Whether or not prophylactic excision of the extrahepatic bile duct is appropriate for patients with pancreaticobiliary maljunction without bile duct dilatation.

BACKGROUND/AIMS: The standard treatment for patients with a pancreaticobiliary maljunction (PBM) without bile duct dilatation remains controversial. METHODOLOGY: We followed up 29 patients with such PBM who mainly underwent a cholecystectomy alone. The ages of the patients ranged from 3 to 76 years (average age 47.3 years) and the ratio of males to females was 8 vs. 21. When the diameter of the common bile duct was less than 10mm, such bile ducts were diagnosed to have no dilatation. The main clinical indications for surgery were cholecystolithiasis in 15 patients, choledocholithiasis in 3, cholecystocholedocholithiasis in 2, gallbladder polyp in 2, adenomyomatosis in 2, cholecystitis in 2, and protein plug in 1. RESULTS: The amylase levels of gallbladder bile in 20 patients ranged from 115 to 460,200 IU/mL (a mean of 191,698 IU/mL). One patient died of gastric cancer 182 months after surgery and two patients died of other diseases 153, 171 months after surgeries, respectively. The remaining 26 patients have all been doing well for 36 months to 326 months after surgery (a median follow-up period, 160.5 months). The 10- and 15-year survival rates were 100% and 89.7%. CONCLUSIONS: In conclusion, a prophylactic resection of the extrahepatic bile duct and biliary diversion could be unnecessary for patients with PBM without bile duct dilatation.

Experimental study on pathogenesis and histomorphology of early carcinoma of the extrahepatic bile duct in the Syrian hamster.

To elucidate the pathogenesis of carcinomas in the extrahepatic bile duct, we investigated the histomorphological characteristics of adenomas and early carcinomas induced in the extrahepatic bile duct of hamsters. Syrian hamsters underwent a cholecystoduodenostomy along with a dissection of the common duct, while also being administered N-nitrosobis(2-oxopropyl)amine (BOP). The tumors that arose from the extrahepatic bile duct included 10 adenomas and 55 early carcinomas in 56 of the 156 hamsters sacrificed. All the adenomas were found to be polypoid in shape. The early carcinomas, which were restricted within the mucosal layer of the bile duct, showed the following three different growth patterns: (1) protruding type in 41 (75%), consisting of 27 polypoid and 14 papillary tumors; (2) superficial spreading type in 9 (16%); and (3) periductal glandular type in 5 (9%). There were no depressed tumors observed. Carcinomas existing either alone or associated with adenomas were evident in 12 (22%) tumors, and 11 of these were polypoid. Atypical papillary hyperplasia within the tumor mass was noted in 22 early carcinomas (40%) and was particularly prominent in papillary type tumors. These results support the concept of an adenoma-carcinoma sequence in the majority of polypoid tumors of the extrahepatic bile duct. Atypical papillary hyperplasia might also be premalignant, and these precursor lesions should reflect the growth patterns of tumors, at least in the early stage of tumorigenesis.

Characteristics of and interventions for fever in Japan.

PURPOSE: As part of a larger multinational validation study of the International Classification for Nursing Practice (ICNP) alpha version, a survey was conducted in Japan to determine characteristics of 'fever' and interventions to treat febrile patients. SAMPLE: Three hundred and fifty-six acute and critical care Japanese nurses participated in this study. METHOD: The major and minor characteristics of 'fever' perceived by Japanese nurses and interventions used by the nurses in managing febrile patients were identified using the Diagnostic Content Validity (DCV) model. RESULTS: Two characteristics, 'increased body temperature' and 'chills' were selected as major characteristics from the standardized list of the ICNP alpha version validation study. Nine characteristics among the standardized list of characteristics were rated as minor characteristics, and six of the ICNP characteristics were rejected. 'Shivering' and 'infectious lab data' were added with a level of representativeness similar to a major characteristic by nine of the nurses. A variety of interventions to treat fever were reported. The most frequently reported intervention was cooling, followed by warming and medication. Nine dimensions were derived from all reported interventions. DISCUSSION: As well as perceived characteristics of fever, these interventions may have aspects unique to Japanese nursing practice and to the acute and critical care settings. These results can be compared to those of other populations in future studies.

