Routine laparoscopic ultrasound can significantly reduce the need for selective intraoperative cholangiography during cholecystectomy.

BACKGROUND: The use of intraoperative cholangiography (IOC), routinely rather than selectively, during laparoscopic cholecystectomy (LC) is controversial. Recent findings have shown laparoscopic ultrasound (LUS) to be safe, quick, and effective not only for screening of the bile duct for stones, but also for evaluating the biliary anatomy. This study aimed to evaluate, on the basis of the LC outcome and the cost of LUS and IOC, whether and how much the routine use of LUS would be able to reduce the need for IOC. METHODS: During LC, LUS was used routinely to screen the bile duct for stones and to evaluate the biliary anatomy, whereas IOC was used selectively only when LUS was unsatisfactory or unsuccessful. RESULTS: For 193 (96.5%) of 200 patients, LUS was completed successfully, whereas IOC was needed for 7 patients (3.5%). Bile duct stones were identified in 20 patients (10%). For the detection of bile duct stones, LUS yielded 19 true-positive, 175 true-negative, 0 false-positive, and 1 false-negative results. It had a sensitivity of 95%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 99.4%. The postoperative complications included bile leaks from the liver bed in two patients and a retained bile duct stone in one patient. If IOC had been used selectively in a traditional manner on the basis of preoperative risk factors, IOC would have been needed for 77 patients (38.5%). The total cost of LUS plus IOC for the current 200 patients was 26,256 dollars. The total estimated cost of selective IOC, if it had been performed for the 77 patients, would have been 31,416 dollars. CONCLUSIONS: Routine LUS accurately diagnosed bile duct stones and significantly reduced the need for selective IOC from a potential 38.5% to an actual 3.5% without adversely affecting the outcome of the LC or increasing the overall cost. The routine use of LUS during LC is accurate and cost effective.

Safety and efficacy of radiofrequency thermal ablation in advanced liver tumors.

HYPOTHESIS: Radiofrequency thermal ablation (RFA) can be performed safely and effectively to control local disease in patients with advanced, unresectable liver tumors. DESIGN, SETTING, AND PATIENTS: Prospective study of 76 patients with unresectable liver tumors who underwent RFA at a private tertiary referral hospital. INTERVENTIONS: Ninety-nine RFA operations were performed to ablate 328 tumors. MAIN OUTCOME MEASURES: Complications and local recurrence. RESULTS: There was 1 death (1%), major complications occurred in 7 operations (7%), and minor complications occurred in 10 operations (10%). Local recurrence was identified in 30 tumors (9%) at a mean follow-up of 15 months. Size (P<.001), vascular invasion (P<.001), and total volume ablated (P<.001) were associated with recurrence but the number of tumors was not (P =.39). CONCLUSION: Radiofrequency thermal ablation provides local control of advanced liver tumors with low recurrence and acceptable morbidity.

Ultrasound-guided radiofrequency thermal ablation of liver tumors: percutaneous, laparoscopic, and open surgical approaches.

Only 10% to 20% of patients with primary and colorectal metastatic liver tumors are candidates for curative surgical resection. Even after curative treatment, tumors recur commonly in the liver. As a less invasive therapy, radiofrequency thermal ablation (RFA) of primary, metastatic, and recurrent liver tumors was performed under percutaneous, laparoscopic, or open intraoperative ultrasound guidance. The safety and local control efficacy of RFA were investigated. RFA was performed mostly in patients with unresectable hepatomas or metastatic liver tumors. Patients with large tumors, major vessel or bile duct invasion, limited extrahepatic metastases, or liver dysfunction were not excluded. An RFA system with a 15-gauge electrode-cannula with four-pronged retractable needles was used. All patients were followed for more than 8 months to assess morbidity and mortality, and to determine tumor recurrence. Sixty RFA operations were performed in 46 patients: 11 patients underwent repeat RFA once or twice. A total of 204 tumors were treated: 70 hepatomas and 134 metastatic tumors. Tumor size ranged from 5 mm to 180 mm (mean 36 mm). RFA was performed in 29 operations for 81 tumors percutaneously, in seven operations for 14 tumors laparoscopically, and in 24 operations for 109 tumors by open surgery. Combined colorectal resection was carried out in five operations and combined hepatic resection was carried out in three operations. There was one death (1.7%) from liver failure, and there were three major complications (5%): one case of bile leakage and two biliary strictures due to thermal injury. There were no intra-abdominal infectious or bleeding complications. The length of hospital stay ranged from 0 to 2, 1 to 3, and 4 to 7 days for percutaneous, laparoscopic, and open surgical RFA, respectively. During a mean follow-up period of 20.5 months, local tumor recurrence at the RFA site was diagnosed in 18 (8.8%) of 204 tumors. The risk factors for local recurrence included large tumor size and major vessel invasion: recurrence rates for tumors less than 4 cm, 4 to 10 cm, and greater than 10 cm, and for those with vessel invasion were 3.3%, 14.7%, 50%, and 47.8%, respectively. Ten of 18 tumors recurring locally were retreated by RFA, and eight of them showed no further recurrence. Ultrasound-guided RFA is a relatively safe, well-tolerated, and versatile treatment option that offers excellent local control of primary and metastatic liver tumors. The appropriate use of percutaneous, laparoscopic, and open surgical RFA is beneficial in the management of patients with liver tumors in a variety of situations.

