Endoscopic mucosal resection of superficially spreading colonic neoplasms larger than 5 cm in the right colon after injection of dilute sodium hyaluronate: report of two cases.

Submucosal injection is the most important procedure for the safe performance of endoscopic mucosal resection in the large intestine while avoiding the risk of perforation. We used dilute sodium hyaluronate containing Bosmin and achieved safe piecemeal resection of large superficial tumors in the right colon in two patients. Piecemeal snare resection is considered to be acceptable if all the tissue pieces can be collected for histopathological diagnosis.

Efficacy of oral UFT plus leucovorin therapy for colon cancer with ovarian and multiple liver metastases: report of two cases.

Case 1: a patient was diagnosed as having ascending colon cancer with right ovarian metastasis, and underwent palliative right hemicolectomy plus oophorectomy. The tumor was a well-differentiated adenocarcinoma with right ovarian metastasis, and the disease was classified as stage IV. Oral chemotherapy with UFT plus LV was performed for about 3 years, and the patient is still being followed up with no recurrence at 5 years postoperatively. Case 2: a patient was diagnosed as having incomplete large bowel obstruction caused by ascending colon cancer, and underwent curative right hemicolectomy. The tumor was a moderately differentiated adenocarcinoma, and the disease was classified as stage II. Since multiple liver metastases developed at 3 months postoperatively, oral chemotherapy with UFT plus LV was started. Imaging studies showed the complete elimination of liver metastases after 2 months. Subsequently, liver metastasis recurred about 10 months later. The patient died of unrelated cerebral infarction at 2 years and 6 months postoperatively.

Evaluation of a surgical gamma probe for detection of 18F-FDG.

Because fluorine-18 fluorodeoxyglucose (18F-FDG) is an excellent tumor-localizing radio-pharmaceutical, a hand-held radiation detection probe capable of localizing an area with high 18F-FDG uptake would make radioguided surgery possible. In this laboratory study, we investigated the capability of a widely used intraoperative gamma probe with a cadmium zinc telluride (CdZnTe) detector for detection of 18F-FDG. For sensitivity tests, an 0.1- ml 18F-FDG preparation was made to act as a point source with radioactivities of 1.0, 2.0, and 3.0micro Ci (37 kBq, 74 kBq, 111 kBq). Relative transmission across the side wall of the probe and sensitivity at each source-to-probe distance were measured. For simulation studies, 2 l of 18F-FDG solution (0.02micro Ci, 0.74 kBq/ml) served as normal background. One ml of 18F-FDG was prepared to simulate tumors with radioactivities of 0.05, 0.1, 0.2, and 0.4micro Ci (1.85 kBq, 3.7 kBq, 17.4 kBq, and 14.8 kBq). The ratios of the radioactive concentration of tumor to that of the background were 2.5, 5, 10, and 20:1, respectively. The tested gamma probe was shown to be sensitive to 18F. The high-energy annihilation radiation was detected from the side wall of the probe despite application of a supplementary collimator. The count rate decreased markedly as the source-to-probe distance increased, owing to the effects of the inverse-square law. In the simulation studies, the probe detected a considerable amount of background activity. However, the measured count rate increased with the increasing source-to-background ratio. In our setting, the probe was capable of distinguishing the 18F-FDG source from the background when the source-to-background ratio was no less than 5:1. To make a surgical application feasible, however, collimation or shielding against high background radiation is necessary.

[Cooperative study of intraarterial preventive chemotherapy after resection of hepatic metastasis from colorectal cancer].

