Management and outcomes of haemorrhage after pancreatogastrostomy versus pancreatojejunostomy.

BACKGROUND: Postpancreatectomy haemorrhage (PPH) is a major cause of morbidity and mortality after pancreaticoduodenectomy (PD). It remains unclear whether performance of a pancreatogastrostomy (PG) instead of a pancreatojejunostomy (PJ) improves outcomes owing to better endoscopic accessibility. METHODS: A large retrospective analysis was undertaken to compare outcomes of PPH, depending on whether a PG or PJ was performed. The primary outcome was the rate of successful endoscopy. A secondary outcome was the therapeutic success after adding surgery. RESULTS: Of 944 patients who had a PD, 8·4 per cent developed PPH. Endoscopy was the primary intervention in 21 (81 per cent) of 26 patients with a PG and 34 (64 per cent) of 53 with a PJ; it identified the bleeding site in 35 and 25 per cent respectively (P = 0·347). Successful endoscopic treatment was more common in the PG group (31 versus 9 per cent; P = 0·026). Surgery was performed for PPH in 15 patients (58 per cent) with a PG and 35 (66 per cent) with a PJ (P = 0·470). The majority of haemorrhages that required surgery were non-anastomotic intra-abdominal haemorrhages (12 of 15 versus 21 of 35; P = 0·171). Endoscopic or conservative treatment for PPH was successful in 42 per cent of patients with a PG and 32 per cent with a PJ (P = 0·520). The success rate increased to 85 and 91 per cent respectively when surgery was included in the algorithm (P = 0·467). CONCLUSION: The type of pancreatic anastomosis and its inherent effect on endoscopic accessibility had very little impact on the outcome of PPH. This was because haemorrhage frequently occurred from intra-abdominal or non-anastomotic intraluminal lesions.

[Second-look operation in pancreatic carcinoma previously assessed as unresectable]. / Pankreasmalignom: Second-Look-Operation trotz auswärtiger Inoperabilität?

BACKGROUND: The only curative therapy for patients with pancreatic carcinoma consists of -complete surgical tumour removal. Preoperative diagnostic investigations may help, however, the definite decision on tumour resectability can only be made intraoperatively during explorative laparotomy. PATIENTS AND METHODS: We report herein on 17 patients who were judged during exploratory laparotomy elsewhere to suffer from non-resectable pancreatic cancer and who underwent a second-look operation after referral to our hospital. RESULTS: During the second-look operation 13 patients (76.5 %) underwent tumour resection, where-as in 4 patients (23.5 %) the tumour remained non-resectable. An R0 resection was achieved in 9 of 13 (69 %) and an R1 resection in 4 of 13 (31 %) patients, respectively. The classic Kausch-Whipple operation was performed in 4, pylorus-preserving pancreaticoduodenectomy in 5, and left pancreatic -resection in another 4 patients. Mean survival in patients after tumour resection was increased, reach-ing 17.6 months compared to 6.5 months in patients with non-resectable pancreatic cancer. CONCLUSIONS: Our results suggest that the prediction of resectability depends highly on the experience of the surgical team. Although considered as non-resectable during prior laparotomy else-where, the majority of patients (76.5 %) suffered from a resectable tumour disease. Moreover, most of them (69 %) underwent complete (R0) -tumour removal. Thus, complex visceral operations like pancreatic carcinoma resection should preferably be performed in high-volume centres exclusively.

Methylprednisolone therapy in deceased donors reduces inflammation in the donor liver and improves outcome after liver transplantation: a prospective randomized controlled trial.

OBJECTIVE: To investigate potential beneficial effects of donor treatment with methylprednisolone on organ function and outcome after liver transplantation. SUMMARY BACKGROUND DATA: It is proven experimentally and clinically that the brain death of the donor leads to increased levels of inflammatory cytokines and is followed by an intensified ischemia/reperfusion injury after organ transplantation. In experiments, donor treatment with steroids successfully diminished these effects and led to better organ function after transplantation. METHODS: To investigate whether methylprednisolone treatment of the deceased donor is applicable to attenuate brain death-associated damage in clinical liver transplantation we conducted a prospective randomized treatment-versus-control study in 100 deceased donors. Donor treatment (n = 50) consisted of 250 mg methylprednisolone at the time of consent for organ donation and a subsequent infusion of 100 mg/h until recovery of organs. A liver biopsy was taken immediately after laparotomy and blood samples were obtained after brain death diagnosis and before organ recovery. Cytokines were assessed by real-time reverse transcriptase-polymerase chain reaction. Soluble serum cytokines were measured by cytometric bead array system. RESULTS: After methylprednisolone treatment, steroid plasma levels were significantly higher (P < 0.05), and a significant decrease in soluble interleukins, monocyte chemotactic protein-1, interleukin-2, interleukin-6, tumor necrosis factor-alpha, and inducible protein-10 was observed. Methylprednisolone treatment resulted in a significant downregulation of intercellular adhesion molecule-1, tumor necrosis factor-alpha, major histocompatibility complex class II, Fas-ligand, inducible protein-10, and CD68 intragraft mRNA expression. Significantly ameliorated ischemia/reperfusion injury in the posttransplant course was accompanied by a decreased incidence of acute rejection. CONCLUSIONS: Our present study verifies the protective effect of methylprednisolone treatment in deceased donor liver transplantation, suggesting it as a potential therapeutical approach.