Late-onset biliary leakage after laparoscopic cholecystectomy using laparoscopic coagulating shears. Report of a case.

We recently encountered a rare case of late-onset biliary leakage after laparoscopic cholecystectomy using laparoscopic coagulating shears (LCS). The patient was a 49-year-old Japanese man who had undergone a laparoscopic cholecystectomy at Hamamatsu Medical Center after a diagnosis of cholecystolithiasis associated with localized adenomyomatosis. The cystic duct and the cystic artery were closed using LCS instead of metal endoclips. The postoperative course was uneventful, and the patient was discharged on the 4th operative day. However, on the 7th day after the surgery, the patient developed severe upper abdominal pain and was readmitted to our center with the diagnosis of a late biliary leakage, which was confirmed by an endoscopic retrograde cholangiogram. We then treated the leak successfully with endoscopic nasobiliary drainage.

Gallbladder volvulus: experience of six consecutive cases at an institute.

Recently we treated three patients with gallbladder volvulus within a short period. All three patients were examined preoperatively using computed tomography (CT). The first two cases were not diagnosed accurately before laparotomy. A precise diagnosis was made for the third one prior to surgery, based on our former experiences. Typical images, with marked edema and thickened wall of the gallbladder volvulus were shown on CT. We discuss six consecutive cases of the disease experienced at Hamamatsu Medical Center (i.e., the three patients rofed above, and three who did not have preoperative CT).

Tauroursodeoxycholate and cholestyramine enhance biliary carcinogenesis in hamsters.

The aim of this study was to examine whether tauroursodeoxycholate (TUDC) and cholestyramine resin (CR) enhance biliary carcinogenesis in the hamster model. A cholecystoduodenostomy with dissection of the extrahepatic bile duct on the distal end of the common duct was performed on Syrian hamsters. The hamsters were then divided randomly into 3 groups: control group, TUDC-treated group, and CR-treated group. All animals received N-nitrosobis(2-oxopropyl)amine (BOP) to initiate pancreaticobiliary cancer. The experiment was terminated at week 16 and the number of neoplastic lesions was counted microscopically. In the TUDC group, the intrahepatic biliary carcinogenesis was more accelerated than that observed in the control group, but no promoting effect was seen in the pancreas, gallbladder, or extrahepatic bile duct. In the CR group, both the intrahepatic biliary and the gallbladder carcinogenesis were inhibited compared with that observed in the control group and the TUDC group. TUDC enhanced the intrahepatic bile duct carcinogenesis, whereas CR inhibited both the intrahepatic bile duct and the gallbladder carcinoma. Bile acids were suggested to promote biliary carcinoma in the hamster model.

Immunohistochemical demonstration of cytokeratin is useful for detecting micrometastatic foci from gallbladder carcinoma in regional lymph nodes.

BACKGROUND: The histological detection of lymph node metastasis in patients with gallbladder carcinoma is of major prognostic significance. However, it may be difficult to identify nodal involvement by conventional pathological examination of hematoxylin-eosin (HE)-stained sections when metastases are of microscopic size. In the present study, an attempt was made to detect lymph node metastasis precisely from gallbladder carcinoma, even by low-power microscopic examination, using immunohistochemistry with an anti-cytokeratin antibody. METHODS: A total of 431 lymph node specimens dissected during surgery from 33 patients with carcinoma of the gallbladder were investigated. A pair of mirror-image sections were obtained from each of the dissected lymph nodes and then stained using standard HE and immunohistochemical methods utilizing a monoclonal antibody against cytokeratin 7. The HE- and immunohistochemically stained sections were examined for the presence of tumor cells using light microscopy. RESULTS: All 78 lymph nodes from 12 patients with early gallbladder carcinoma were negative for both HE- and cytokeratin-positive cancer cells. Of 353 lymph nodes from 21 patients with advanced gallbladder carcinoma, HE staining showed that 98 were metastasis-positive. Among these 98 lymph nodes, 95 (97%) proved to be positive for metastasis based on cytokeratin immunostaining. On the other hand, the remaining 255 lymph nodes were cancer-free on the basis of HE staining results. Of the 255 HE-negative lymph nodes, seven (2.7%) were found to be positive for micrometastasis on the basis of cytokeratin staining. CONCLUSIONS: Cytokeratin staining of dissected lymph nodes is a useful new diagnostic tool for detecting micrometastatic foci in regional lymph nodes of patients with gallbladder carcinoma.