This is a compilation of the results of preventive intraarterial infusion following resection of hepatic metastasis from colorectal cancer at four surgical centers. The cases studied included two groups: A) 76 patients who underwent normal liver resection only, and B) 78 patients who underwent resection with adjuvant chemotherapy. Methods included: 1) WHF, 50 cases; 2) other methods using 5-FU, 18 cases; and 3) intraarterial infusions other than 5-FU, 10 (2 cases, outcome unknown). Survival rates for groups A and B for 1 and 5 years were 71.2, 18.9% and 91.5, 56.2%, respectively, with the rates for the intraarterial infusion group showing far better results. The 1- and 5-year survival rates in terms of infusion methods were: 1) 90.7% and 64.6%; 2) 94.4% and 39.3%; and 3) 90% and 60%, respectively, showing no remarkable differences between methods. Total doses of 5-FU were (a) less than 5 g, 7 patients (b) 5-15 g, 16 patients (c) 15-30 g, 22 patients (d) greater than 30 g, 23 patients. A comparison of 1- and 5-year survival rates shows (a) 85.7% and 17.1%; (b) 66.5% and 44.3%; (c) 100% and 62.7%; (d) 100% and 66.5%, respectively, with doses (c) and (d) showing markedly better results than the (a) dosage. From this we conclude that the group undergoing intraarterial hepatic infusion had a markedly improved prognosis compared to the group not undergoing any type of adjuvant therapy. Also, groups receiving a dosage of 15 g or greater of 5-FU showed prolonged survival rates.

A surgical treatment of infected pancreatic necrosis: retroperitoneal laparotomy.

BACKGROUND/AIMS: Due to the anatomical location of the pancreas, sufficient drainage of a pancreatic necrosis by laparotomy may be unsatisfactory. METHODS: CT and helical CT have provided extremely useful information on the surgical treatment of necrotic pancreatitis. The retroperitoneal approach (RPA) allows direct and complete removal of necrotic tissues. RESULTS: RPA was used to treat 8 patients with infected pancreatic necrosis. Excision of necrotic tissues was effective and could minimize the complications often associated with laparotomy such as bleeding and intestinal injuries. CONCLUSION: By CT and helical CT, three-dimensional images of pancreatic necrosis are obtained. These investigations have greatly facilitated RPA, which has advantages over laparotomy in the treatment of infected pancreatic necrosis.

Gut bacterial translocation during total parenteral nutrition in experimental rats and its countermeasure.

BACKGROUND: The use of total parenteral nutrition (TPN) is commonly associated with mucosal lining of the intestinal tract, causing degenerative changes within the gut-associated lymphoid tissue (GALT). These phenomena are probably caused by the translocation of indigenous intestinal bacteria into other organs and tissues where they induce infections. METHODS: Using TPN model rats, this paper looks at the result of the investigation of the action of PSK (proteoglycan), a biological response modifier, which appears to suppress bacterial translocation and maintain local immunity activity. RESULTS: Culture of mesenteric lymph nodes obtained post-TPN demonstrate a bacterial rate as high as 60%. Immunohistochemical examination indicates a reduction in the number of plasma cells and a decrease in S-IgA production and secretion. A similar reduction in S-IgA within bile and portal venous blood was also confirmed. Continuous oral administration of PSK in a daily dose of 1,000 mg/kg had a protective effect against the degeneration of GALT. A staining in immunocytes of Peyer's patches using immunohistochemical study was performed after administration of PSK and revealed constant levels of MHC-I, MHC-II, T helper cells, and interleukin-2 producing cells, supporting the protective role of PSK against degeneration of GALT with a subsequent reduction in bacterial translocation. CONCLUSIONS: Proteoglycan can restore the impaired local immunity in the intestinal tract to normal levels and suppression of the bacterial translocation to provide an important function for patients receiving TPN treatment.

Clinical and biochemical aspects of thiamine treatment for metabolic acidosis during total parenteral nutrition.

