Neosurugatoxin: CNS acetylcholine receptors and luteinizing hormone secretion in ovariectomized rats

Neosurugatoxin, a neurotoxin isolated from the Japanese ivory shell, inhibits ganglionic nicotinic acetylcholine receptors but not skeletal muscle nicotinic acetylcholine receptors. It has also been reported to inhibit (3H) L-nicotine binding to high-affinity agonist acetylcholine receptors in rat brain membrane preparations. In the present study, 10(-5) M neosurugatoxin inhibited the in vitro binding of (3H) L-nicotine to the medial habenular nucleus of frozen, coronal sections of rat brain as did 10(-5) M cytisine or nicotine and 10(-4) M dihydro-beta-erythroidine. Neosurugatoxin did not inhibit (125I) alpha-bungarotoxin binding to hypothalamic synaptosomal preparations or to frozen, coronal sections of rat brain. Injection of neosurugatoxin into the third ventricles of ovariectomized rats resulted in a significant decrease in the frequency of pulses of luteinizing hormone (LH) secretion but had no effect on the amplitude of pulses. A low dose (1 microgram/injection) of the nicotinic acetylcholine agent cytisine injected into the third ventricle had no significant effect on pulsatile LH secretion. Coadministration of cytisine could block the inhibitory effect of neosurugatoxin on LH secretion. It is suggested that neosurugatoxin is a useful antagonist to study the biological roles of a specific subclass of nicotinic acetylcholine receptors in mammalian brain and reproductive neuroendocrine functions.     

Extension of the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer: long-term results

OBJECTIVE: To evaluate retrospectively the long-term results of an approach consisting of performing surgery in every patient in whom radical removal of all metastatic disease was technically feasible. SUMMARY BACKGROUND DATA: The indications for surgical resection for liver metastases from colorectal cancer remain controversial. Several clinical risk factors have been reported to influence survival. METHODS: Between March 1980 and December 1997, 235 patients underwent hepatic resection for metastatic colorectal cancer. Survival rates and disease-free survival as a function of clinical and pathologic determinants were examined retrospectively with univariate and multivariate analyses. RESULTS: The overall 3-, 5-, 10-, and 15-year survival rates were 51%, 38%, 26%, and 24%, respectively. The stage of the primary tumor, lymph node metastasis, and multiple nodules were significantly associated with a poor prognosis in both univariate and multivariate analyses. Disease-free survival was significantly influenced by lymph node metastasis, a short interval between treatment of the primary and metastatic tumors, and a high preoperative level of carcinoembryonic antigen. The 10-year survival rate of patients with four or more nodules (29%) was better than that of patients with two or three nodules (16%), and similar to that of patients with a solitary lesion (32%). CONCLUSIONS: Surgical resection is useful for treating liver metastases from colorectal cancer. Although multiple metastases significantly impaired the prognosis, the life expectancy of patients with four or more nodules mandates removal.     

Surgical treatment of intrahepatic cholangiocarcinoma: four patients surviving more than five years.

BACKGROUND. To find the rational surgical strategy for the treatment of intrahepatic cholangiocarcinoma (ICC), clinical features of ICC were studied in 20 patients who underwent hepatic resection in the National Cancer Center Hospital from 1980 to 1990. METHODS. According to the morphologic pattern, we classified the ICCs into two subcategories, mass-forming and infiltrating, which correlated with their biologic behavior. RESULTS. Of 10 patients who underwent hepatectomy for mass-forming ICC, three survived more than 5 years without recurrence. The 1-, 3-, and 5-year survival rates were 59.3%, 44.4%, and 44.4%, respectively. Of 10 patients who underwent hepatectomy for infiltrating ICC, one survived more than 5 years without recurrence. The 1-, 3-, and 5-year survival rates were 72.0%, 27.0%, and 27.0%, respectively. The pathologic findings and recurrences indicated that the salient feature of the mass-forming type was its tendency for intrahepatic metastasis especially near a main lesion, and of the infiltrating type was the infiltrative spread via Glisson's capsule and hilar lymph nodal metastasis. CONCLUSIONS. An anatomic and extensive liver resection should be performed for mass-forming ICC, whereas a hepatectomy with excision of the extrahepatic bile duct and hilar lymph nodal dissection is recommended for infiltrating ICC.     

Selection criteria for simultaneous resection in patients with synchronous liver metastasis

HYPOTHESIS: While simultaneous resection has been shown to be safe and effective in patients with synchronous metastasis, neoadjuvant chemotherapy followed by hepatectomy has gradually gained acceptance for both initially nonresectable metastasis and resectable metastasis. The boundary between these treatments is becoming unclear. We hypothesized that factors associated with colorectal cancer may play an important role in the prognosis of patients with synchronous metastasis and may be useful for identifying patients who can be expected to have adequate results following simultaneous resection. DESIGN: Outcome study. SETTING: Tertiary referral center. PATIENTS: From January 1980 to December 2002, 187 patients underwent curative resection for synchronous liver metastasis from colorectal cancer. One hundred forty-two patients received simultaneous resection, 18 underwent staged resection, and 27 underwent delayed hepatic resection. Twenty-one clinicopathological factors were analyzed, and long-term prognosis was assessed. MAIN OUTCOME MEASURES: Prognostic factors and patient survival. RESULTS: There was no in-hospital death. In a multivariate analysis, the factors that significantly affected the prognosis of synchronous metastasis were 4 or more lymph node metastases around the primary cancer (P<.001) and multiple liver metastases (P = .003). In patients with 3 or fewer lymph node metastases around the primary cancer, the 5-year survival rates of those with 1, 2 to 3, and 4 or more liver metastases were 63%, 33%, and 40%, respectively, but these rates were 15%, 22%, and 0%, respectively, in patients with 4 or more lymph node metastases around the primary cancer. CONCLUSIONS: The results support the application of simultaneous resection in patients with 0 to 3 colorectal lymph node metastases. However, in patients with 4 or more colorectal lymph node metastases, biological selection by neoadjuvant chemotherapy may be more suitable.     