Lymphatic mapping and sentinel lymph node biopsy in epidermoid carcinoma of the anal canal.

AIM: Although 15-25% of patients with anal cancer present with superficial inguinal lymph node metastases but the routine application of groin irradiation is controversial because of serious side effects. Inguinal sentinel lymph node biopsy (SLNB) can be used to select patients appropriately for inguinal radiation. The study evaluates the efficiency and clinical impact of SLNB. METHODS: Forty patients with anal cancer underwent 1 ml Tc(99m)-Nanocolloid injection in four sites around the tumour. Patients with inguinal radio colloid enrichment were selected for sentinel lymph node biopsy (SLNB). Lymph node status was examined by haematoxylin and eosin (H&E) as well as immunohistochemistry-staining. All SLN-positive patients were scheduled for inguinal radiation; SLN-negative patients with T1 and early T2 tumours were not scheduled for inguinal radiation. RESULTS: SLN were detected in 36/40 patients. Three common patterns of lymphatic drainage were observed: mesenterial, iliacal and inguinal. Twenty patients with inguinal SLN underwent SLN-biopsy. 6/20 patients were SLN-positive. In 10/20 patients SLNB altered the therapy plan--four patients with T1-tumours and positive SLN had additional groin irradiation, whereas 6 patients with small T2-tumors and tumour-free inguinal SLN did not undergo inguinal irradiation. CONCLUSIONS: Inguinal sentinel node biopsy in anal cancer is efficient and could assist in the decision for inguinal radiation. The validity and safety of the proposed therapeutic algorithm has to be proven by a larger, prospective study.

The location of small tumor deposits in the SLN predicts Non-SLN macrometastases in breast cancer patients.

AIMS: The extent to which the location of micrometastases (MIC) or isolated tumor cells (ITC) in sentinel lymph nodes (SLNs) is correlated with the risk of downstream metastases is still unknown. This study examined this issue and compared the impact of MIC/ITC location with other established risk factors. METHODS: Paraffin slides of SLNs with MIC/ITC-involvement obtained from 68 breast cancer patients were evaluated for MIC/ITC location, lesion size, and various SLN morphologic features. These parameters, together with demographic data and primary tumor characteristics, were analyzed using univariate and multivariate analysis to determine their association with the presence of downstream macrometastases in Non-SLN. RESULTS: Eighteen of 68 patients with MIC (n=37) or ITC (n=31) had Non-SLN metastases. After multivariate analysis, the location of MIC/ITC in the SLN (parenchyma vs. sinus/vessel) had the strongest association with the presence of Non-SLN macrometastases (p<0.0001), followed by the pT-category (p=0.008). Sixteen of 18 patients with parenchymal involvement but only 2 of 31 without parenchymal involvement had Non-SLN macrometastases. The metric size of the primary tumor and the estrogen receptor status were significantly associated only on univariate analysis (p=0.041, 0.034), whereas the correlation to the size classification for tumor cell deposits (MIC vs. ITC) was not significant (p=0.077). CONCLUSIONS: The results indicate that lesion location is an important predictor of Non-SLN-macrometastases. This finding may simplify the decision for axillary treatment in patients with small tumor deposits in the SLN.

Recurrent CDC group IVc-2 bacteremia in a human with AIDS.

A 30-year-old man with AIDS developed separate episodes of bacteremia with multiple organisms including CDC group IVc-2, related to an indwelling central venous catheter. Recovery at each interval followed antibiotic therapy and replacement of the central venous access. This is the first reported case of infection with this organism in a patient with AIDS. A review of the biochemical features of this bacterium as well as pertinent literature is presented.

Rabbit skeletal muscle sarcoplasmic reticulum Ca(2+)-ATPase activity: stimulation in vitro by thyroid hormone analogues and bipyridines.