We encountered six cases of total parenteral nutrition (TPN)-associated lactic acidosis during the 6-y period of 1988-1993. The patients were characterized by severe disease of the digestive organs, minimal food intake before surgery, and postoperative TPN with no food intake and with no vitamin supplements. Within 4 wk of TPN, they developed hypotension (< or = 80/60 mmHg), Kussmaul's respiration, and clouding of consciousness, as well as abdominal pain not directly related to the underlying disease. Routine laboratory examinations revealed no acute aggravation in hepatic, renal, or pancreatic functions. Arterial blood gas analysis showed pH < or = 7.134 and base excess < or = -17.5 mmol/L. Additional laboratory examinations revealed serum lactate > or = 10.9 mmol/L, serum pyruvate > or = 159 mumol/L, and lactate/pyruvate ratio > or = 0.029. None of the patients responded to sodium bicarbonate or other conventional emergency treatments for shock and lactic acidosis. After the first case, we suspected that thiamine deficiency might be responsible for this pathologic condition, Serum thiamine was proved to be < or = 196 nmol/L in 5 patients. Thiamine replenishment at intravenous doses of 100 mg every 12 h resolved lactic acidosis and improved the clinical condition in 3 patients. This article includes a review of 11 relevant reports published from 1982-1992 and a discussion of the biochemical mechanism of onset of thiamine deficiency-associated lactic acidosis. We emphasize the needs (1) to supplement TPN with thiamine-containing vitamins for the patients whose food intake does not meet nutritional requirements; (2) to monitor the patients routinely measuring serum thiamine concentration and erythrocyte transketolase activity during TPN; and (3) to intravenously replenish using high-dose thiamine simultaneously with the manifestation of signs and symptoms of lactic acidosis.

[Esophageal cancer and multiple primary cancer].

Two hundred eleven cases, 27.1%, of multiple primary cancers of esophagus and other organs were found in 778 cases of esophageal cancers which were treated in our institution. Among them, double cancer accounted for 92.9%, triple cancer accounted for 6.6% and quadruple cancer for 0.5%. As for the other organ of esophageal double cancer. 59.9% of them were head and neck, 25.1% were stomach, 4.9% were colon and rectum, and remaining included liver, breast, lymphoma lung kidney etc. Head and neck cancers consisted with hypopharynx, tongue, larynx, oral floor and gingiva regarding incidence in its order. For discovering of double cancer in esophagus and other organs, 1. head and neck, stomach, colon and rectum, lung, liver etc. should be investigated preoperatively in the patients of esophageal cancer, 2. Esophagus should be examined preoperatively in the patients of these cancers, 3. Screening of esophageal cancer should be performed in the patients of high risks of esophageal cancer. As for the multiple primary cancer of esophagus and other organs, the balance of treatment should be considered to take the priority of the cancer limiting the prognosis.

The effects of proteoglycan on GALT in rats treated with TPN.

It is well known that total parenteral nutrition (TPN) causes atrophy of the intestinal mucosa, resulting in degeneration and atrophy of the gut-associated lymphoid tissues (GALT). This study was conducted to examine the suppressive effect of TPN on GALT in rats. Rats that received TPN alone for 2 weeks, i.e., the TPN group, showed a decreased number of Peyer's patches and thoracic duct lymphocytes (TDL), as well as atrophy. Conversely, those treated with TPN in combination with polysaccharide K (PSK) at a daily dose of 1000 mg/kg for 2 weeks, i.e., the PSK group, showed increases in the number of Peyer's patches and TDL and improvement in the TDL subsets compared with the TPN group. Immunohistological examination of the changes in immunocytes in GALT using monoclonal antibodies revealed increases in the production of the major histocompatibility complex (MHC)-I and (MHC)-II, helper T cells, and interleukin 2 (IL-2). These findings indicate that PSK improves GALT suppression induced by TPN.

[Countermeasures for hypofunction of gut associated lymphoid tissue during TPN in rats].

Total parenteral nutrition (TPN) causes atrophy of the intestinal mucosa, resulting in the degeneration and atrophy of gut associated lymphoid tissues (GALT). This suppressive effect of TPN on GALT was examined using rats. In rats receiving TPN for 2 weeks, a decrease and atrophy of Peyer's patches and a decrease in thoracic duct lymphocytes (TDL) were observed. Daily oral administration of 1000 mg/kg PSK to the rat in the TPN group corrected the number and size of Peyer's patches, and the number of TDL and its subsets were also improved compared with the TPN group. Diminution of the S-IgA of bile and portal venous blood was noticed during TPN in rats. But the groups PSK administrated were increased the amount of S-IgA in bile and portal venous blood. The immune plasma cells in the Peyer's patches were observed, the number of the MHC-class II, T helper, and IL-2 (T CGF) positive cells were decreased in the TPN group compared with control group (PSK group). It has been concluded, therefore, that PSK is effective for improving GALT inhibition caused by TPN.