Detection of the pancreas-specific gene in the peripheral blood of patients with pancreatic carcinoma.

The prognosis of patients with pancreatic carcinoma remains very poor. To improve the therapeutic results, the early detection of this cancer is needed. The present study was performed to detect the pancreas-specific gene, chymotrypsinogen, in the peripheral blood from patients with pancreatic carcinoma by using reverse transcription polymerase chain reaction (RT-PCR) in order to evaluate the clinical significance of this gene. Ten patients with pancreatic carcinoma, two with acute pancreatitis, three with chronic pancreatitis and ten control subjects were examined for the presence of chymotrypsinogen using RT-PCR techniques in the peripheral blood. To confirm that the chymotrypsinogen gene was expressed in a pancreas-specific manner, the expression of chymotrypsinogen in various types of human adult tissue was evaluated by RT-PCR. The specific band of the chymotrypsinogen gene was detected in the pancreas. Serial dilution studies demonstrated the chymotrypsinogen gene to be detected at a concentration of one pancreatic cell per 10(6) peripheral blood cells. Seven out of the ten (70%) patients with pancreatic carcinoma were found to be positive based on the RT-PCR findings. In contrast, no pancreas-specific gene was detected in the peripheral blood of any patients with acute pancreatitis, chronic pancreatitis or the control subjects. Our observations show that the detection of the pancreatic specific gene, chymotrypsinogen, is therefore useful as a genetic diagnostic marker in pancreatic carcinoma.

Cloning and characterization of a close homologue of human UDP-N-acetyl-alpha-D-galactosamine:Polypeptide N-acetylgalactosaminyltransferase-T3, designated GalNAc-T6. Evidence for genetic but not functional redundancy.

The UDP-GalNAc:polypeptide N-acetylgalactosaminyltransferase, designated GalNAc-T3, exhibits unique functions. Specific acceptor substrates are used by GalNAc-T3 and not by other GalNAc-transferases. The expression pattern of GalNAc-T3 is restricted, and loss of expression is a characteristic feature of poorly differentiated pancreatic tumors. In the present study, a sixth human UDP-GalNAc:polypeptide N-acetylgalactosaminyltransferase, designated GalNAc-T6, with high similarity to GalNAc-T3, was characterized. GalNAc-T6 exhibited high sequence similarity to GalNAc-T3 throughout the coding region, in contrast to the limited similarity that exists between homologous glycosyltransferase genes, which is usually restricted to the putative catalytic domain. The genomic organizations of GALNT3 and GALNT6 are identical with the coding regions placed in 10 exons, but the genes are localized differently at 2q31 and 12q13, respectively. Acceptor substrate specificities of GalNAc-T3 and -T6 were similar and different from other GalNAc-transferases. Northern analysis revealed distinct expression patterns, which were confirmed by immunocytology using monoclonal antibodies. In contrast to GalNAc-T3, GalNAc-T6 was expressed in WI38 fibroblast cells, indicating that GalNAc-T6 represents a candidate for synthesis of oncofetal fibronectin. The results demonstrate the existence of genetic redundancy of a polypeptide GalNAc-transferase that does not provide full functional redundancy.

Structural analysis of peptide substrates for mucin-type O-glycosylation.