Sarcoplasmic reticulum-enriched membranes from rabbit skeletal muscle contained Ca(2+)-ATPase activity which was significantly enhanced (26% increase, P < 0.001) in vitro by physiological concentrations (10(-10) M) of L-thyroxine (T4) and 3,3',5-triiodo-L-thyronine (T3). In contrast, the biologically inactive iodothyronine analogues D-T4 and 3,3',5,5'-tetraiodothyroacetic acid (Tetrac) (10(-10) M) were without effect on enzyme activity. 3,5-Dimethyl-3'-isopropyl-L-thyronine (Dimit), a bioactive analogue, was highly effective as a Ca(2+)-ATPase stimulator, increasing enzyme activity by 43% (P < 0.02 vs. T4 effect). A bipyridine cardiac inotropic agent, milrinone, has been reported to be thyromimetic in a myocardial membrane Ca(2+)-ATPase system, and in concentrations from 10(-10) to 10(-5) M enhanced skeletal muscle SR membrane Ca(2+)-ATPase activity in vitro (P < 0.001). Milrinone analogues which have been previously shown to enhance rabbit myocardial membrane Ca(2+)-ATPase activity, and which have a twist relationship of the pyridine rings, were also striated muscle Ca(2+)-ATPase stimulators. We conclude that (1) striated muscle is a mammalian tissue in which physiological levels of biologically relevant thyroid hormone analogues, particularly Dimit, stimulate Ca(2+)-ATPase activity in vitro by a non-genomic mechanism; (2) cardiac bipyridine analogues which are thyromimetic in vitro in rabbit heart, and which have structural homologies with thyroid hormone, are stimulators of rabbit striated muscle sarcoplasmic reticulum Ca(2+)-ATPase activity.

Reduced C8 beta messenger RNA expression in families with hereditary C8 beta deficiency.

Individuals with functional C8 beta deficiency are at increased risk for systemic neisserial infections. Studies by others have shown that the structural gene for this protein appears intact in deficient individuals. We studied affected individuals from 10 unrelated families to determine the basis for their defect. Using chain-specific antisera, C8 beta was undetectable on immunoblots of their sera. The polymerase chain reaction was used to probe cDNA synthesized from RNA isolated from human liver cells, HepG2 cells, peripheral blood monocytes, and fibroblasts to identify a readily available cell source expressing C8 beta message. Cells from each of these sources expressed C8 beta message. The identity of the amplified product was confirmed and this approach was used to probe cDNA synthesized from RNA harvested from monocytes or fibroblasts obtained from two unrelated families with C8 beta deficiency. C8 beta mRNA was readily detectable in C8 beta sufficient and heterozygous family members but required Southern blotting and hybridization to the 32P-labeled C8 beta probe for detection in the homozygous deficient probands. These results suggest that C8 beta-deficient individuals produce less C8 beta-specific mRNA than do normals and that the underlying basis for this deficiency is an abnormality in intracellular events that precede secretion.

Calcium channel blocker inhibition of the calmodulin-dependent effects of thyroid hormone and milrinone on rabbit myocardial membrane Ca2+-ATPase activity.

The Ca2+-ATPase activity of rabbit myocardial membranes is stimulated in vitro by L-thyroxine and by milrinone, a bipyridine. These effects are concentration dependent and calmodulin requiring. The calcium channel blockers nifedipine and verapamil have been reported to have anti-calmodulin effects in other assay systems. In this study we have examined the effects of nifedipine and verapamil on rabbit myocardial membrane Ca2+-ATPase activity, in the absence (basal activity) and presence of exogenous L-thyroxine (T4), 10(-10) M, and milrinone, 10(-7) M. Basal enzyme activity was inhibited by a minimum of 10(-6) M nifedipine (IC50 of 3.4 X 10(-5) M) and 10(-5) M verapamil (IC50 of 1.5 X 10(-4) M). Both calcium antagonists inhibited enzyme stimulation by T4 and milrinone, with half-maximal inhibition of T4 and milrinone effects, respectively, at 2.9 X 10(-5) M and 9.0 X 10(-6) M nifedipine and 3.0 X 10(-5) M and 5.2 X 10(-5) M verapamil. The addition of exogenous purified calmodulin, 40 ng/micrograms membrane protein, in the presence of 10(-5) M nifedipine or verapamil restored T4-stimulated enzyme activity. Nifedipine and verapamil, each at a concentration of 10(-6) M, significantly inhibited binding of radioiodinated calmodulin to rabbit heart membranes in vitro. These studies provide evidence that nifedipine and verapamil have an anti-calmodulin effect in this myocardial enzyme system. Through interaction with calmodulin, the channel blockers inhibit thyroid hormone and milrinone stimulation of myocardial membrane Ca2+-ATPase.