Simple laparoscopic ultrasound technique for prevention of bile duct injuries.

BACKGROUND: Bile duct injuries are serious complications of laparoscopic cholecystectomy. Laparoscopic ultrasonography (LUS) has been utilized over the last several years to screen for bile duct calculi and to delineate biliary anatomy. We have found a simple LUS scanning technique that can be useful for preventing bile duct injuries. METHOD: After initial scanning for screening, laparoscopic dissection is continued, isolating the cystic duct. If necessary, scanning can be performed to assure the location of the cystic duct before clipping. After clips are applied to the cystic duct, prior to its incision or transection, LUS is repeated to examine the cystic and bile ducts. RESULTS: This postclipping study can confirm that the clips are applied to the cystic duct and that the hepatic and common bile ducts are intact without occlusion. CONCLUSION: This additional LUS scanning maneuver is simple and quick and may help prevent bile duct injuries.

[Support for patients with a respirator at home].

Five patients with a respirator were managed at home by staff from our visiting nurse station. One patient has been at home for 4 years after discharge. She is 60 years old. Her disease was striatonigral degeneration. Five years ago she could not breathe because of her disease and breathing with a respirator was started. However, she and her family wanted her to be at home. We respected their wish, and helped her stay at home. She has maintained a good condition with nursing at home, and her QOL is high.

In vitro B-mode ultrasonographic criteria for diagnosing axillary lymph node metastasis of breast cancer.

Axillary lymph node status is an important factor for staging and treatment planning in breast cancer. Our study was performed in vitro on a node-by-node basis to evaluate the ability of B-mode ultrasonographic images to distinguish metastatic from nonmetastatic nodes. Immediately prior to histologic examination, individual dissected axillary nodes were scanned in a water bath using a 10 MHz B-mode ultrasonographic transducer. Four B-mode features (size, circularity, border demarcation, and internal echo) were evaluated for their ability to distinguish metastatic from nonmetastatic lymph nodes. Lymph node metastasis was indicated by (1) a large size (i.e., a length of the longest axis of 10 mm or greater); (2) a circular shape (i.e., the ratio of the shortest axis to the longest axis between 0.5 and 1.0); (3) a sharply demarcated border compared with surrounding fatty tissue; and (4) a hypoechoic internal echo, with obliteration of the fatty hilum. The sensitivity and specificity were compared for all combinations of features. We examined 84 histologically characterized axillary nodes from 27 breast cancer patients, including 64 nonmetastatic and 20 metastatic nodes. Of the criteria cited, circular shape was the best single feature for distinguishing metastatic from nonmetastatic nodes (sensitivity, 65%; specificity, 73%). The best combination of sensitivity (85%) and specificity (73%) was obtained using the criterion that a lymph node contained cancer when at least three positive features were present. The present in vitro study demonstrated that the sensitivity and specificity of B-mode ultrasonography for diagnosing lymph node metastasis were lower than 90%. Therefore, B-mode ultrasonography may not be an optimal noninvasive screening method for diagnosing axillary lymph node metastasis in breast cancer patients, particularly under in vivo clinical conditions.

Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography.

BACKGROUND: Laparoscopic ultrasonography (LUS) has been used increasingly over the last several years as a new imaging modality. To define the role of LUS during laparoscopic cholecystectomy, we evaluated LUS by prospectively comparing it with operative cholangiography (OC), by reviewing the literature on LUS, and by retrospectively comparing it with intraoperative ultrasonography performed during open cholecystectomy. STUDY DESIGN: LUS and OC were compared prospectively in 100 consecutive patients during laparoscopic cholecystectomy. The success rate of examination, the time required, the accuracy in diagnosing bile duct calculi, and the delineation of biliary anatomy were evaluated. RESULTS: The success rate of examination was 95% for LUS and 92% for OC. The main reason for unsatisfactory LUS was incomplete visualization of the distal common bile duct. The time required was 8.2 minutes for LUS and 15.9 minutes for OC (p<0.0001). Nine patients had bile duct calculi. LUS had one false-negative result and OC had two false-positives and one false-negative. The accuracies of LUS and OC were comparable except for a slightly better positive predictive value of LUS (100% versus 77.8%; p>0.1). In a literature review, 12 recent prospective studies comparing LUS and OC and three studies on open intraoperative ultrasonography were reviewed. Twelve studies of LUS with a total of 2,059 patients demonstrated results similar to the present study. The success rate was 88% to 100% for both tests. The time for LUS was approximately 7 minutes, about half of the time needed for OC. Overall, LUS was associated with fewer false-positive results than OC; the positive predictive value and specificity of LUS were better, while the sensitivity and negative predictive value of LUS and OC were comparable. OC detected ductal variations or anomalies more distinctly than LUS. Compared with open intraoperative ultrasonography, LUS had a slightly lower success rate and required a slightly longer time because it was technically more demanding, but the two procedures had a similar accuracy for diagnosing bile duct calculi. CONCLUSIONS: Because of their different advantages and disadvantages, LUS and OC can be used in a complementary manner. There is a learning curve for LUS because of its technical difficulty. Once learned, however, LUS can be used as the primary screening procedure for bile duct calculi because of its safety, speed, and cost-effectiveness. OC can be used selectively, particularly when ductal anatomic variations or anomalies or bile duct injuries are suspected.

Laparoscopic inguinal herniorrhaphy: the new gold standard of hernia repair?

The surgical treatment of the common inguinal hernia has been one of the most analyzed and debated topics in medicine. Recently, with the success of laparoscopic cholecystectomy, interest in minimally invasive surgical techniques has led to it's application for inguinal hernia repair. Current laparoscopic herniorrhaphies are based on the principles of conventional open preperitoneal repairs and are classified into two types: 1) transabdominal preperitoneal repair (TAPP) and 2) totally extraperitoneal repair (TEP). Common advantages to both techniques include a decrease in postoperative pain, earlier return to normal activity, and improved cosmesis. Both laparoscopic techniques have the disadvantage of requiring general or regional anesthesia and increased procedural costs. Lastly, there is a concern that laparoscopic hernia repair has not been around long enough to know the risk of late recurrences. Laparoscopic herniorrhaphy, however, is a viable alternative to standard open inguinal hernia repair.

Laparoscopy in the trauma patient.

The first laparoscopic exam of the abdominal viscera was done by Keillng in 1902. Since that time, laparoscopy has been used more extensively in abdominal and pelvic disorders by gynecologists and gastroenterologists than general surgeons. However, since the introduction of laparoscopic cholecystectomy in the 1980s by Mouret in France and Muhe in Germany, laparoscopy has been embraced by the general surgeon and has exponentially increased in number and types of procedures being done. New technology, such as the enhancement of video image along with better instrumentation, has further accelerated the acceptance of "minimally invasive" surgery in all surgical specialties.

Effect of dibutyryl cyclic adenosine 3',5'-monophosphate on morphological features and biological markers of human salivary myoepithelial cell line in culture.

