Association of Adiponectin Genotypes With Colorectal Cancer Susceptibility in Taiwan.

AIM: To investigate the association between adiponectin (ADIPOQ) genotypes and colorectal cancer (CRC) risk among Taiwanese. MATERIALS AND METHODS: Polymerase chain reaction-restriction fragment length polymorphism was adopted to identify ADIPOQ rs266729, rs2241766 and rs1501299 genotypes among 362 CRC patients and 362 healthy controls. RESULTS: ADIPOQ rs266729 GG genotype (p=0.0075) and G allele (p=0.0061) are associated with a significantly increased CRC risk. There is no differential distribution of rs2241766 and rs1501299 genotypes. As for the gene-lifestyle interaction, there are obvious joint effects of rs266729 genotype on the CRC risk among non-smoker, non-alcohol drinker, while not on smoker or non-drinker subgroups. No significant correlation was observed between rs266729 genotypic distributions and age, gender, tumor size, location or metastasis status. Interestingly, a correlation of rs266729 genotype and larger BMI on CRC risk was found. CONCLUSION: G allele at ADIPOQ rs266729 may serve as a determiner for CRC risk, especially for those with BMI ≥24.

Dual role of CD44 isoforms in ampullary adenocarcinoma: CD44s predicts poor prognosis in early cancer and CD44ν is an indicator for recurrence in advanced cancer.

BACKGROUND: Although postoperative adjuvant chemoradiotherapies prevent recurrence for some patients with ampullary cancer, the recurrence rate is as high as 29% in patients with stage I cancer. In an effort to identify predictors of recurrence in patients with ampullary adenocarcinoma, we investigated the clinical value of assessing standard and variant forms of CD44. METHODS: Immunohistochemistry staining and reverse-transcription polymerase chain reaction (RT-PCR) was used to detect standard and variant forms of CD44 in samples of ampullary adenocarcinoma. The cDNA microarray analysis comparing tumors with or without pancreatic invasion was undertaken and analyzed by Ingenuity Pathway Analysis. RESULTS: The standard CD44 (CD44s) isoform was detected in 76 of 98 patients with ampullary adenocarcinoma, and the negative or weak expression of CD44s was correlated with pancreatic invasion, lymphovascular invasion, advanced stage and bone metastasis. Moderate to dense expression of CD44s was correlated with shorter overall survival in patients with localized cancer (T1 or T2 disease, P=0.0268). The patients with advanced cancer (T3 or T4 disease) and moderate or dense CD44s expression had a trend toward better survival. Alternative splicing of CD44 was confirmed using RT-PCR, which revealed that the CD44ν3-10 isoform was only expressed in patients with cancer recurrence. Fold change of CD44ν6-10 was also increased. In addition, networks containing CD44, vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR), transforming growth factor-ß (TGF-ß), matrix metalloproteinase 2 (MMP2), AKT, extracellular signal-regulated protein kinase 1 and 2 (ERK1/2), p38 MAPK, activated protein 1 (AP1)' and CTNNB1 were constructed after comparing microarray data from patients with and without pancreatic invasion. CONCLUSIONS: Whereas CD44s functions as tumor-promoting oncoprotein in early localized ampullary adenocarcinoma, CD44 variants are expressed in advanced cancer and patients with recurrence. Regional invasiveness and distant metastasis of ampullary cancer is controlled by a complex interacting network.

Zinc deficiency in patients undergoing pancreatoduodenectomy for periampullary tumors is associated with pancreatic exocrine insufficiency.

BACKGROUND AND PURPOSE: The present study was done to investigate the prevalence of zinc deficiency after pancreatoduodenectomy (PD) and its correlation with pancreatic exocrine insufficiency. MATERIALS AND METHODS: Patients were included in this study if they had undergone PD for periampullary tumors without recurrence and had received follow-up for more than 6 months between February 2006 and June 2007. Serum levels of zinc, fasting glucose, albumin, and iron were obtained. The pancreatic exocrine function was evaluated by a fecal elastase-1 assay, stool fat assessment, and a pancreatic duct-parenchymal ratio (DPR) at the L1 level using abdominal computed tomography (CT). The quality of life was estimated with a questionnaire of EORTC QLQ-C30 and PAN26. All of these patients were then supplemented with oral pancreatic enzymes for 4 weeks to evaluate the effect of these enzymes on zinc deficiency. RESULTS: Forty-eight eligible patients, 27 men and 21 women, were included. The mean age was 61.3 ± 1.7 years. Thirty-three (68%) patients had a zinc deficiency with a mean zinc level of 72.3 ± 2.9 mcg/dl (normal range: 80-120 mcg/dl). Patients with lower serum zinc levels tended to have typical presentations of zinc deficiency (P = 0.039, χ(2)). The serum zinc level was significantly negatively correlated with pancreatic duct diameter, DPR, and positive stool fat during the late follow-up period. The most common presentations of patients with lower serum zinc levels were skin rash, photophobia, and glossitis. These gastrointestinal disorders, as well as symptoms of zinc deficiency, improved after pancreatic enzyme supplementation. CONCLUSIONS: Zinc deficiency after PD was a common phenomenon and correlated with pancreatic exocrine insufficiency.

