Management of cholelithiasis in combination with cardiovascular surgery

A retrospective review of the perioperative management of patients with cardiovascular surgical disorders and cholelithiasis was conducted, and the surgical strategies employed are discussed. Between 1988 and 1998, 18 patients having cardiovascular surgical disorders underwent cholecystectomy. These patients were divided into three groups: group I, given a one-stage operation (n = 9); group II, given a two-stage operation (n = 3); and group III, given cholecystectomy during follow-up after cardiovascular surgery (n = 6). In group I, a median laparotomy was adopted for patients with an abdominal aortic aneurysm (AAA) to allow both disorders to be treated through the same incision, whereas a right subcostal approach was employed to separate the incisions for patients who underwent cardiac operations. In group II, one patient underwent cholecystectomy before cardiac surgery, and two patients underwent cholecystectomy for postoperative cholecystitis after cardiovascular operations. One patient from group II and all from group III were on preoperative anticoagulant therapy, two of whom underwent laparoscopic cholecystectomy. No fatal complications such as prosthetic infection, intraperitoneal hemorrhage, or cerebral attack were encountered. In conclusion, we consider that performing cholecystectomy during AAA repair may be safe and prevents the risk of postoperative cholecystitis; it is preferable to treat cholelithiasis coexisting with cardiac disorders concomitantly with or before cardiac operations; and laparoscopic cholecystectomy can be safely performed under anticoagulant therapy. Received: March 1, 1999 / Accepted: March 24, 2000     

Tuberous Sclerosis in a 19-Week Fetus: Immunohistochemical and Molecular Study of Hamartin and Tuberin

Tuberous sclerosis complex (TSC) is a genetically heterogeneous disease caused by mutations of TSC1 or TSC2 genes. It involves multiple organ systems resulting in mild to lethal hamartoma formation due to gene mutation in the germ line and loss of heterozygosity (LOH) in somatic cells. Hamartin (TSC1) and tuberin (TSC2) are expressed broadly. However, little is known about tissue susceptibility to hamartomas when equal or similar amounts of TSC gene expression are present. In this study, we present a 19-week gestational age fetus with pathological features of TSC, which was confirmed by finding LOH of TSC2 in a cardiac rhabdomyoma. Developmental expression of hamartin and tuberin in the TSC fetus, an age-matched non-TSC fetus, and a 26-week gestational age non-TSC fetus were analyzed by immunohistochemistry. We found that in addition to the differential expression of the TSC genes in some normal tissues compared with that in the TSC-affected fetus, the cellular localization and distribution of hamartin and tuberin were dramatically different in different tissues. In general, hamartin and tuberin are mainly expressed in epithelial cells, myocytes, and neural tissues. By comparing the incidence of the hamartomas in early childhood and gene expression in tissues, it appears that tissues with co-expression of hamartin and tuberin are prone to a higher incidence of hamartomas than those expressing only one protein, or two proteins but in different patterns of cellular localization.     

An extremely rare case of adenoma malignum with large cystic tumor which resulted in urinary obstruction.

BACKGROUND: Adenoma malignum is a rare variant of uterine cervical adenocarcinoma. In this report, we present an extremely rare case of adenoma malignum with large cystic lesions (diameter of more than 10 cm) which elicited urinary obstruction. CASE: A 46-year-old Japanese woman, gravida 2, para 2, visited her local doctor for urinary obstruction, and 950 ml of urine was catheterized. Since abdominal ultrasonography suggested ovarian cystic tumor, she was referred to our hospital. Vaginal examination and ultrasonography revealed a child-head-sized multilocular cystic tumor in the Douglas pouch. Abnormal massive discharge was not observed at the time of admission. During preoperative examination, massive mucinous discharge suddenly occurred without pain. The cystic tumor size shrank from x10 cm to x4.0 cm in maximum diameter. Emergent abdominal hysterectomy was performed. The operative findings revealed collapsed cystic lesions in the posterior wall of the uterine cervix. Microscopically, the multiple cysts in the cervix were composed of high columnar and slightly atypical monolayer cells similar to endocervical mucinous cells. Vaginal invasion was also partly observed. Most of the tumor cells were positive for carcinoembryonic antigen and HIK1083 in their cytoplasm, and scattered chromogranin A-positive endocrine cells were also found in tumor glands, corresponding to minimal deviation adenocarcinoma (adenoma malignum). These lesions were diagnosed as FIGO stage IIa. The patient is disease-free 2 years after primary surgery. CONCLUSION: In the present report, we describe an extremely rare case of adenoma malignum with large cystic lesions reaching a diameter of 12 cm which resulted in urinary obstruction.     