We have found the emergence of myoepithelial cells (HSG-AZA1) in neoplastic human salivary intercalated duct cell line HSG in culture after treatment with 5-azacytidine. When HSG-ZAZ1 cells were cultured in the presence of N6,O2-dibutyryl cyclic adenosine 3',5'-monophosphate (dB-cAMP), they formed long cytoplasmic processes which were densely packed with ample microfibrils in addition to microtubule bundles. The expression of neuron-specific enolase, synaptophysin, and catecholamine as well as neurofilaments in the treated HSG-AZA1 cells was found by the immunofluorescence staining technique, immunoblotting, immunoelectron microscopy, or catecholamine fluorescence. Both the anchorage-independent and anchorage-dependent growths of HSG-AZA1 cells were suppressed in the presence of dB-cAMP. After the removal of dB-cAMP from the culture, the treated cells returned rapidly to the phenotype and growth rate of the untreated cells. These findings indicate that reversible differentiation into the neuron-like cells of HSG-AZA1 cells occurs in growth medium containing dB-cAMP.

[Modeling and simulation on the appearance of peak value of breath alcohol concentration after various drinking methods].

In this paper, we try to estimate directly the time variations and the peak values of the breath alcohol concentration (BrAC) after drinking. First, the time variations of the BrAC is applied to the impulse response models of the 2nd order lag + time delay and the 3rd order lag. The Dirac's Delta functions are used to investigate the difference between drinking directly and out of a cup in many times. The relationship between the appearance of the peak value as time increases and the various drinking methods (i.e., quantity or interval) is discussed by using these models, and the results is confirmed experimentally. According to the simulation results, the appearance of the peak value of the BrAC depends on the various drinking methods considerably. Provided the parameters of these models are known in advance, time variations of the BrAC can be predicted immediately. Lastly, these results might be use in practice to reduce the risk of traffic accidents and maintenance of health.

Effect of hexamethylene bisacetamide and cyclosporin A on recovery of herpes simplex virus type 2 from the in vitro model of latency in a human neuroblastoma cell line.

The goal of the present work was to examine whether hexamethylene bisacetamide (HMBA) and cyclosporin A affect the recovery of herpes simplex virus type 2 (HSV-2) from an in vitro model of HSV-2 latency in human neuroblastoma cell line IMR-32. IMR-32 cells were infected with HSV-2 at a multiplicity of infection of 0.1 plaque-forming units/cell and were cultured at 40 degrees C for 14 days, resulting in the establishment of a model of HSV-2 latency in IMR-32 cells. When the cultivation temperature was shifted down from 40 to 37 degrees C, recovery of virus growth began to occur after an incubation period of 2 days. During the time of shift-down of the incubation temperature, the latently infected cells were further cultured at 37 degrees C in the presence or absence of 5 mM HMBA or 0.5 micrograms/ml cyclosporin A, which does not affect stability of HSV-2 nor proliferation of IMR-32 cells. Consequently, the rate of HSV-2 recovery from the latently infected cells cultured in the presence of 5 mM HMBA was significantly increased, as compared with the untreated controls. In addition, the DNA methylation level of the latently infected IMR-32 cells cultured in the presence of HMBA was significantly decreased when compared to the level in the untreated controls. On the other hand, the cultivation of the latently infected cells in the presence of 0.5 micrograms/ml cyclosporin A resulted in a significant decrease in the rate of HSV-2 recovery. These findings indicate that the recovery of HSV-2 from the model of latency in IMR-32 cells is enhanced by HMBA treatment, which induces a significant decrease of total genomic DNA methylation level, and is inhibited by cyclosporin A treatment.

Hemopneumothorax due to pulmonary metastasis with malignant hemangioendothelioma: CT and pathological findings.

Malignant hemangioendothelioma is a rare vascular tumor. The disease frequently recurs and eventually metastasizes to the lung in most cases. Hemopneumothorax developing soon after metastasis to the lung indicates on unfavorable prognosis. We had an opportunity to examine a patient who had malignant hemangioendothelioma in the occipital scalp and developed hemopneumothorax following metastasis to the lung. We report the computed tomographic (CT) and pathological finding in the patient, and review the literature on hemopneumothorax.

Cellular proliferation and ras oncogene of p21 21,000 expression in relation to the intracellular cyclic adenosine 3':5'-monophosphate levels of a human salivary gland adenocarcinoma cell line in culture.