MDCT in the early recognition of isolated non-penetrating pancreatic transection.

Isolated pancreatic transection is rare. Associated main pancreatic duct injury is the principal determinant factor of outcome. Earlier computed tomographic scanner may be unreliable in determining the location and severity of pancreatic injury. Multiplanar reconstruction (MPR) and curved views of multidetector computed tomography are helpful in accurate diagnosis of pancreatic transection with the main pancreatic duct injury.

Acinar cell carcinomas with exophytic growth and intraductal pancreatic duct invasion: peculiar multislice computed tomographic picture.

On an ultrasound and multislice computed tomography (MSCT), a 76-year-old woman was found to have a huge mass lesion in the pancreatic head. MSCT showed 8.4 cm well-enhancing exophytic tumor of the pancreatic head which also protruded into the duodenum. A tongue-like protrusion into the main pancreatic duct was depicted. Laboratory data showed elevated carbohydrate antigen 19-9. Whipple's operation was performed. The pathological diagnosis was acinar cell carcinoma (ACC) originating in the pancreatic head and directly invading through the duodenal wall and the main pancreatic duct, without any lymph node involvement. A peculiar ACC with good enhancement, exophytic picture and tongue-like protrusion into the main pancreatic duct on MSCT is presented.

Restenotic hepaticojejunostomy secondary to laparoscopic cholecistectomy bile duct injury treated with self- modified Gianturco-Rosh stents.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is considered as a standard procedure for symptomatic gallstones. However, the incidence of iatrogenic bile duct injury is higher that the conventional cholecystectomy. In the present study was analyzed the results in 6 patients with iatrogenic bile duct injury during laparoscopic cholecystectomy with restenotic hepaticojejunostomy treated with self-modified Gianturco-Rosch stents. METHODOLOGY: Data were collected retrospectively on May 2000 to October 2008 on six patients with major bile duct injury secondary to cholecystectomy. All patients underwent surgical reconstruction with a Roux-en-Y hepaticojejunostomy and presented clinically as obstructive jaundice. Percutaneous transhepatic and/or endoscopic retrograde cholangiography, cholangioplasty by balloon dilation and biliary catheter placement were done in each patient prior to stents placement. Modified Gianturco-Rosch stents with 3cm length and 10mm diameter were used. Follow-up was obtained with direct patients contact or hospital records. RESULTS: Metallic stents were successfully implanted in all 6 patients and the mean patency rate was 46.5 months (range = 14-101 months). One patient required percutaneous recanalization procedure for recurrent cholangitis and obstruction. CONCLUSIONS: Gianturco-Rosch stents placement should be considered in patient with post-hepaticojejunostomy restenosis that repeat surgery is not feasible.

Tumor size is a major determinant of recurrence in patients with resectable gastrointestinal stromal tumor.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumor of the gastrointestinal tract. Surgery remains the mainstay of curative treatment. Recurrence after surgery was frequent and was associated with poor prognosis. In this study, we tried to identify predictors of recurrence in resectable GISTs. METHODS: Between January 1995 and December 2005, 100 patients undergoing surgical resection for GISTs in 2 hospitals were studied. RESULTS: There were 67 gastric and 33 intestinal GISTs. Recurrence was noted in 11 patients (median follow-up of 43 months). Overall 5-year survival was 84%. Multivariate analysis demonstrated that tumor size > or = 10 cm was associated with higher recurrence rates (P = .032) and was the only independent poor prognostic factor for survival (P = .020). CONCLUSIONS: We concluded that tumor size > or = 10 cm carried both a higher risk of recurrence and worse survival in resectable GISTs and could be considered an indicator for adjuvant therapy.

Predictors of recurrence after pancreaticoduodenectomy in ampullary cancer: comparison between non-, early and late recurrence.

BACKGROUND/PURPOSE: Ampullary cancer is one of the periampullary cancers with a better prognosis, but relapse still occurs early in some patients. We sought to find predictors of recurrence to facilitate decisions about postoperative therapy. METHODS: Between January 1989 and March 2006, information was gathered on a total of 127 patients undergoing pancreaticoduodenectomy with regional lymphadenectomy for ampullary cancer at National Cheng Kung University Hospital and Tainan Municipal Hospital. Clinical information, histopathologic results and long-term outcomes were collected and predictors for recurrence were identified. RESULTS: Fifty-eight patients (46%) survived without evidence of recurrence (non-recurrence), while 32 patients (25%) suffered recurrent disease after 12 months (late recurrence) and 37 patients (29%) developed recurrent disease within 12 months (early recurrence). The median follow-up for non-recurrence was 65 months, 13 months for early recurrence, and 36 months for late recurrence. Patterns of recurrence were similar, without any significant difference between the early recurrence and late recurrence groups. The early and late recurrence patients had higher levels of microscopically (R1) or macroscopically (R2) positive margin of resection and more advanced disease (advanced tumor stage, numbers of lymph nodes involved, lymph node status, pancreatic invasion and TNM stage) than the non-recurrence group. After multivariate analysis, positive resection margin, pancreatic invasion and lymph node involvement were significant predictors for disease recurrence. Lymph node involvement was the main differentiating predictor between the late and early recurrence groups (odds ratio, 1.982; 95% confidence interval, 1.101-3.567; p = 0.022). CONCLUSION: Positive resection margin, pancreatic invasion, and lymph node involvement were found to be predictors for disease recurrence and indicators for postoperative treatment.

