Primary sclerosing cholangitis successfully treated by resection of the confluence of the hepatic duct.

Primary sclerosing cholangitis (PSC) is a cholestatic disease characterized by chronic inflammatory fibrosis of the extra- and intrahepatic bile ducts. Although the prognosis of patients with PSC was believed to be poor, some patients have not experienced the expected rapid clinical progression. A 51-year-old man with PSC was initially hospitalized for jaundice. Laboratory data showed low levels of the complement components C3, C4, and CH50. Percutaneous transhepatic biliary drainage was performed. Cholangiography revealed complete obstruction of the common bile duct below the confluence of the cystic duct. The confluence of the hepatic duct was resected and it was reconstructed by hepaticojejunostomy for palliation of the obstructive jaundice. Increased thickness of the walls of the common bile duct, right hepatic bile duct, and gallbladder was observed. Histopathological examination of the resected specimen revealed periductal fibrosis, with an onion-skin-like appearance. The patient is currently doing well, approximately 7 years after the surgery, without any signs of PSC recurrence. In this extraordinary patient, the laboratory data for C3, C4, and CH50 showed a complete return to normal levels. The positive results in this patient suggest that resection of the confluence of the hepatic duct may be an effective surgical treatment for noncirrhotic PSC patients who have dominant extrahepatic strictures.

Change of liver function in hypertrophying lobe of rabbit liver after portal branch ligation.

Preoperative portal embolization (PE) is useful for the prevention of postoperative liver failure after extended hepatectomy. However, clinical evaluation of liver function in the hypertrophying lobe after PE has not been studied. Here we report functional changes in the hypertrophying lobe using a 80% portal-branch-ligation rabbit model. Liver function was evaluated by the expression of liver-specific genes detected by Northern blot analysis and plasma disappearance rate of indocyanine green (ICG). The weight of the unligated lobe after portal ligation increased about twofold on the 7th postoperative day (POD) and about threefold on the 14th POD. The mRNA levels of the liver-specific genes (albumin, aldolase B, and tyrosine aminotransferase) in the unligated lobe decreased to about 50% on the 1st POD and returned to the preoperative levels on the 7-14th POD. In contrast, the expression of histone H2B mRNA increased on the 3rd-7th POD. The plasma disappearance rate of ICG (K-ICG) in the rabbit that has only the unligated lobe did not significantly change during the first 7 days, but then improved and recovered to 80% of that in the rabbit that has whole liver on the 14th POD. These results indicate that liver function of the hypertrophying lobe after portal branch ligation does not increase during the first 7 days despite an increase in liver weight. This finding suggests that the compensatory hypertrophying liver is enlarging without functional augmentation in the early period after PE.

Experimental study on the bilirubin metabolism after major hepatectomy: alterations in the proportions of bile bilirubin subfractions.

Bilirubin metabolism after major hepatectomy was investigated experimentally using rats. After a 70% and an 80% hepatectomy, proportions of bilirubin diglucuronide (BDG) decreased, and reversely, those of bilirubin monoglucuronide (BMG) increased. These changes were even more remarkable after an 80% hepatectomy. Parallel to the decrease in the proportions of BDG, the concentrations of uridine diphosphoglucuronic acid (UDP-GA) in the remnant liver decreased, and there was a significant correlation between the changes in BDG and UDP-GA. Although UDP-glucuronyltransferase (UDP-GT) activity and energy charge of the remnant liver also decreased after surgery, these decreases were mild and returned to the control level earlier than BDG. And there was no significant correlation between the changes in BDG and those in UDP-GT activity and energy charge. In this study, the decrease of the proportions of BDG in the bile juice was long term after partial hepatectomy and the period of the decrease became longer according to the augmentation of the volume of the hepatectomized liver. We clarified that the process of the UDP-GA production was inhibited after hepatectomy and the decrease of the proportions of BDG was derived from a deficiency of substrate of the glucuronidation, UDP-GA.

Altered biliary bilirubin profile in patients with persistent hyperbilirubinaemia after hepatic resection: analysis of bile bilirubin subfractions by high-performance liquid chromatography.

Subfractions of bilirubin in bile, obtained via biliary drainage tubes from 23 patients who had undergone radical surgery for bile duct cancer, were analysed by high-performance liquid chromatography for 14 days after surgery. Five principal conjugated bilirubins were resolved: bilirubin diglucuronide (BDG); bilirubin monoglucuronide monoglucoside (BGG); bilirubin monoglucuronide monoxyloside (BGX); and two isomers of bilirubin monoglucuronide. After surgery, depression in concentration of BDG and elevation of BGG and BGX were found. These alterations were of higher magnitude in patients who had undergone hepatectomy, and especially prolonged in patients with hyperbilirubinaemia. These results suggest that the alteration in proportions of bilirubin conjugates might be a cause of hyperbilirubinaemia after hepatectomy.

Results of surgical treatments and prognostic factors for hepatic hilar bile duct cancer.