An oral anticancer drug, TS-1, enabled a patient with advanced gastric cancer with Virchow's metastasis to receive curative resection

We encountered a patient with advanced gastric cancer, with Virchow's lymph node metastasis, who subsequently underwent curative resection after neoadjuvant chemotherapy with the newly developed oral anticancer drug, TS-1. The patient was a 67-year-old woman who had a type 2 tumor in the middle third of the stomach, and Virchow's lymph node metastasis, which was diagnosed by fine-needle aspiration cytology; she also had swollen paraaortic lymph nodes. Curative resection was considered impossible, and TS-1 (100 mg/day) was administered for 28 days in one course, mainly in the outpatient clinic. Although grade 2 stomatitis interrupted the therapy on day 21 of the second course and on day 7 of the third course, the type 2 tumor showed marked remission (partial response; PR) and the metastasis in the Virchow's and paraaortic lymph nodes had completely disappeared after the third course (complete response; CR). Eleven weeks after the completion of the TS-1 treatment, total gastric resection with D3 lymph node dissection was performed. Histopathological examination revealed tumor involvement only in the mucosal and submucosal layers of the stomach and the no. 4d lymph node. Most of the tumor was replaced with fibrosis with granulomatous change in the muscularis propria of the stomach and in the no. 3, no. 6, and no. 7 lymph nodes. This may be the first report of a patient with advanced gastric cancer with Virchow's lymph node metastasis who successfully received curative resection following neoadjuvant chemotherapy with a single oral anticancer drug. Received: August 7, 2001 / Accepted: January 28, 2002     

Enhanced antitumor effect of ultrasound in the presence of piroxicam in a mouse air pouch model.

The antitumor effects of piroxicam, a non-steroidal anti-inflammatory drug, on sarcoma 180 cells under ultrasonic irradiation were examined in a mouse air pouch model. When piroxicam was added to sarcoma 180 suspension under ultrasound irradiation (2 MHz, 10 W, 120 s), the mortality rate of tumor cells immediately after the irradiation and the survival rate of mice were significantly higher than those when ultrasound alone was applied, and these effects of piroxicam were dose-dependent. When D-mannitol was used with piroxicam, the mortality rate of the tumors cells after the irradiation was comparable with that when piroxicam alone was applied, but when L-histidine was used concurrently, the antitumor effect was significantly lower than that when piroxicam alone was applied. Histological examinations one week after the ultrasound irradiation in the presence of piroxicam showed sparse tumor tissue in the air pouch and normal appearance of the air pouch and surrounding tissue. The findings suggest that piroxicam enhances the anti-tumor effects of ultrasound in vivo by increasing the production of singlet oxygen without damage to tissue surrounding the tumor.     

Multiplexed analysis of post-PCR fluorescence-labeled microsatellite alleles and statistical evaluation of their imbalance in brain tumors.

Detection of the loss of chromosomal regions in cancerous tissues has diagnostic and prognostic relevance, and the development of a reliable and cost-effective technique for this is clinically important. Here we present an efficient technique for quantitative detection of microsatellite alleles, using a post-PCR fluorescence-labeling procedure and multiplexed analysis. We also present a new statistical method for the interpretation of the data that permits reliable and sensitive evaluation of the allelic status of sampled DNA. A high-resolution analysis of allelic imbalance on chromosomes 1p, 10 and 19q in 28 glioma samples of various types using this method revealed that allelic imbalances are more frequent than have been reported, suggesting the diagnostic value of this method in examining the genetic profiles of gliomas.     

Hepatitis B and C viruses infection, lifestyle and genetic polymorphisms as risk factors for hepatocellular carcinoma in Haimen, China.

A case-control study was carried out to investigate the impact of factors including virus infection, aflatoxin B1, microcystins, smoking/drinking and dietary habits as well as genetic polymorphisms of aldehyde dehydrogenase 2 (ALDH2) and cytochrome P4502E1 (CYP2E1), on susceptibility to hepatocellular carcinoma (HCC) in Haimen, China. A total of 248 patients with HCC and 248 sex-, age- and residence-matched population-based controls were recruited into the study. Virus infection, and ALDH2 and CYP2E1 gene polymorphisms were assessed in 134 paired cases and controls. By univariate analysis, hepatitis B virus (HBV) infection (odds ratio [OR]=9.75; 95% confidence interval [CI]=4.71-20.2), history of intravenous injection (OR=1.50; 95%CI=1.02-2.22), average income (OR=0.63; 95%CI=0.43-0.92), frequent intake of foods rich in protein, e.g., egg (OR=0.6; 95%CI=0.42-0.87), chicken (OR=0.53; 95%CI=0.35-0.79), pork (OR=0.67; 95%CI=0.46-0.98) and fresh fish (OR=0.58; 95%CI=0.39-0.87) significantly differed between cases and controls. However, peanut intake (OR=0.66; 95%CI=0.43-1.01), source of drinking water, including tap (OR=1.33; 95%CI=0.81-2.20), deep well (OR=0.94; 95%CI=0.56-1.55), shallow well (OR=0.85; 95%CI=0.55=1.30), river (OR=0.95; 95%CI=0.65-1.38), ditch (OR=1.09; 95%CI=0.76-1.55) and pond water (OR=1.0; 95%CI=0.14-7.10) were not significantly associated with risk. Univariate analysis also indicated that the 1-1 genotype of ALDH2 (OR=1.38; 95%CI=0.86-2.23) as well as the Pst1- and Rsa1-digested c1/c1 genotype of CYP2E1 (OR=1.36; 95%CI=0.81-2.28), was slightly more frequent in the case group. On multivariate analysis, HBV infection (OR=13.9; 95%CI=5.78-33.6) and history of intravenous injection (OR=2.72; 95%CI=1.24-6.00) were still associated with significantly increased risk of HCC, while frequent intake of fresh fish (OR=0.32; 95%CI=0.12-0.86) decreased this risk. These findings suggest that whereas peanut intake, water sources as well as genetic polymorphisms in ALDH2 and CYP2E1 do not significantly correlate with the risk of HCC, HBV infection is a main risk factor, and dietary items rich in protein, especially fresh fish, might protect against the risk of HCC in Haimen, China.     