The structures of three nine-residue peptide substrates that show differential kinetics of O-linked glycosylation catalyzed by distinct recombinant uridine diphosphate-N-acetylgalactosamine:polypeptide N-acetylgalactosaminyltransferases (GalNAc transferases) were investigated by NMR spectroscopy. A combined use of NMR data, molecular modeling techniques, and kinetic data may explain some structural features required for O-glycosylation of these substrates by two GalNAc transferases, GalNAc-T1 and GalNAc-T3. In the proposed model, the formation of an extended backbone structure at the threonine residue to be glycosylated is likely to enhance the O-glycosylation process. The segment of extended structure includes the reactive residue in a beta-like or an inverse gamma-turn conformation and flanking residues in a beta-strand conformation. The hydroxyl group of the threonine to be glycosylated is exposed to solvent, and both the amide proton and carbonyl oxygen of the peptide backbone are exposed to solvent. The exchange rate of the amide proton for the reactive threonine correlated well with substrate efficiency, leading us to hypothesize that this proton may serve as a donor for hydrogen bonding with the active site of the enzyme. The oxygens of the residue to be glycosylated and several flanking residues may also be involved in a set of hydrogen bonds with the GalNAc-T1 and -T3 transferases.

Species differences in the expression of transforming growth factor-alpha (TGF-alpha) in the submandibular gland and pancreas.

CONCLUSION: Significant differences exist in the expression of transforming growth factor-alpha (TGF-alpha) in the submandibular glands (SMG) and the pancreas of different species and among cell components in the same species. BACKGROUND: Our previous studies have shown marked differences in the expression of TGF-alpha in the pancreas of humans and Syrian hamsters. To examine whether these differences also exist in other species, we examined the expression of TGF-alpha in the pancreas of mouse, rat, Syrian hamster, guinea pig, rabbit, pig, dog, and monkey. We included the SMG of these species for comparison. MATERIALS AND METHODS: The formalin-fixed tissues of these species (n = 3) were investigated by immuno-histochemistry using a monoclonal antibody to TGF-alpha. The SMG of rat, mouse, hamster, rabbit, pig, dog, and monkey were examined by RT-PCR to assure the specificity of the antibody. RESULTS: Remarkable species differences were found in the expression of this peptide in both the SMG and the pancreas. In the SMG, the expression varied in different cell components, even in the same tissue of the species. Although excretory and secretory ducts of the SMG of most species reacted with the antibody, intercalated ducts were immunoreactive only in mouse and guinea pig. Acinar cells were either weakly positive or nonimmunoreactive. In the pancreas of most species, the cells of the large and medium-sized ducts expressed TGF-alpha, whereas centroacinar cells of only rat and dog reacted with the antibody. Marked differences were found in the expression of TGF-alpha in islet cells and in its spatial distribution. Differences were also found in the immunoreactivity of mesenchymal and neural cells among the species.

In vitro pancreatic ductal cell carcinogenesis.

Our experiments were designed to identify initial biochemical and biological changes that occur during pancreatic carcinogenesis. TAKA-1, an immortal hamster pancreatic ductal cell line, was treated in vitro for up to 11 weeks with the pancreatic carcinogen N-nitorosobis(2-oxopropyl)amine (BOP). These treated cells were designated TAKA-1 + BOP. The growth of TAKA-1 and TAKA-1 + BOP cell lines was investigated in soft agar and in hamsters intradermally. The resulting tumor from TAKA-1 + BOP was re-cultured in vitro and designated TAKA-1 + BOP-T. Mutation of c-K-ras and p53 oncogenes, chromosomal changes, expression of transforming growth factor alpha (TGF-alpha) and epidermal growth factor (EGF) receptor and several biochemical markers were examined in all cell lines. TAKA-1 + BOP but not TAKA-1 cells grew in soft agar and produced an invasive tumor in vivo. However, there were no differences in cell growth rate, DNA flow cytometry, or immunohistochemical findings between the non-transformed and transformed cells. TAKA-1, TAKA-1 + BOP and TAKA-1 + BOP-T cells all expressed mRNA of TGF-alpha and EGF receptor in a comparable pattern. DNA sequence analysis following polymerase chain reaction showed that neither TAKA-1 nor TAKA-1 + BOP cells has a mutation of c-K-ras or p53. Karyotype analysis demonstrated that TAKA-1 + BOP cells had more chromosomal abnormalities compared with TAKA-1 cells. Mutation of c-K-ras and p53 was not essential for carcinogenesis in hamster pancreatic ductal cells in vitro. In conclusion, immortality of the TAKA-1 cells caused expression of TGF-alpha to the same extent as in malignant cells. Chromosomal and ultrastructural patterns were the only differences detected between the non-transformed and BOP-transformed cells.