Results of surgical treatments for 57 patients who underwent resection for hepatic hilar bile duct cancer between 1984 and 1997 were studied. Bile duct resection was performed in eight patients, and combined resection of bile duct and liver was performed in 49 patients, of whom vascular reconstruction was added in 15 patients and pancreatoduodenectomy (PD) in six patients. All the operations of bile duct resection that were not combined with hepatectomy were non-curative. In the patients who underwent combined resection of the bile duct with liver, outcomes of the patients with well-differentiated adenocarcinoma were better than those with other lower-grade tumors. The factors related to the degree of tumor extension, such as serosal invasion, lymph node metastasis, lymphatic vessel invasion, perineural invasion, venous vessel invasion, and vascular involvement, were other factors which significantly influenced the survival. Curative resection yielded significantly better results than non-curative resection. Of all these variables, good tumor differentiation and vascular involvement were recognized as important prognostic factors by multivariate analysis. Most of the postoperative deaths were encountered in patients who underwent additional operations to hepatectomy, such as vascular reconstruction or PD. Improvement of surgical techniques and perioperative care has yielded better outcomes of vascular reconstruction. However, the application of hepatopancreatoduodenectomy should be limited due to poor outcomes of widespread bile duct cancer of which the histological grade is usually low. Whereas prognosis of bile duct cancer involving the hepatic hilus is mainly determined by the biologic characteristics of the tumor, surgeons should consider the fact that most patients die of local recurrence regardless of the biologic character of the tumor when curative resection is not performed.

[A new reconstructive procedure, interposition of a jejunal pouch after proximal gastrectomy].

In this chapter we mention the significance or advantage of the new reconstructive procedure, interposition of a jejunal pouch after proximal gastrectomy. Instead of oesophagogastrostomy which often brought many postoperative complications, various techniques of anastomosis such as conventional jejunal interposition or double tract method were contrived. Although these techniques could reduce the incidence of postoperative problems such as reflux oesophagitis, it is very difficult to examine or remedy beyond the oesophagojejunostomy site after surgery. On the other hand, interposition of a jejunal pouch showed us many advantages. The volume of reconstructed stomach was adequate and the patients could eat enough actually. In case of need, endoscopic fiber could enter the remnant stomach or duodenum very easily. This is the big advantage for the treatment of the upper GI and hepato-biliary pancreatic diseases endoscopically or radiologically after proximal gastrectomy. For these reasons, we usually use interposition of a jejunal pouch between the oesophagus and remnant stomach after proximal gastrectomy.

Staphylococcal enterotoxin B-activated T cells can be redirected to inhibit multicycle virus replication.

Cell-mediated immunity is a crucial part of recovery from virus infections. Adoptive transfer of T cells into infected animals is restricted by the need for Ag-specific and MHC-restricted T cells. One way to overcome these limitations is to use bifunctional Abs to redirect the T cells against virus-infected cells. We have demonstrated that bifunctional Abs can inhibit virus replication in the presence of activated T cells. To generate a large number of activated T cells in a short time, we tested the ability of the superantigen, staphylococcal enterotoxin B (SEB), to activate T cells. We demonstrate that SEB-activated T cells are effective killers when bridged to Fc receptor-bearing target cells using anti-CD3 Abs. SEB T cells can lyse virus-infected target cells in the presence of HHA6, a bifunctional Ab specific for the V beta 8 TCR product and the H1 hemagglutinin of influenza A/PR/8/34 virus. In addition, bifunctional Ab and SEB T cells can inhibit multicycle virus replication in vitro. In a conventional 4-h chromium release assay, SEB-activated CD8 T cells are efficient killers, whereas CD4 T cells are not. Yet both subpopulations have the ability to inhibit multicycle replication in vitro. Superantigens may represent a potent method for generation of effector cells for use in redirected immunotherapy protocols.

Contrasting efficacy of presentation by major histocompatibility complex class I and class II products when peptides are administered within a common protein carrier, self immunoglobulin.

Major histocompatibility complex (MHC) class I and II products are specialized to present antigens via different intracellular processing routes. Peptides originating from proteins in the cytoplasm can gain access to class I peptide-binding grooves, most likely in the rough endoplasmic reticulum. Peptides from proteins in acidic endocytic vacuoles gain access to class II. It has been proposed that MHC class I products also can capture peptides from "exogenous" or noninfectious sources, and this assumption underlies the use of intact proteins as vaccines for CD8+ cytotoxic T lymphocytes. Here we describe quantitative information comparing the efficacy of peptide presentation from exogenous proteins by administering a class I- and II-restricted peptide within the same context, the CDR3 loop of the VH domain of a self immunoglobulin. Antigen-presenting cells (APC), including primary dendritic cells, efficiently present an influenza hemagglutinin peptide from the immunoglobulin (Ig) carrier (50% maximal response at 10 nM Ig-HA) to an MHC class II-restricted T cell. In contrast, these same APC are unable to present an influenza nucleoprotein (NP) peptide from the same context (1 microM Ig-NP) to an MHC class I-restricted T cell. Ig-NP DNA transfectants do present the nucleoprotein viral peptide on class I. Thus, peptides within the complementarity-determining region loops of Ig carriers can be presented on class I or II MHC products, but the endocytic compartment, when offered MHC class I- and II-restricted peptides within the same carrier protein context, favors presentation by class II by at least 1000-fold.

