and invasive tumor (p<0.01).

CONCLUSIONS

The deranged expressions of G1 cyclins correlate with the p53 mutation, tumor progression, and tumor biologic behavior of hepatocellular carcinoma. Overexpression of cyclin E occurs early, and downregulation of cyclin D1 late in hepatocellular carcinoma growth.

Ferrous-citrate complex and nigral degeneration: evidence for free-radical formation and lipid peroxidation

Increased nigral iron content in the parkinsonian brain is now well documented and is implicated in the pathogenesis of this movement disorder. Free iron in the pigmented DA-containing neurons catalyze DA autoxidation and Fenton reaction to produce cytotoxic .OH, initiating lipid peroxidation and consequent cell damage. The present results clearly demonstrate that a regional increase in the levels of the "labile iron pool" can result in the degeneration of dopaminergic nigral neurons as reflected by a significant inhibition in the expression of tyrosine hydroxylase mRNA and DA depletion. Iron-complex-induced damage of dopaminergic neurons in the substantia nigra, might have resulted from a sequence of cytotoxic events including the .OH generation and lipid peroxidation as demonstrated in this study. This free-radical-induced oxidative nigral injury may be a reliable free-radical model for studying parkinsonism and may be relevant to idiopathic Parkinson's disease. This apparent nigral injury stimulated by Fe(2+)-citrate is more severe than that produced by ferric iron and its citrate complex. Moreover, these data indicate that Fe(2+)-citrate is as potent as MPP+ in causing oxidative injury to the substantia nigral neurons. However, the nigral toxicity of MPTP and its congeners are not progressive, while Fe(2+)-citrate complex may produce a progressive degeneration of the nigrostriatal neurons which is similar to the progression of ideopathic Parkinson's disease. Thus, this unique Fe(2+)-citrate complex animal model could be used for studying neuroprotective treatments for retarding or halting the progressive nigrostriatal degeneration caused by free radicals in the iron-rich basal ganglia.

[Glucagonoma syndrome report of one case and review of the chinese literature]

This paper reports one case with glucagonoma syndrome that resection of the primary glucagonoma in the pancreas was done. There was metastasis one in liver and lymph node. The definitive diagnosis was established by immunohistochemical analysis. The patient by immunohistochemical analysis. The patient remained well for 27 months and gained 5 kg of weight. Another experiences of diagnosis and treatment of 8 cases of malignant glucagonoma collected in chinese literature were reviewed. The clinical specialty of glucagonoma syndrome. diagnosis and management were discussed suggesting two points: on diagnosis the clinical specialty is a important clues: palliative primary tumor resection may be significant clinical improvement and prolonged survival.

Lipiodolization with or without gelatin sponge in hepatic arterial chemoembolization for hepatocellular carcinoma

Fifty-two patients with unresectable hepatocellular carcinoma were divided into 2 groups. Group A (n = 24) received lipiodolization with gelatin sponge and group B (n = 28) lipiodolization alone. Angiography after hepatic arterial chemoembolization revealed a satisfactory accumulation of lipiodol and obliteration of the microvasculature in the tumors in both groups. However, prolonged obliteration of proximal hepatic arteries was noted in 70%-80% of patients in group A, in contrast to the patency of the arteries in group B. Collateral circulation was found more frequently in group A than in group B, in which recanalization of tumor vessels and phenomenon of iodized oil "wash-out" were seen. There were no significant differences in therapeutic effects in patients with low risk. In those with high risk, the response rates were 28.6% and 64.2%. The half-year survival rates were 28.5% and 62.8%, 1-year survival rates 7.1% and 27.5%, and 2-year survival rates 0% and 13.7% in group A and B respectively. The differences were significant (P < 0.05). Serious complications occurred more frequently in group A than in group B. The therapeutic effects of lipiodolization without gelatin sponge for patients with high risk were significantly superior to those of lipiodolization with gelatin sponge. We conclude that the modality of hepatic arterial chemoembolization should be chosen according to the patient's clinical conditions.

Allelotype and loss of heterozygosity of p53 in primary and recurrent hepatocellular carcinomas. A study of 150 patients

BACKGROUND

The allelotype and loss of heterozygosity (LOH) of the p53 gene in human hepatocellular carcinoma (HCC) were studied in 150 patients with resected primary HCC and 18 with recurrent HCC.

METHODS

DNA samples of paired HCC and livers were cut with BanII enzyme for the study of p53 allelotype and allele loss. The medical records of the patients were carefully reviewed.

RESULTS

Sixty-four (42.7%) patients were heterozygous for the p53 gene, 69 (46%) were homozygous for the 1.5/1.4 kb small (S) allele, and 17 (11.3%) were homozygous for the 2.9 kb large (L) allele. The frequencies of the minor L allele (0.323) and of the major S allele (0.677) in this population of Chinese patients differed from the frequencies previously reported for North American Caucasians (0.13 and 0.87, respectively). The heterozygous patients tended to have lower serum hepatitis B surface- and e antigens (HBsAg and HBeAg) and higher diabetes mellitus (DM) than did homozygous patients (SS and LL). Thirty-seven (57.8%) of the 64 heterozygous patients had a tumor-specific p53 allele LOH, being two times more common in HCC tumors larger than 8 cm than in HCC tumors 2 cm or smaller. The frequency of DM was four times higher in the heterozygous patients who had p53 LOH than in those who retained both alleles. LOH of p53 did not correlate with tumor invasiveness or differentiation, hepatitis B or C virus infection, or prognosis.

