Long-term results of a randomized, observation-controlled, phase III trial of adjuvant interferon Alfa-2b in hepatocellular carcinoma after curative resection.

OBJECTIVE: To investigate the clinical efficacy of adjuvant interferon alfa-2b (IFNα-2b) therapy on recurrence-free survival (RFS) of patients with postoperative viral hepatitis-related hepatocellular carcinoma (HCC). BACKGROUND: Despite most individual trials have failed to meet their primary endpoint, recent pooled-data meta-analyses suggest that adjuvant IFN therapy may significantly reduce the incidence of recurrence in curatively ablated HCC. METHODS: Patients with curative resection of viral hepatitis-related HCC were eligible, and were stratified by underlying viral etiology and randomly allocated to receive either 53 weeks of adjuvant IFNα-2b treatment or observation alone. The primary endpoint of this study was RFS. RESULTS: A total of 268 patients were enrolled with 133 in the IFNα-2b arm and 135 in the control arm. Eighty percent of them were hepatitis B surface antigen seropositive. At a median follow-up of 63.8 months, 154 (57.5%) patients had tumor recurrence and 84 (31.3%) were deceased. The cumulative 5-year recurrence-free and overall survival rates of intent-to-treat cohort were 44.2% and 73.9%, respectively. The median RFS in the IFNα-2b and control arms were 42.2 (95% confidence interval [CI], 28.1-87.1) and 48.6 (95% CI, 25.5 to infinity) months, respectively (P = 0.828, log-rank test). Adjuvant IFNα-2b treatment was associated with a significantly higher incidence of leucopenia and thrombocytopenia. Thirty-four (24.8%) of treated patients required dose reduction, and 5 (3.8%) of these patients subsequently withdrew from therapy because of excessive toxicity. Adjuvant IFNα-2b only temporarily suppressed viral replication during treatment period. CONCLUSIONS: In this study, adjuvant IFNα-2b did not reduce the postoperative recurrence of viral hepatitis-related HCC. More potent antiviral therapy deserves to be explored for this patient population. This study is registered at ClinicalTrials.gov and carries the identifier NCT00149565.

Surgical anatomy of the external branch of the superior laryngeal nerve in Chinese adults and its clinical applications.

BACKGROUND: The purpose of this study was to determine the anatomic features of the external branch of the superior laryngeal nerve (EBSLN) in Chinese adults. METHODS: We analyzed the anatomic distribution of the 86 EBSLNs in 43 cadavers. RESULTS: The incidences of the EBSLN in the thyroid area were 94.2% and 91.3% on the right and left sides, respectively. In accord with the Cernea classification, type 1 was 16.2%, type2a was 39.5%, and type 2 was 38.3%. There were no significant differences between the right and the left side. The high-risk position of the EBSLN was 77.8%. CONCLUSIONS: The inferior cornu of the thyroid cartilage was a reliable landmark in identifying the external branch of superior laryngeal nerve. Racial variations between the white and the Chinese should be taken into consideration for an explanation of the differences.

Surgical anatomy of the gastroduodenal artery in Chinese adults and its clinical applications.

BACKGROUND/AIMS: Hemorrhage occurs in 15-25% of duodenal ulcers, mostly on the posterior wall of the proximal duodenum. Erosion of the gastroduodenal artery is responsible for serious hemorrhages. Therefore, the relationship between bile duct and gastroduodenal artery should be discerned to prevent bile duct injury. METHODOLOGY: Cadavers from 52 Chinese adults (44 males, 8 females) were dissected for the anatomic relationships of the GDA and bile duct. RESULTS: The gastroduodenal artery has many possible origins, with the common hepatic artery (92.3%) the most common. The mean distance between gastroduodenal artery and pylorus was 2.7 cm; arterial length (from its origin) was 1.2 cm. The relationships between gastroduodenal artery and bile duct could be divided into 4 anatomic types according to Prudhomme's classification. We found 22 samples (42%) of Type 1; 10 samples (19%) of Type 2; 14 samples (27%) of Type 3 (in 8 samples of Type 3, there was about 8mm thickness of pancreatic tissue between the artery and the bile duct); 6 samples (12%) of Type 4. In 12 cases (24%) there was no interposed pancreatic tissue. CONCLUSIONS: These anatomic variations could lead to injury during surgical intervention. Our study provides detailed information about anatomic variability in Chinese adults that may help avoid such injury to the common bile duct during duodenal bleeding hemostasis.