Frequent microsatellite instabilities and analyses of the related genes in familial gastric cancers.

Microsatellite instability or replication error seems to be related to defective DNA mismatch repair genes, such as hMSH2, hMLH1, hPMS1 and hPMS2, which have been identified as causative genes of hereditary nonpolyposis colorectal cancers (HNPCC). Recently, it was reported that mutations at the simple repeated sequences in the transforming growth factor-beta type II receptor (TGF-beta RII) gene occurred in replication error-positive colorectal cancers. To determine genetic alterations in familial gastric cancers (FGC, we examined replication error using eight microsatellite DNA markers, and screened mutations in the hMSH2, hMLH1 and TGF-beta RII genes in six cases from four FGC kindreds. Moreover, hMTH1, a human homolog of the bacterial mutT gene, was also screened. Four of six (67%) cancers showed the replication error-positive phenotype, indicating that microsatellite instability is highly associated with not only HNPCC, but also FGC. No germline mutation was found in the whole coding sequences of hMSH2 and hMTH1, or in the conservative regions of hMLH1 in any patient, while one cancer DNA showed a somatic mutation at codon 682 (threonine to alanine) in hMSH2. No alteration was found at the small repeated sequences in TGF-beta RII in FGC tumor DNA. These results indicate that the carcinogenetic process of FGC may be different from that of HNPCC.

Effect of the proteoglycan (PSK) on lymphocyte subsets in normal rats.

The effect of the proteoglycan biologic response modifier, PSK, on lymphocyte subsets was investigated in normal rats. Six-week-old male SPF Wistar-Imamichi rats were fed a diet containing 2% PSK. Peripheral blood lymphocytes (PBL), thoracic duct lymphocytes (TDL), and those existing in the thymus, spleen and Peyer's patches were collected for analysis of subsets of T cells, helper/inducer T (Th) cells, suppressor/cytotoxic T (Ts) cells and B cells compared with those of the control group. In the PBL, differential and absolute counts of T and Th cells were lower in the group fed PSK (the PSK group) than the control group. There was no difference in Ts cells between the groups, and the PSK group showed a higher B-cell differential count. In the case of TDL, the PSK group showed greater absolute counts of T and Th cells than the control group. In tissue lymphocytes, differential T and Th cell counts were significantly greater in the PSK group than the control group, as observed first in Peyer's patches and later in the spleen. No differences between the groups were observed in these counts in the thymus. Changes in body distribution of T and Th cells induced by PSK treatment first appeared in lymphocytes in Peyer's patches, followed by PBL and TDL, and those in the spleen. No such changes were observed in the thymic lymphocytes.

Production and properties of mouse monoclonal anti-adriamycin antibody.

Eight mouse IgG1 monoclonal anti-Adriamycin antibodies were produced in culture and in ascites in BALB/c nude mice. The binding constant and specificity was measured by an inhibition ELISA method. The assay was an indirect method using horseradish peroxidase-labeled goat Fab' antibody and 2mM ABTS (2,2'-azino-bis (3-ethylbenzthiazoline-6-sulfonic acid) containing 2.5 mM H2O2 as a color reaction reagent. The binding constant of the antibodies was 10(6) to 10(8) M-1. The antibodies possessed different specificities and affinities to the adriamycin. Though adriamycin is a low molecular weight (M.W. 579.99) hapten antigen, it possesses several epitopes as antigenic determinant sites. The antigenic epitopes of the adriamycin, which until recently were unknown, were analyzed by the monoclonal antibodies.

Inhibitory effect of simultaneous intraportal administration of 5-fluorouracil, uracil and degradable starch microspheres on experimental hepatic micrometastasis, is of colon cancer.