CONCLUSION

The allelotype of p53 gene in HCC correlates with HBsAg and HBeAg seropositivities and DM. LOH of the p53 gene is a common event in HCC, correlates with DM, and occurs less often in familial HCC. LOH can identify the clonal origin of recurrent HCC but is not a critical prognostic factor.

Genetic alterations at the splice junction of p53 gene in human hepatocellular carcinoma

The tumor-suppressor gene p53 may transactivate the transcription of genes that down-regulate cellular growth-related genes and may become oncogenic as a result of the production of mutant proteins or the loss of its protein expression. This study reports that alterations of the highly conserved consensus intervening sequences at the splice junctions may lead to the inactivation of the p53 gene. Analyses with the combined polymerase chain reaction and single-strand conformational polymorphism and direct DNA sequencing of DNAs amplified by means of asymmetric polymerase chain reaction demonstrated sequence alterations at the splice junctions of introns 5 and 7 in four human hepatocellular carcinomas, with a single base substitution at the splice junction in three and a 10-bp deletion starting from the dinucleotide AG of the acceptor site of intron 5 in the fourth. Restriction fragment length polymorphism analysis disclosed allele loss in all three informative cases. The p53 mRNA concentrations were remarkably reduced or undetectable in two hepatocellular carcinomas, whereas the two tumors (cases 2 and 3) that had single base changes at the acceptor site of intron 7 had both normal and abnormally sized p53 mRNAs. Immunocytochemistry failed to detect the wild-type and mutant p53 proteins in all four tumors. Western-blot analysis disclosed an abnormal, larger p53 protein of 55 kD in the tumor of case 3.(ABSTRACT TRUNCATED AT 250 WORDS)

Allelotype and loss of heterozygosity of p53 in primary and recurrent hepatocellular carcinomas. A study of 150 patients

BACKGROUND

The allelotype and loss of heterozygosity (LOH) of the p53 gene in human hepatocellular carcinoma (HCC) were studied in 150 patients with resected primary HCC and 18 with recurrent HCC.

METHODS

DNA samples of paired HCC and livers were cut with BanII enzyme for the study of p53 allelotype and allele loss. The medical records of the patients were carefully reviewed.

RESULTS

Sixty-four (42.7%) patients were heterozygous for the p53 gene, 69 (46%) were homozygous for the 1.5/1.4 kb small (S) allele, and 17 (11.3%) were homozygous for the 2.9 kb large (L) allele. The frequencies of the minor L allele (0.323) and of the major S allele (0.677) in this population of Chinese patients differed from the frequencies previously reported for North American Caucasians (0.13 and 0.87, respectively). The heterozygous patients tended to have lower serum hepatitis B surface- and e antigens (HBsAg and HBeAg) and higher diabetes mellitus (DM) than did homozygous patients (SS and LL). Thirty-seven (57.8%) of the 64 heterozygous patients had a tumor-specific p53 allele LOH, being two times more common in HCC tumors larger than 8 cm than in HCC tumors 2 cm or smaller. The frequency of DM was four times higher in the heterozygous patients who had p53 LOH than in those who retained both alleles. LOH of p53 did not correlate with tumor invasiveness or differentiation, hepatitis B or C virus infection, or prognosis.

CONCLUSION

The allelotype of p53 gene in HCC correlates with HBsAg and HBeAg seropositivities and DM. LOH of the p53 gene is a common event in HCC, correlates with DM, and occurs less often in familial HCC. LOH can identify the clonal origin of recurrent HCC but is not a critical prognostic factor.

Amplification of the c-myc gene in human hepatocellular carcinoma: biologic significance

To elucidate the prevalence and biologic significance of the c-myc gene in human hepatocellular carcinoma (HCC), DNA samples were taken from the paired tumorous and nontumorous tissues of 77 cases of resected primary HCC and were analyzed by Southern blot hybridization. We demonstrated modest, but significant c-myc amplification (group A) in 28 (36.4%) of the cases: 1.6- to 2.0-fold in 18, 2.1- to 3.0-fold in four, and > 3.0-fold in six. Compared to HCC without c-myc amplification (group B), group A HCC occurred more often in patients < 50 years old (54.5% vs 29.1%, p < 0.02) with serum alpha-fetoprotein (AFP) levels > 320 ng/mL (61.1% vs 14.6%, p < 0.00002). Group A HCC occurred more frequently in patients with hepatitis B virus infection than in those with hepatitis C virus infection (p < 0.03). Group A HCC was more likely to be poorly differentiated (44.8% vs 10.5%, p < 0.004) and associated with intrahepatic portal vein spread (57.1% vs 28.6%, p < 0.02). The c-myc amplification did not correlate with sex or tumor size. For small HCC, group A had a worse one-year survival rate than group B (72.2% vs 90.9%, p < 0.04). These findings suggest that c-myc amplification is not an uncommon event in human hepatocarcinogenesis, occurs more frequently in young patients who have an elevated serum AFP level or HBV infection, and is related to the biologic behavior of HCC.