Malignant solid and pseudopapillary tumor of the pancreas--clinicohistological, immunohistochemical, and flow cytometric evaluation.

BACKGROUND/AIMS: Solid and pseudopapillary tumor of the pancreas is a benign and low malignant potential tumor. Prognosis is good after surgical resection but its malignant potential is usually defined after metastasis. We compared benign and malignant cases with clinicopathological, immunohistochemical and DNA flow cytometric studies. METHODOLOGY: From January 1991 to July 2004, seven patients were found to have solid and pseudopapillary tumor of the pancreas at Taipei Veterans General Hospital. The paraffin sections were reevaluated with hematoxylin & eosin stain, immunohistochemical stains, and DNA flow cytometric studies. RESULTS: It included 6 benign and one malignant case. The progesterone receptor, vimentin, neuron-specific enolase, and chromogranin A showed diffused positive stain in all cases. Estrogen receptor and P53 stain were negative in all 7 patients. Synaptophysin stain was negative in 6 no recurrence patients, but was positive only in the patient who suffered from recurrence. DNA flow cytometry showed diploid results in six non-malignant tumors. In the malignant patient, the tumor in the first operation showed diploid result, but tumors in second and third operations showed aneuploidy. CONCLUSIONS: Solid and pseudopapillary tumor of the pancreas should be considered as a potentially malignant disease in all patients and regular follow-up is mandatory.

Interval appendectomy after conservative treatment of an appendiceal mass.

INTRODUCTION: The purpose of this study was to clarify the role of interval appendectomy after conservative treatment of an appendiceal mass. METHODS: From January 1998 to December 2003, patients with an appendiceal mass who received conservative treatment at the Taipei Veterans General Hospital were studied retrospectively. Data on demographics, rate of appendicitis recurrence, duration of hospital stay, and complication rate were collected and analyzed. RESULTS: A total of 165 patients were included (89 males, 76 females). The mean age was 53.6 years (range 7-89 years). The rate of appendicitis recurrence after conservative treatment was 25.5%; most recurred within 6 months after discharge (83.3%). The benefit of preventing recurrence is less than 16% if interval appendectomy is performed 6 weeks after discharge and less than 10% if it is done 12 weeks later. The complication rate of appendectomy performed before or after recurrence was 10% in both groups. The duration of the second hospital stay for patients who underwent interval appendectomy before or after recurrence was 4.43 +/- 3.32 vs. 6.75 +/- 5.73 days (P = 0.023). Of the 165 patients, 17 (10.3%) had their diagnosis changed after survey or surgery, and 5 (3.03%) were found to have colon cancer upon follow-up. CONCLUSIONS: Patients who recovered from conservative treatment of an appendiceal mass should undergo colonoscopy or barium enema to detect any underlying diseases and to rule out coexistent colorectal cancer. Routine interval appendectomy benefits less than 20% of patients.

Watchful waiting versus interval appendectomy for patients who recovered from acute appendicitis with tumor formation: a cost-effectiveness analysis.