We have found that reversible differentiation into the myoepithelial cells of a human salivary gland adenocarcinoma cell line (HSG) occurs in growth medium containing dibutyryl cAMP (dB-cAMP). In the current study, the relationship between intracellular cAMP levels and anchorage-dependent and -independent growth or ras oncogene of p21 levels was analyzed in the differentiation process toward myoepithelial cells of HSG cells cultured in the presence of dB-cAMP. Correlation between the concentrations of dB-cAMP and intracellular cAMP in the HSG cells was statistically significant. There was a significant inverse correlation between the concentrations of dB-cAMP and colony-forming ability of the cells in semisolid agar or on a plastic surface. We have found the expression of ras p21 protein in HSG cells. When HSG cells were cultured in the presence of dB-cAMP and were committed to differentiate into myoepithelial cells, it was shown by double-antibody labeling technique and/or immunoblotting that the committed cells expressed myosin with a concomitant decrease of ras p21 protein. Moreover, intracellular cAMP levels were found to be inversely associated with ras p21 content of the cells. These findings indicate that the intracellular cAMP levels regulate significantly cell proliferation and ras p21 expression in HSG cells.

Monoclonal antibody to the streptococcal preparation OK-432: tissue OK-432 localization and analysis of interaction between OK-432 and macrophages or NK cells in human salivary adenocarcinoma-bearing nude mice given OK-432.

An immunoglobulin M mouse monoclonal antibody (MAb) to the streptococcal preparation OK-432, TS-1, was generated. The TS-1 antigen is a carbohydrate epitope. This antigen is stable upon fixation and embedding in paraffin. The tissue and cellular OK-432 localization in human salivary adenocarcinoma-bearing nude mice given OK-432 intratumorally was examined by various methods according to the immunological procedures using the purified TS-1 MAb. The presence of OK-432 antigen recognized by TS-1 MAb was clearly observed in the tumor as well as the spleen and lung 24 or 48 h after OK-432 administration, whereas transfer of OK-432 from the site of injection to the organs, such as liver and kidney, was rarely seen. The presence of OK-432 antigen in some immunocompetent cells, as defined by Mac-1 antigen or asialo GM1 antigen, was observed by the double-antibody labeling technique in the tumor and spleen from tumor-bearing nude mice. Moreover, interaction between OK-432 and macrophages or natural killer (NK) cells in relation to expression of interferon (IFN) in tumor-bearing nude mice given OK-432 was observed. Consequently, significant increases of Ia-positive or Ia-negative macrophages, NK cells as well as IFN-alpha/beta- or IFN-gamma-positive cells in the tumor and/or spleen were found when compared with those without OK-432 administration.

Interferon activity and its characterization in the sera of patients with premalignant lesions arising in oral mucosa.

The interferon (IFN) assay of the sera from the 26 patients with premalignant lesions such as lichen planus and leukoplakia arising in oral mucosa was performed by the plaque-reduction assay with vesicular stomatitis virus in FL cells derived from human amniotic membrane. When the serum IFN activity was characterized by acid treatment, significant increase of acid-stable IFN in the patients was found as compared with those in the normal controls. The titers of gamma-like IFN defined by anti-HuIFN-alpha and anti-HuIFN-beta in the sera of patients of 50-79 years age group (n = 17, P less than 0.002) showed a highly significant increase as compared with the relevant normal controls (n = 20). All of the 26 patients were treated with topical administration of HuIFN-beta. When the correlation between prognosis of the disease and titers of serum IFN was investigated by measuring gamma-like IFN and acid-stable IFN in the sera of patients, all of 13 patients with good prognosis after the HuIFN-beta therapy showed significantly decreased levels of gamma-like IFN (P less than 0.01), whereas the serum level of acid-stable IFN after HuIFN-beta therapy showed a significant increase compared to that before the therapy (P less than 0.05). These findings indicate that the endogenous IFN system may be associated with the pathophysiology in patients with the oral mucosal lesions.

Evaluation of the degree of severity in liver cirrhosis by computed tomography.