Expression of p53 gene in 184 unifocal hepatocellular carcinomas: association with tumor growth and invasiveness

To elucidate the biological significance of the p53 gene expression in human hepatocellular carcinoma (HCC), the p53 protein was studied in 184 resected unifocal primary HCCs, including 102 small (< or = 5 cm) and 82 large HCCs (> 5 cm), using immunocytochemistry. The p53 mRNA expression was analyzed in 69 cases using Northern hybridization. The p53 protein, which was detected in 58 HCCs (31.5%), was overexpressed more frequently in HCC with elevated serum alpha-fetoprotein level (37.9 versus 25%, P < 0.04), in large HCC (39.0 versus 25.5%, P < 0.03), and in invasive HCC (35.1 versus 13.3%, P < 0.01). The overexpression of p53 protein closely correlated with p53 mRNA overexpression (75 versus 44.4%, P < 0.003), and p53 gene mutation (76.9 versus 19.2%, P < 1 x 10(-9)). HCCs with p53 protein expression (group A) and those negative for both p53 protein and mRNA expression (group B) had an unfavorable outcome, while HCC with no p53 protein but with p53 mRNA overexpression (group C) had the best outcome; the 4-year survival was 26.1, 26.3, and 62.5%, respectively. The p53 gene mutation was significantly higher in group A HCC (76.9%) than in groups B (27.3%) and C (23.5%), P < 0.0001. The results suggest that the p53 protein and mRNA expression patterns in HCC correlate with p53 gene mutation and tumor behavior and may serve as a molecular prognostic factor.

Expression and hypomethylation of alpha-fetoprotein gene in unicentric and multicentric human hepatocellular carcinomas

The messenger RNA and DNA methylation of the alpha-fetoprotein gene were studied in 101 resected primary hepatocellular carcinomas, of which 93 were unicentric and 8 were multicentric. Fifty-five were 5 cm or less in diameter (small) and 46 were more than 5 cm in diameter (large). In 48.5% of the cases, we detected alpha-fetoprotein messenger RNA in hepatocellular carcinomas, more frequently in large (60.9%) than in small (38.2%; p < 0.00001) but not in any of the nontumorous livers. The alpha-fetoprotein messenger RNA was detected in 83%, 70% and 6.8% of patients with serum alpha-fetoprotein levels of 320 ng/ml or more, 100 to 319 ng/ml and less than 100 ng/ml, respectively. This finding suggests that alpha-fetoprotein gene expression in hepatocellular carcinoma contributes to the serum alpha-fetoprotein elevation in patients with hepatocellular carcinoma. alpha-Fetoprotein messenger RNA appeared as a major band of 2.4 kb, with two minor species of about 6.5 and 3.6 kb in the hepatocellular carcinoma and the fetal liver. Hypomethylation of the 5' end of the alpha-fetoprotein gene was detected in 78.3% of hepatocellular carcinomas expressing alpha-fetoprotein messenger RNA but infrequently (16.7%) in hepatocellular carcinomas with no detectable alpha-fetoprotein messenger RNA (p < 0.0003). This finding suggests that hypomethylation at the 5' region of the gene is associated with alpha-fetoprotein gene reexpression in hepatocellular carcinoma. The alpha-fetoprotein gene expression helped to differentiate unicentric from multicentric hepatocellular carcinomas and to identify other hidden alpha-fetoprotein-secreting hepatocellular carcinomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased mortality of Norman murine sarcoma in mice treated with the immunomodulator, Acemannan

An extract from the parenchyma of Aloe barbadensis Miller shown to contain long chain polydispersed beta (1,4)-linked mannan polymers with random O-acetyl groups (acemannan, Carrisyn) was found to initiate the phagocyte production of monokines that supported antibody dependent cellular cytotoxicity and stimulated blastogenesis in thymocytes. Acemannan, in both enriched and highly purified forms, was administered intraperitoneally to female CFW mice into which murine sarcoma cells had been subcutaneously implanted. The rapidly growing, highly malignant and invasive sarcoma grew in 100% of implanted control animals, resulting in mortality in 20 to 46 days, dependent on the number of cells implanted. Approximately 40% of animals treated with acemannan at the time of tumor cell implantation (1.5 x 10(6) cells) survived. Tumors in acemannan-treated animals exhibited vascular congestion, edema, polymorphonuclear leukocyte infiltration, and central necrosing foci with hemorrhage and peripheral fibrosis. The data indicate that in vivo treatment of peritoneal macrophages stimulates the macrophage production of monokines, including interleukin-1 and tumor necrosis factor. The data further indicate that sarcomas in animals treated i.p. with acemannan at the time of tumor cell implantation were infiltrated by immune system cells, became necrotic, and regressed. The combined data suggest that acemannan-stimulated synthesis of monokines resulted in the initiation of immune attack, necrosis, and regression of implanted sarcomas in mice.