Competition of milrinone, a non-iodinated cardiac inotropic agent, with thyroid hormone for binding sites on human serum prealbumin (TBPA).

Milrinone [2-methyl-5-cyano-(3,4'-bipyridin)-6(1H)-one] is a positive cardiac inotropic agent recently shown to have thyromimetic activity in vitro in a rabbit myocardial membrane Ca2+-ATPase system [K. M. Mylotte et al., Proc. natn. Acad. Sci. U.S.A. 82, 7974 (1985)]. In the present studies, milrinone was examined for activity as an inhibitor of iodothyronine binding by human serum thyroid hormone transport proteins, thyroxine-binding globulin (TBG), prealbumin (TBPA) and albumin. Polyacrylamide gel electrophoresis at pH 9.0 of sera equilibrated with [125I]thyroxine showed that milrinone competed with L-thyroxine (T4) for binding sites on TBPA (10 and 100 microM milrinone caused 61 and 73% reductions, respectively, in T4 binding to TBPA, P less than 0.01); T4 displaced from TBPA was bound by TBG and albumin. Comparable reductions in T4 binding to TBPA were observed in electrophoretic studies conducted at pH 7.4. Binding of triiodo-L-thyronine (T3) to TBPA was electrophoretically confirmed and shown to be decreased in the presence of milrinone. Electrophoresis of purified TBPA also demonstrated that [14C]milrinone co-migrated with this transport protein and that milrinone displaced tracer T4 from TBPA. Amrinone, the 2-H-5-NH2 analog of milrinone, had less than 5% of the activity of milrinone as an inhibitor of T4 binding in electrophoretic studies. Scatchard analysis of T4 and milrinone binding to purified TBPA, measured by equilibrium dialysis, showed two classes of binding sites, with association constants, respectively, of 6.1 X 10(7) M-1 and 1.6 X 10(6) M-1 for T4, and 1.7 X 10(6) M-1 and 8.9 X 10(2) M-1 for milrinone. Computer graphic modeling of the binding of milrinone to the T4 site in the crystal structure of TBPA showed that milrinone best occupied this site when the substituted bipyridine ring overlapped the phenolic ring of T4. In this orientation the 5-cyano group, which has an electronegativity similar to that of iodine, occupied the same volume as the 5'-iodine of T4. The 5-amino group of amrinone lacks these characteristics. In this orientation, the keto function of milrinone overlapped the T4 4'-hydroxyl and could participate in similar intermolecular interactions. Thus, milrinone, a non-iodinated bipyridine, and thyroid hormone share structural and biochemical homologies and compete for the same binding site on TBPA.

Differential activities of tolbutamide, tolazamide, and glyburide in vitro on rabbit myocardial membrane Ca2+-transporting ATPase activity.

At clinically achievable concentrations (10(-9) to 5 X 10(-6) M), tolbutamide and tolazamide are in vitro inhibitors of Ca2+-transporting ATPase activity in sarcolemma-enriched rabbit myocardial membranes (sulfonylurea IC50, 10(-7) M). Thyroid hormone stimulation of this calcium pump-associated enzyme in vitro has been previously reported; in our study, this hormonal action was shown to be inhibited by tolbutamide and tolazamide. In contrast to these two sulfonylureas, glyburide (up to 5 X 10(-6) M) had no effect on basal or thyroid hormone-stimulable Ca2+-ATPase activity in vitro. Studies of binding of radiolabeled purified calmodulin to heart membranes showed that tolbutamide and tolazamide inhibited this interaction, whereas glyburide had no effect on calmodulin binding. Addition of purified calmodulin (5-40 ng/micrograms membrane protein) to myocardial membranes incubated with 10(-7) M tolbutamide or tolazamide restored Ca2+-ATPase activity and thyroid hormone responsiveness of the enzyme. Inhibition by tolbutamide and tolazamide of myocardial sarcolemmal Ca2+-ATPase is a mechanism by which these two sulfonylureas may at least transiently raise resting sarcoplasmic Ca2+ concentration. This effect of sulfonylureas on Ca2+-ATPase is not expressed in the presence of the benzamide side chain of glyburide. The inhibitory action of certain sulfonylureas on Ca2+-ATPase is mediated by interference of the agents with the binding of calmodulin to cardiac membranes.