This study was designed to examine the optimal regimen of 5-fluorouracil (5-FU), uracil and degradable starch microspheres (DSM) to prevent the hepatic metastasis of colorectal cancer. BALB/C mice were used as a model of hepatic micrometastasis of mouse transplantable colorectal cancer, Colon 26. We intraportally administered to the mice 5-FU at a dose of 34.8 mg/kg body weight; uracil at the dose equal to, or 8 times higher than that of 5-FU in molar weight and DMS at a dose of 5 mg/kg body weight. We investigated the hepatic and serum concentrations of 5-FU and uracil and the inhibitory effect of various combinations of the three substances on hepatic metastasis. The study showed that concurrent use of 5-FU with uracil at a dose 8 times higher than that of 5-Fu could keep 5-FU concentration high in hepatic tissue and relatively low in serum. This tendency became more marked with the presence of DSM. These findings support the previous study results that uracil antagonizes breakdown of 5-FU in the liver and with the aid of DSM, retards excretion of 5-FU from the liver. Further investigations for clinical application of this method will lower the incidence of hepatic metastasis of colorectal cancer.

Analysis of intestinal flora of a patient with congenital absence of the portal vein.

A 14-year-old female patient, admitted for a closer examination of liver tumour (hepatocellular adenoma), was diagnosed as having a congenital absence of the portal vein. The blood ammonia level (approximately 120 micrograms dl-1) in the superior mesenteric vein was markedly low compared to the normal value of 300-350 micrograms dl-1 in the portal vein. The decreased ammonia concentration and urease activity of the patient's faeces were demonstrated. The dominant intestinal flora in the faeces of the patient, before operation, was Bifidobacterium sp., Bifidobacterium breve, Bifidobacterium lonqum, Lactobacillus plantarum, and after the operation Bacteroides vulgatus, Veillonella parvula, Peptococcus magnus Bifidobacterium longum. In contrast, Bifidobacterium bifidum, Bacteroides ureolyticus, Bacteroides ovatus and Bacteroides distasonis, B. ovatus, Bifidobacterium adolescentis were dominant flora in the faeces of two healthy volunteers, respectively. Among microorganisms isolated from the patient, Morganella morganii, Candida sp., Eubacterium aerofacience and Eubacterium rectale were strongly positive in urease activity in vitro; Streptococcus mitior, Staphylococcus intermedius, Micrococcus kristinae, Selenomonas ruminantum, Bacteroides ureolyticus and Lactobacillus casei ss. pseudoplantarum from the healthy volunteers. These results imply the homeostatic regulation system of faecal ammonia concentration by urease-producing microorganisms in the patient.

Estimation of the functional reserve of the human liver by urinary D-glucaric acid excretion after vitamin C administration.

The excretion of D-glucaric acid in the urine (uGA) correlates with the total liver content of hepatic cytochrome P-450, the metabolism of which depends on adenosine triphosphate (ATP) being produced by intrahepatic cellular mitochondria. Five cases of compensated liver cirrhosis group with less than 0.4 mg/kg/min of the maximum removal rate of indocyanine green (ICGR max), and 5 cases with normal hepatic function (control group), were monitored for uGA before and after P-450 activation induced by administration of 1 g of vitamin-C. Before vitamin-C administration, no differences in uGA excretion were observed comparing the cirrhosis with the control group. After administration of vitamin-C, the excretion of uGA was significantly lower in the cirrhosis group. The measurement of uGA is considered to represent vitamin-C induced activation by P-450, and is a new method for evaluation of the functional reserve of the liver.

The technical problems shoot for the production of anti low molecular weight hapten antibody.