Extended Left Hepatectomy by Severing All Major Hepatic Veins with Reconstruction of the Right Hepatic Vein

Curative liver resection is technically challenging when multiple liver metastases from colon cancer involve the confluence of the three major hepatic veins. We report two cases of successful extended left hemihepatectomy achieved by severing all of the major hepatic veins together with the wall of the inferior vena cava, to resect liver metastases from colon cancer. Reconstruction of the right hepatic vein was done after unroofing the right anterior area of the liver with a direct anastomosis of the right hepatic vein. We did not need to perform total vascular exclusion or portovenous shunting during the liver transection. This simple and safe method can increase the surgical indications for previously unresectable tumors.     

Arterial Reconstruction during Pancreatoduodenectomy in Patients with Celiac Axis Stenosis—Utility of Doppler Ultrasonography

Celiac axis stenosis is found at an incidence of 2%–24% in the general population. During pancreatoduodenectomy in patients with celiac axis stenosis, division of the gastroduodenal artery from the common hepatic artery may cause acute ischemia of the upper abdominal organs, such as the liver, stomach, or spleen. Under these circumstances, the clinical indications of arterial reconstruction remain controversial. Between 1994 and 2003, seven patients with celiac axis stenosis (n = 4) or occlusion (n = 3) underwent pancreatoduodenectomy at our hospital. Arterial reconstruction, including division of the median arcuate ligament, was conducted in two patients; the replaced right hepatic artery was preserved in one patient, and no vascular refinement was undertaken in the remaining four of the seven patients. In two of the four patients without arterial reconstruction or preservation, the serum levels of liver enzymes were markedly elevated (> 800 IU/l) on postoperative day 1, and these patients subsequently developed liver abscesses. Two patients who underwent arterial reconstruction and three patients who showed no decrease in intrahepatic arterial flow under Doppler ultrasonography after clamping of the gastroduodenal artery developed no ischemic complications. Although our experience is limited, when intraoperative Doppler ultrasonography indicates a decrease in the hepatic arterial signals, we believe that reconstruction of the hepatic artery will be necessary to minimize ischemic complications in the liver in patients with celiac axis stenosis.     

A case of complete double aortic arch visualized by transthoracic echocardiography

A case of double aortic arch that was well visualized using transthoracic echocardiography is reported. A 38‐year‐old man underwent transthoracic echocardiography for the evaluation of dyspnea. A suprasternal view of transthoracic echocardiography showed the ascending aorta bifurcate to left and right aortic arches, with blood flow from the ascending aorta to bilateral aortic arches. The diagnosis of right side–dominant double aortic arch was made, and the patient's symptom was conceivably related to compression of the trachea due to a vascular ring. This report indicates the potential usefulness of transthoracic echocardiography for noninvasive detection of double aortic arch in adults.     

Severe hypoproteinemia in a fetus after pleuro-amniotic shunts with double-basket catheters for treatment of chylothorax

The prognosis of a fetus with hydrothorax at mid-trimester is extremely poor. We encountered a fetus who developed bilateral chylothoraxes at 23 weeks of gestation. Bilateral pleuroamniotic shunts with double-basket catheters were successfully installed at 25 weeks of gestation. Hydrothorax did not recur in this fetus. After the shunting, however, polyhydroamnios, fetal hypoproteinemia, and placental edema developed, and the hydrops worsened. The drainage of the fetal pleural effusion into the amniotic cavity was believed to have contributed to these complications. The infant, born at 29 weeks of gestation, died of cardiac failure and pulmonary hypoplasia. Thus, the shunts did not ameliorate the adverse conditions in this patient.     

Successful Radical Surgery for an Undifferentiated Gallbladder Carcinoma with Lymph Node Metastases to the Mesocolon

We report successful radical systematic surgery for an undifferentiatedgallbladder carcinoma with metastasis to the mesocolonic lymphnodes. The patient, a 70-year-old woman, was admitted with abdominalfullness and appetite loss. Imaging modalities revealed a 10-cmtumor originating from the gallbladder and infiltrating boththe liver and transverse colon. As multiple mesocolonic lymphnode metastasis was confirmed on laparotomy, right hemicolectomywith systematic lymph node dissection (D3 resection) was performed,in addition to extended cholecystectomy with partial resectionof segments 4, 5 and 6 of the liver and distal gastrectomy.Histologically, the tumor was diagnosed as an undifferentiatedcarcinoma, and metastases were indentified in the mesocoloniclymph nodes (17/50 nodes) but not in the peri-gallbladder lymphnodes (0/16 nodes). The patient has been recurrence-free for4 years after the operation. This case illustrates that evenif gallbladder cancer infiltrates into adjacent organs withregional lymph node metastasis, it is of value to perform radicalsurgery with systematic lymph node dissection for the involvedorgans.