Experimental evidence for the origin of ductal-type adenocarcinoma from the islets of Langerhans.

To investigate the role of the islets of Langerhans in pancreatic carcinogenesis, freshly isolated islets from male Syrian hamsters were transplanted into the right submandibular glands of 50 female hamsters that were or were not pre-treated with streptozotocin. Thyroid gland fragments, cellulose powder, and immortal hamster pancreatic ductal cells were injected into the left submandibular gland of the same hamsters. All recipient hamsters were then treated with the potent pancreatic carcinogen N-nitrosobis(2-oxopropyl)amine weekly at a dose of 40 mg/kg of body weight for 3 weeks. Between 3 and 8 weeks later, 18 of 75 (24%) hamsters developed large ductal-type adenocarcinomas in the submandibular gland region, where islets were transplanted, but none developed tumors in the left submandibular gland. In 9 of 18 hamsters, tumors were multiple so that a total of 31 cancers were found. Eleven of these carcinomas were in the vicinity of transplanted islets, eight of which showed intra-insular ductular or cyst formation as seen in the pancreas of hamsters during pancreatic carcinogenesis. The formation of ductular structures within islets was also demonstrated in vitro. Some tumor cells in the vicinity of these islets were reactive with anti-insulin. Y chromosome message was found by polymerase chain reaction analysis in one of the three tumors examined. Also, like the induced pancreatic tumors, all three submandibular gland tumors that were examined had the mutation of the c-Ki-ras oncogene at codon 12 and all tumors expressed blood group A antigen. These and other findings strongly suggest that some components of islets, most probably stem cells, are the origin of ductal-type adenocarcinomas in this model.

Bilioenterostomy enhances biliary carcinogenesis in hamsters.

The aim of this study was to examine whether the type of bilioenterostomy enhances biliary carcinogenesis in the hamster model. Syrian hamsters were divided into the following groups; simple laparotomy (control group), cholecystoduodenostomy with dissection of the extrahepatic bile duct on the distal end of the common duct (CDDB group) and cholecystoileostomy with dissection of the extrahepatic bile duct on the distal end of the common duct (CIDB group). Following these procedures, all hamsters received N-nitrosobis(2-oxopropyl)amine. The diameter of the extrahepatic bile duct and plasma levels of cholecystokinin (CCK) were measured and the number of neoplastic lesions was counted microscopically. Proliferative effect of the procedures on the biliary epithelium was examined by proliferative cell nuclear antigen. In the CDDB group the extrahepatic bile duct was significantly dilated and carcinogenesis of the gall-bladder and extrahepatic bile ducts was enhanced. In the CIDB group the CCK bioactivity was stimulated and intrahepatic biliary duct, but not gall bladder and extrahepatic bile duct, carcinogenesis was promoted more than that observed in the CDDB group. Proliferation of the biliary duct epithelium was enhanced in both the CDDB and CIDB groups. Cholecystoduodenostomy enhanced intra- and extrahepatic bile duct carcinoma, whereas cholecystoileostomy promoted only intrahepatic bile duct carcinoma. Some factors in the intestinal juice seem to play a role in the promotion of biliary tract carcinoma.

Leiomyoma of the lesser omentum: report of a case.