As CT findings useful for the evaluation of the degree of severity in liver cirrhosis, the following items were chosen for statistical analysis: atrophy of the right lobe, enlargement of the left lobe, irregularity of the liver surface, ascites, varices or collaterals, and dilatation of the SMV. According to the frequency with which these six items were found, the CT findings were expressed in the form of a score, and the resulting scores agreed well with ICG values, portal-venous flow (Qp) ratios obtained from radionuclide angiography, and the scores on the Child-Turcotte criteria. A score of 5 or 6 meant severe cirrhosis. A score of 4 meant liver cirrhosis, however, the degree of severity could not be determined, because there was overlap among the cirrhotic groups. A score of 3 meant liver cirrhosis with a probability of about 90%. A score of 1 or 2 was nonspecific for evaluation. When a score of 0 was noted with splenomegaly, there was a probability of more than 90% that it was chronic hepatitis. In conclusion, this approach was considered to be useful for evaluating the degree of severity in liver cirrhosis and differentiating between liver cirrhosis and chronic hepatitis to some degree in Japanese.

Interferon activity and its characterization in the sera of patients with head and neck cancer.

The interferon (IFN) assay of the sera from the 40 patients with head and neck cancer was performed by the plaque-reduction assay with vesicular stomatitis virus in FL cells derived from human amniotic membrane. The patients mainly had Stage III or IV lesion without distant metastasis, and previously had not received any cancer therapy. All of the patients were histologically diagnosed as squamous cell carcinoma. When the serum IFN activity was characterized by acid treatment, significant increases of IFN-alpha/beta/gamma (n = 24, P less than 0.05) and acid-labile IFN (n = 24, P less than 0.001), and significant decrease of acid-stable IFN (n = 24, P less than 0.001) in the cancer patients of 50-to-79-year age group were found, as compared with those in the normal controls of the same age group (n = 20). When IFN titers including various immunologic parameters of the patients and normal controls were simultaneously assayed prior to the beginning of the cancer therapy, the titers of IFN-alpha/beta/gamma, acid-stable IFN, and acid-labile IFN were significantly correlated with some immunologic parameters such as natural killer (NK) activity, the absolute number of T gamma lymphocytes, the percentages of beta- and gamma-globulin, and the amounts of IgA, IgG, IgM, and beta 2 microglobulin. To define further the nature of this IFN, both sera of the patients and normal donors of 50-to-79-year age group were characterized by a neutralization assay with an antiserum to HuIFN-alpha and HUIFN-beta. The IFN activity left when the testing sera were neutralization with these antisera was expressed as gamma-like IFN. The titers of gamma-like IFN in the sera of patients (n = 24, P less than 0.0001) showed a highly significant increase as compared with the normal controls (n = 20). When the correlation between prognosis of the disease and titers of serum IFN were investigated by measuring gamma-like IFN and acid-stable IFN in the sera of patients, all of nine patients with good prognosis after the cancer treatment showed significant decreased levels of gamma-like IFN (P less than 0.01) and acid-stable IFN (P less than 0.05) as compared with those on the time before cancer therapy. On the other hand, titers of gamma-like IFN in the sera of six patients with recurrent disease showed a significant increase as compared with those on the IFN measurement before cancer therapy (P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

Measurement of 24-hour whole-body retention of Tc-99mMDP with a thyroid uptake probe: quantitative assessment of metabolic and metastatic bone diseases.

A new method for the measurement of 24-hour whole-body retention (WBR) of Tc-99mMDP, using a thyroid uptake probe with a normal scintigraphic dose was established. Its clinical significance was evaluated in 106 subjects over 20 years old with various bone disorders, including metabolic and metastatic bone diseases. Reproducibility of 24-hour WBR in 10 patients was very good (y = x - 0.3, r = 0.996). The 24-hour WBR of Tc-99mMDP in healthy subjects was 30.4% +/- 4.6%. The WBR values for patients with chronic renal failure, metastatic bone disease, osteomalacia and hyperthyroidism were 98.4% +/- 3.0%, 44.0% +/- 8.0%, 50.7% +/- 2.8% and 39.4% +/- 6.5%, respectively, which were significantly higher when compared with the healthy group. However the WBR of the steroid-induced osteoporotic group was significantly lower (17.3% +/- 5.4%), suggesting the possibility of being able to differentiate osteoporotic patients from healthy subjects. For assessment of the value of 24-hour WBR, simultaneous bone imaging was essential so as to be able to exclude the effects of arthropathy and/or fracture, which were often found in the older age group.