Priming of cytotoxic T lymphocytes at various stages of ontogeny with transfectoma cells expressing a chimeric Ig heavy chain gene bearing an influenza virus nucleoprotein peptide.

The amino acid residues 147-161 of the nucleoprotein (NP) of influenza virus represent a T cell epitope recognized by cytotoxic T cells (CTLs) in association with Kd class I molecules. When SP2/0 myeloma B cells are transfected with a chimeric heavy chain gene bearing this particular NP(147-161) peptide, they are lysed by CTLs specific for the NP(147-161) peptide. Cells that are transfected with this heavy chain chimera and the parental light chain secreted a soluble Ig-NP chimera and were also lysed by the CTLs. Herein, we present evidence that transfectoma cells are able to induce in vitro proliferation of NP specific CTL, whereas immobilized Ig-NP chimeras do not. Furthermore, the transfectoma cells expressing the chimeric heavy chain prime NP specific CTLs in adult as well as in newborn mice, while SP2/0 cells coated with NP(147-161) synthetic peptide do not. These data indicate that the NP peptide needs to be cleaved from the Ig context in order to be presented to T cells and that only endogenously generated NP peptide is immunogenic.

In vivo priming effect during various stages of ontogeny of an influenza A virus nucleoprotein peptide.

In vivo priming of cytotoxic T lymphocytes (CTL) by an influenza virus nucleoprotein (NP) peptide was studied at various stages of development. Adult mice immunized twice with the NP peptide in complete Freund's adjuvant and incomplete Freund's adjuvant, respectively, produce significant CTL responses. Neonates immunized at birth with large amounts of NP peptide and boosted twice with the peptide during adulthood, also mount a weak but significant CTL response. By contrast, offspring from mothers immunized with the NP peptide at days 15, 17, and 19 of pregnancy showed unresponsiveness to the peptide subsequent to a similar regimen of peptide immunization at the age of 1 month. The data indicate that the contact of T cell precursors with antigen during fetal life induces CTL tolerance, whereas, after birth the precursors are not susceptible to tolerogenic signals.

Effect of distal gastrectomy on gut hormone release following vagal stimulation in dogs.

The effect of distal gastrectomy on gut hormone release was investigated by electrical stimulation of the posterior truncal vagus in dogs. Peripheral and portal plasma gastrin release was significantly inhibited, but peripheral and portal somatostatin release was unchanged. Peripheral and portal pancreatic polypeptide (PP) release was significantly inhibited. Our results suggest that the following factors might be some of the reasons why the secretion of PP was inhibited after distal gastrectomy: (1) transection of the posterior vagal branches close to the antrum and pylorus which might go to the pancreas; (2) changes in other hormones such as gastrin; (3) elimination of the PP secretagogue from the gastric antrum.

Cells expressing an H chain Ig gene carrying a viral T cell epitope are lysed by specific cytolytic T cells.

The epitope corresponding to amino acid residues 147-161 of the nucleoprotein (NP) of influenza A virus is recognized by CTL in association with H-2Kd class I Ag. Herein, we engineered an Ig molecule carrying this CTL epitope by replacing the diversity gene segment of the H chain V region of an anti-arsonate antibody with an oligonucleotide that encodes the CTL epitope. The chimeric H chain gene was expressed either alone or together with the parental L chain in the nonsecreting BALB/c myeloma B cell line, SP2/0. The Ig produced by cells transfected with both the chimeric H chain and parental L chains genes expressed the NP epitope but lost the original arsonate binding activity. In addition, SP2/0 cells expressing the chimeric H chain either alone or together with the parental L chain were lysed by class I restricted NP-epitope specific CTL. By contrast, SP2/0 cells pulsed with soluble chimeric Ig molecules were not lysed by the specific CTL. These observations indicate that: 1) this particular CTL epitope can be expressed on Ig molecules without altering the H and L chain pairing; 2) this CTL epitope can be generated from this chimeric Ig in which it is surrounded by flanking regions distinct from those of the viral NP; and 3) the generation of this CTL epitope from the Ig molecule requires the endogenous pathway as do viral proteins.

Inhibition of multicycle influenza virus replication by hybrid antibody-directed cytotoxic T lymphocyte lysis.

Bifunctional antibodies with specificity for the TCR/CD3 complex as well as to a target cell-surface Ag can redirect CTL to lyse the target cell. We have produced a hybrid hybridoma, HHA6, which secretes bifunctional antibodies capable of redirecting CTL to lyse influenza virus-infected target cells. When added along with CTL to virus-infected cells, these antibodies very efficiently inhibit multicycle virus replication. Because hybrid hybridomas reassort H and L chains randomly we attempted to purify bifunctional antibody by using HPLC. The purification increased the potency of HHA6. This increase probably reflects an enrichment of the active species and the removal of inhibiting antibody species.