The case of a 67-year-old Japanese woman with leiomyoma arising from the lesser omentum is reported herein. Although the patient had no abdominal symptoms, findings of a routine abdominal ultrasound examination suggested a mass between the stomach and the lateral segment of the liver. Subsequent magnetic resonance imaging (MRI) demonstrated a 6-cm well-encapsulated tumor in the lesser omentum, and this was confirmed intraoperatively. Resection of the tumor was performed without any other procedure and the histological diagnosis was confirmed as leiomyoma. The patient has been well for the 6 months since her operation. To our knowledge, this is the first report in the English literature of leiomyoma arising from the lesser omentum.

Cyclic motor activity of the gallbladder maintained in a pylorus-preserving gastrectomy in dogs.

The gallbladder has cyclic motor activity (CMA), which is impaired after a conventional gastrectomy. We conducted experiments to determine whether or not a pylorus-preserving gastrectomy (PPG) could maintain gallbladder CMA. Six strain gauge force transducers were implanted into the gastrointestinal tract and gallbladder of six dogs, respectively. The motor activity of the gastrointestinal tract and gallbladder was recorded as a control. PPG was then carried out. The phasic contractions of the gallbladder, which were correlated with the antral contractions in the control state, were synchronized with contractions of the pylorus after PPG. Intravenous administration of CCK-OP (40 ng/kg) induced phasic contractions of the gallbladder at 4.6 +/- 0.2 c/min in 3 of the 6 days with gastric contractions. After PPG, the gallbladder had phasic contractions (4.5 +/- 0.2 c/m), which were synchronized with the contractions of the pylorus in all dogs regardless of the contractions in the remnant stomach. These findings suggest that gallbladder CMa has a closer relationship with the CMA of the pylorus than with the remnant stomach after PPG. Thus, a preservation of the pylorus at the time of gastric surgery will help in maintaining gallbladder function and coordination with the remnant stomach.

A new, secure drainage method from the cystic duct after choledocholithotomy using the cystic tube and the cystic clip: an experimental study.

The effectiveness of the cystic tube (C-tube) and the cystic clip (C-clip) for primary closure of the common bile duct after choledocholithotomy was examined in 10 dogs, followed by an observation period of either 3 months (n = 6) or 1 year (n = 4). No early complications were observed in any of the animals either during or after surgery. The laboratory data were within the normal range during the observation period. No bile leakage or slippage of the C-clip was evident on fistulography from the C-tube in animals examined 5 days after surgery. The tube could be pulled out easily from the cystic duct without any bile leakage or slippage of the clip. A second operation to confirm late complications showed no adhesions around the common bile duct, no bile duct stenosis similar to the Mirizzi syndrome, and no cystic changes of the bile duct or biloma. Our newly designed C-clip for primary closure of the common bile duct after a choledocholithotomy therefore appears to be beneficial and applicable to clinical patients undergoing traditional as well as laparoscopic surgery.

Spontaneous perforated pyometra presenting as pneumoperitoneum.

BACKGROUND: Spontaneous perforated pyometra presenting as pneumoperitoneum is extremely rare. CASE REPORT: An 80-year-old Japanese female with spontaneous perforating pyometra presenting as pneumoperitoneum is reported. The patient came to our institute with severe abdominal pain. Routine abdominal examination showed muscular defense, and plain chest roentgenograms revealed infradiaphragmatic free gas. Subsequent computed tomography also demonstrated pneumoperitoneum. Laparotomy was performed on the basis of a tentative diagnosis of perforation of the gastrointestinal tract but revealed a perforated pyometra. A simple hysterectomy was performed. The histological diagnosis of the surgical specimen was acute endometritis without neoplasm. The present report is the third case of spontaneous perforated pyometra with pneumoperitoneum to date. CONCLUSION: Although uterine disease presenting as pneumoperitoneum is rare in elderly patients with an acute abdomen, the possibility of a perforated pyometra should be considered in the differential diagnosis.