BACKGROUND: Interval appendectomy after conservative treatment of appendicitis with tumor formation remains controversial. The purpose of this study was to evaluate the efficacy of interval appendectomy based on a cost-effectiveness analysis. METHODS: This was a retrospective study including appendicitis patients with tumor formation who received conservative treatment at first admission to Taipei Veterans General Hospital between January 1998 and December 2003. Demographic data, rate of recurrent appendicitis, and medical costs were analyzed. RESULTS: Of the 165 patients, 1 died after an acute myocardial infarction. The rate of recurrence of appendicitis after conservative treatment was 25.5%. The median cost of follow-up after conservative treatment was NT24,344 dollars. The median cost of interval appendectomy was NT47,746 dollars. The median cost of appendectomy after recurrent appendicitis was NT62,135 dollars. Routine interval appendectomy in all 164 patients would have cost NT7,830,344 dollars. The follow-up protocol with appendectomy after recurrence cost NT5,655,220 dollars. An additional NT2,175,124 dollars (38%) would have been needed for routine interval appendectomy compared with the follow-up policy, an extra NT13,263 dollars per person. CONCLUSION: Routine interval appendectomy would increase the cost per patient by 38% compared with follow-up and appendectomy after recurrence. Routine interval appendectomy is not a cost-effective intervention.

Acute appendicitis in patients with acquired immunodeficiency syndrome.

BACKGROUND: We report our experience with patients who had acquired immunodeficiency syndrome (AIDS) and who presented with signs and symptoms suggesting acute appendicitis. METHODS: Observational data are documented for 9 patients with AIDS who underwent surgery for acute appendicitis. RESULTS: Of the 9 patients, 6 (66.7%) had acute appendicitis without perforation, while the other 3 (33.3%) had perforated appendicitis. An elevated preoperative temperature was found in 4 patients without perforation (66.7%), and in 1 patient with perforation (33.3%). An elevated white blood cell count was found in all 6 patients without perforation (100%), but in none with perforation (0%). The mean interval from surgical referral to laparotomy was 61.1 hours, the mean hospital stay was 9.3 days, and the perioperative mortality rate was 22.2%. CONCLUSION: Our experience should alert emergency medical staff who care for AIDS patients to the need for early diagnosis and prompt surgical treatment of appendicitis.

The anatomical variations of the palmar cutaneous branch of the median nerve in Chinese adults.

BACKGROUND: In a detailed analysis of the palmar cutaneous branch of median nerve (PCN) in the Chinese adults, we tried to evaluate its anatomic variation and clinical significance. METHODS: Observations were described in all the 60 specimens of the PCN at the wrist. RESULTS: The PCN was present in all 60 specimens and in most cases (88.3%) it originated from the radial side of the median nerve and the average length from the palmaris longus was 1.4 cm; ulnarward (11.7%); only 5 cases (4.1%) were located at ulnar side and extended beyond the palmaris longus, the average distance being 0.3 cm. Its mean point of origin was 3.2 cm proximal to the distal wrist crease and the variations of the PCN in Lanz classification were: group 0 (31.7%), group 1 (40%), group 2 (15%), group 3 (0%) and group 4 (13.3%). CONCLUSIONS: Longitudinal incision located 1 cm on the ulnar side from palmaris longus could avoid injury to the PCN during decompression for carpal tunnel syndrome.

Applied anatomy of the genital branch of the genitofemoral nerve in open inguinal herniorrhaphy.

OBJECTIVE: To record the anatomical variations and clinical importance of the genital branch of the genitofemoral nerve in the inguinal canal. DESIGN: Neuropathology study. SETTING: General hospital, Taiwan. SUBJECTS: 58 cadavers. INTERVENTIONS: 116 dissections findings of the genitofemoral nerve in the inguinal canal. MAIN OUTCOME MEASURES: Anatomical variations. RESULTS: All the genital branches passed through the ventral aspect of the internal ring. Almost all these branches entered the ring and continued within the spermatic cord between the fibres of the cremaster and the internal spermatic fascia. In 59% the nerve was related to the inferior fibres and in 38% it was in relation to the lateral or medial fibres. In only 3% did the genital branch run outside the spermatic cord. CONCLUSION: To avoid damage to the genital branch of the genitofemoral nerve, suturing should be done over the dorsal aspect of the internal ring. The cremaster should be incised longitudinal rather than transversely and the genital branch of the genitofemoral nerve should be identified before repair of the posterior wall.