Four kinds of small molecular weight haptens, Desmosine, Adriamycin, 4'-carboxycotinine and 5'-Fluorouracil were used as the immunizing antigens to obtain rabbits polyclonal antisera. All of these haptenes were conjugated to Bovine Serum Albumin (BSA) using 1-ethyl-3(3-dimethylaminopropyl)-carbodiimide (EDCl) reagent. The functional amino or/and carboxyl group in hapten molecules was utilized for conjugation with BSA by EDCl reagent. The hapten conjugated with BSA was mixed with Freund's Complete or Incomplete Adjuvant, and immunized to rabbits abdominal subcutaneous regions. More than 3 times immunized rabbit's antisera were evaluated the titer, and the specificity was investigated by ELISA method. The specific antisera against desmosine and adriamycin were produced. Anti-desmosine antibodies had no cross-reaction to molecular structure resemble pyridinoline. Anti-adriamycin antibodies reacted well to adriamycin and it could distinguish the differences of -epi type of adriamycin. The ELISA assay systems used here had such sensitivity. However the specificity possessing antisera against 4'-carboxycotinine and 5-Fluorouracil could not produce even though the antisera titers were elevated. The reasons why and what kinds of problems were there are discussed in this paper. For the production of the specific affinity possessing antisera, the length and distance between the carrier protein and the hapten and the shape of the functional groups were the important factors for production of the specific antisera which recognize free form hapten molecule.(ABSTRACT TRUNCATED AT 250 WORDS)

Complication of parenteral nutrition composed of essential amino acids and histidine in adults with renal failure.

This is a case report on six patients with hyperammonemia that developed while they were receiving total parenteral nutrition (TPN) as a component of renal failure therapy. Clinically, the hyperammonemia presented as mental status changes in all six cases. Four of the six patients with renal failure initially received 400 mL Amiyu in 1400 mL 17% glucose (total = 1800 mL TPN-A) administered over each 24-hour period. Two patients had been placed on 400 mL complete amino acid in 1400 mL 17% glucose (total = 1800 mL TPN-C over each 24-hour period) prior to therapy with TPN-A. Approximately 3 weeks after initiation of TPN therapy with TPN-A, episodes of mental status changes of increasing duration and paroxysms were documented in five of the six patients. In one of the patients receiving TPN-C prior to TPN-A therapy, toxicity was clinically evident only 4 days after initiation of TPN-A. Serum ammonia levels were obtained and found to be elevated in the acute (ie, presenting) stage in all patients. With the discontinuance of TPN-A, ammonia levels normalized uniformly. Mental status also improved in all cases except for the patient with rapid clinical presentation who died 2 weeks after first evidence of clinical toxicity. In cases 1, 2, and 6, serum amino acid analysis in the acute phase showed reduced levels of ornithine and citrulline, the substrate and product, respectively, of condensation with carbamyl phosphate at its entry into the urea cycle. Moreover, levels of arginine, precursor to ornithine, were found to be elevated.(ABSTRACT TRUNCATED AT 250 WORDS)

[Immunohistochemical studies on tumor associated carbohydrate antigens in gastric cancers of different histological stages].

By comparing gastric cancer tissues treated by the conventional hematoxylin and eosin (HE) staining and those by the chemical staining of immunohistologicals using monoclonal antibodies (MoAB) which recognize different carbohydrate antigens, the relation of cancer tissue patterns between the two staining methods was studied. Consequently, stainability was not seen in MoAB-FH4, AH6, FH6 and TKH2 in the cancer tissues where MoAB-SH1 responded to immunohistological staining. Likewise, each of MoAB-FH4, AH6, FH6 was found to have its own stain localization. The patterns made by immunohistological staining using MoAB showed so-called mosaicism even where the HE stain presented the same histologic form. Study of correlation between gastric cancer patterns and MoAB's localization revealed that localization of MoAB-SH1, AH6 and TKH2 was predominant in well differentiated adenocarcinoma. On the contrary, MoAB-FH4 and FH6, which are more specific, showed predominant localization in poorly differentiated adenocarcinoma of gastric cancers. Localization of MoAB-FH6 and AH6 increased as cancer grew from the early stage to the advanced stage. These results leads to this assumption: cancer, being of an isogenic carbohydrate structure at the initial stage when carcinoma in situ is generated, gains heterogeneity with the process of growth, differentiating into various directions and thus changing into a complicated carbohydrate structure.