Transcatheter arterial coil embolization of iatrogenic pseudoaneurysms after hepatobiliary and pancreatic interventions.

BACKGROUND/AIMS: Visceral and renal arteries pseudoaneurysms are uncommon but potentially lethal complications of hepatic and pancreatobiliary interventions. To evaluate the clinical outcome of transcatheter arterial coils embolotherapy, we reviewed our institution's experience with the management for bleeding pseudoaneurysms. METHODOLOGY: From January 1988 through December 2004, 20 patients were encountered who developed massive bleeding from pseudoaneurysms following hepatobiliary and pancreatic interventions. All patients underwent diagnostic angiography and transarterial embolization was carried out thereafter. RESULTS: Embolization was technically successful without major post-procedural complications in all patients. Bleeding was stopped after embolization in 17 patients (85%), and rebleeding did occur in one patient during the follow-up periods. Repeat coil embolotherapy was performed in one patient with recurrent bleeding, but they needed surgical intervention because of failed re-embolization. Another two patients needed surgical ligation and one of the patients died of sepsis two weeks later. CONCLUSIONS: An emergency angiography should be considered in all patients in whom pseudoaneurysm is suspected following hepatobiliary and pancreatic interventions. Transcatheter arterial coil embolization is a safe and effective treatment for pseudoaneurysm. Surgical intervention should be reserved for patients for whom embolization fails or for whom it is not possible.

Predictors for patterns of failure after pancreaticoduodenectomy in ampullary cancer.

BACKGROUND: Ampullary cancer has the best prognosis in periampullary malignancy but unpredicted early recurrence after resection is frequent. The current study tried to find the predictors for recurrence to be used as determinative for postoperative adjuvant therapy. METHODS: Information was collected from patients who underwent pancreaticoduodenectomy with regional lymphadenectomy for ampullary cancer in high-volume hospitals between January 1989 and April 2005. Recurrence patterns and survival rates were calculated and predictors were identified. RESULTS: A total of 135 eligible patients were included. The 30-day operative mortality was 3%. Median followup for relapse-free patients was 52 months. Disease recurred in 57 (42%) patients, including 31 liver metastases, 26 locoregional recurrences, 9 peritoneal carcinomatoses, 7 bone metastases, and 6 other sites. Pancreatic invasion (P = 0.04) and tumor size (P = 0.05) were the predictors for locoregional recurrence, while lymph node metastasis was the sole predictor for liver metastasis (P = 0.01). The 5-year disease-specific survival rate was 45.7%; 77.7% for stage I, 28.5% for stage II, and 16.5% for stage III; and 63.7% for node-negative versus 19.1% for node-positive patients. Pancreatic invasion and lymph node involvement were both predictors for survival of patients with ampullary cancer. CONCLUSION: Pancreaticoduodenectomy with regional lymphadenectomy is adequate for early-stage ampullary cancer but a dismal outcome can be predicted in patients with lymph node metastasis and pancreatic invasion. Lymph node metastasis and pancreatic invasion can be used to guide individualized, risk-oriented adjuvant therapy.

Preoperative endoscopic sphincterotomy in the treatment of patients with cholecystocholedocholithiasis.

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) prior to laparoscopic cholecystectomy (LC) are the most common methods for the diagnosis and treatment of patients with cholecystocholedocholithiasis. We evaluated the selection criteria for preoperative ERCP examination and the results of endoscopic-laparoscopic treatment of patients with choledocholithiasis. Between January 1993 and December 1998, 1630 patients with symptomatic cholelithiasis were admitted for surgical intervention. Preoperative ERCP was performed in 247 patients according to the selection criteria. The criteria to perform ERCP were dilated common bile duct (CBD; more than 8 mm), abnormal serum liver test results, and a recent history of pancreatitis. Endoscopic sphincterotomy (ES) was performed if CBD stones were found during the procedure. LC was then carried out within 3 days after ES. Of the 247 patients selected for preoperative ERCP, CBD stones were confirmed in 146 patients (59.1%). ES was successful in 141 patients, and stone clearance was achieved in 133 patients, resulting in a 94.3% success rate. Eight patients (5.5%) had complications after endoscopic intervention, all of which resolved uneventfully. Open operative procedures were carried out in a total of 31 patients. Overall, 115 patients were successfully treated by this endoscopic laparoscopic sequence. The length of hospital stay in these groups was significantly lower than that for patients in whom an open method was employed. Preoperative ES combined with LC is a safe and effective therapy for cholecystocholedocholithiasis, and the criteria that we used for the selection of patients seem to be appropriate.