Effects of antioxidant 1-O-hexyl-2,3,5-trimethylhydroquinone or ascorbic acid on carcinogenesis induced by administration of aminopyrine and sodium nitrite in a rat multi-organ carcinogenesis model.

The effect of antioxidant, 0.25% 1-O-hexyl-2,3,5-trimethylhydroquinone (HTHQ) or 0.25% ascorbic acid (AsA), on carcinogenesis induced by administration of 0.05% aminopyrine (AP) and 0.05% sodium nitrite (NaNO2), was examined using a rat multi-organ carcinogenesis model. Groups of twenty F344 male rats were treated sequentially with an initiation regimen of N-diethylnitrosamine, N-methyl-N-nitrosourea, N-butyl-N-(4-hydroxybutyl)nitrosamine, N,N'-dimethylhydrazine and 2,2'-dihydroxy-di-n-propylnitrosamine during the first 4 weeks, followed by AP+NaNO2, AP+NaNO2+HTHQ, AP+NaNO2+AsA, NaNO2+HTHQ, NaNO2+AsA, each of the individual chemicals alone or basal diet and tap water as a control. All surviving animals were killed at week 28, and major organs were examined histopathologically for development of preneoplastic and neoplastic lesions. In the AP+NaNO2 group, the incidences of hepatocellular adenomas and hemangiosarcomas were 95% and 35%, respectively. When HTHQ or AsA was simultaneously administered, the incidences decreased to 58% and 11%, or to 80% and 15%, respectively. On the other hand, in the AP+NaNO2 group and the NaNO2-alone group, when HTHQ, but not AsA, was simultaneously administered, the incidence of carcinomas in the forestomach significantly increased. The results suggest that HTHQ can prevent tumor production induced by AP and NaNO2 more effectively than AsA. On the other hand, an enhancing or possible carcinogenic effect of simultaneous administration of HTHQ and NaNO2 only on the forestomach is suggested, while simultaneous treatment with the same dose of AsA and NaNO2 may not be carcinogenic to the forestomach or other organs.     

Suppression of Lung Metastasis by Aspirin but Not Indomethacin in an in vivo Model of Chemically Induced Hepatocellular Carcinoma

To examine the effect of non-steroidal anti-inflammatory drugs on metastasis formation, aspirin (ASP, 0.5% in diet) and indomethacin (IM, 0.005% in drinking water) were applied to an in vivo highly metastatic rat hepatocellular carcinoma (HCC) model in F344 male rats. Administration for 8 weeks after induction of highly metastatic HCC by sequential treatment with diethylnitrosamine and N-nitrosomorpholine did not cause any significant change in survival rate or body weight. Multiplicity of HCC in the liver increased during ASP or IM treatment without any significant histological alteration. Although absent in the rats killed at the end of the period of carcinogen exposure, lung metastasis at the end of the experiment was found in 100%, 89% and 100% of rats in the control, ASP and IM groups, respectively. Degree of metastasis was classified into three groups according to the number of metastatic nodules, i.e., slight (1–5 nodules), moderate (6–50) and severe (more than 51), which amounted to 0%, 43% and 57% in the control group. ASP significantly reduced the degree of metastasis, the incidences being 33%, 44%, and 11%, respectively, whereas IM was without significant influence. Both agents suppressed cell proliferation in HCCs, without any alteration of pan-cadherin expression. However, expression in HCC of mRNAs for intercellular adhesion molecule-1 and vascular cell adhesion molecule-1, both of which are considered to play key roles in attachment of cancer cells to the endothelium, was significantly suppressed by ASP. Thus, the present study demonstrated that ASP, but not IM, has the potential to inhibit lung metastasis of rat HCC in vivo , possibly via reduced attachment of tumor cells to the vascular endothelium. Moreover, these data indicate this in vivo model for induction of rat highly metastatic HCC to be a useful tool for the assessment of the efficacy of therapeutic treatments to block metastasis formation.     

Reduction of blood loss using tranexamic acid in total knee and hip arthroplasties

There have been several attempts to reduce postoperative blood loss in patients undergoing total arthroplasty. Benoni et al. reported the usefulness of tranexamic acid in total knee arthroplasty (TKA). We investigated its effect in TKA and total hip arthroplasty (THA). Blood loss was significantly reduced in patients given tranexamic acid in both the TKA and THA groups, and no severe complications, such as venous or pulmonary thrombosis, were noted in any of the patients who received the agent. Administration of tranexamic acid seems to be useful for reducing postoperative blood loss in TKA and THA. Received: 26 May 1999