Is there a place for gastroenterostomy in patients with advanced cancer of the head of the pancreas?

There remains doubt about the need for gastroenterostomy in patients with advanced cancer of the pancreatic head, performed either prophylactically or when passage of food becomes impossible. The records of 142 patients admitted for advanced pancreatic cancer to the Erasmus University Hospital over a period of 11 years were reviewed. We concentrated especially on the pre- and postoperative intake of food in cases involving gastroenterostomy and the morbidity and mortality associated with abdominal surgery in these patients. Of 129 patients without symptoms of gastric outlet obstruction at the time of diagnosis, 31 underwent prophylactic gastroenterostomy. The procedure did not prevent gastric outlet obstruction in 4 patients. Of the remaining 98 patients, 15 developed gastric outlet obstruction. Cox proportional hazards analysis showed no significant difference in the interval to the occurrence of a symptomatic obstruction between these two groups, taking into account other covariables. Postoperative complications and mortality regarding a gastroenterostomy were high, ranging from 9% to 41% and 11% to 33%, respectively. Our results do not indicate that prophylactic gastroenterostomy may significantly prevent future gastric outlet obstruction; therefore, as it also increases morbidity, it should not be performed. A gastroenterostomy to relieve symptoms should be considered carefully, as the success rate is low and is accompanied by a considerable incidence of morbidity and mortality.

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Resumen Persiste la duda sobre la necesidad de practicar gastroenterostomía en pacientes con cáncer avanzado de la cabeza del páncreas, así sea profiláctica o en presencia de obstrucción al paso de los alimentos. Se revisaron las historias de 142 pacientes con cáncer avanzado de la cabeza del páncreas en el Hospital de la Universidad de Erasmo observados en un periodo de 11 años. El estudio se concentré especialmente sobre la ingesta pre y postoperatoria de alimentos en los pacientos con gastroenterostomía y en la morbilidad y mortalidad asociada con la cirugía abdominal. De 129 pacientes libres de síntomas de obstrucción en el momento del diagnóstico, 31 fueron sometidos a gastroenterostomía profiláctica; el procedimiento no logró prevenir la obstrucción gástrica en 4 casos. De los 98 pacientes restantes, 15 desarrollaron obstrucción gástrico. El análisis proporcional de Cox no demostró diferencia significativa en el intervalo transcurrido hasta la aparición de los sintomas entre los dos grupos, tomando en consideración diversas variables. Las tasas de complicaciones y de mortalidad postoperatoria en relación con la gastroenterostomía fueron elevadas, 9–41% y 11–33%, respectivamente. Nuestros resultados no indican que la gastroenterostomía profiláctica pueda prevenir la obstrucción gástrica y, por cuanto incrementa la morbilidad, no debe ser realizada. La gastroenterostomía por razones de sintomatologia debe ser cuidadosamente considerada, puesto que la tasa de éxito es baja y se acompana de considerable morbilidad y mortalidad.

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Résumé Réaliser une gastroentérostomie de faÇon prophylactique ou seulement lorsque l'alimentation devient impossible chez un patient ayant un cancer de la tÊte du pancréas reste une question sans réponse. Les dossiers de 142 patients ayant un cancer avancé de la tÊte du pancréas, observés à l'HÔpital Universitaire Erasmus en l'espace de 11 ans, ont été revus. Nous avons noté la possibilité d'alimentation en périodes préet postopératoire ainsi que la morbidité et mortalité en rapport avec la chirurgie chez ces patients. Des 129 patients n'ayant pas de symptÔmes d'obstruction postpylorique au moment du diagnostic, 31 ont eu une gastroentérostomie à titre prophylactique. Cette intervention n'a pu prévenir l'obstruction chez 4 de ces patients. Des 98 autres patients, 15 ont développé une obstruction postpylorique. Une analyse multifactorielle selon le modèle de Cox n'a pu démontrer de différence significative entre les deux groupes pour l'intervalle entre le moment du diagnostic et la survenue de l'obstruction. Le taux de complications et de décès postopératoires après gastroentérostomie était élevée, variant respectivement entre 9% et 41% et 11% et 33%. Nos résultats indiquent que la gastroentérostomie à titre prophylactique ne prévient pas la survenue d'une obstruction postpylorique mais qu'elle accroÎt la morbidité. Dans ces conditions, la gastroentérostomie ne devrait Être réalisée qu'en cas d'obstruction symptomatique, mais en sachant qu'elle n'est pas toujours couronnée de succès et que les taux de mortalité et de morbidité ne sont pas nuls.

     

Expression of cell-matrix molecules and integrin receptors in human liver grafts during chronic rejection

Abstract The inflammatory response of immune cells to target cells and cell-matrix molecules is regulated by several receptor-ligand molecules. As fibrosis develops in ongoing chronic rejection after liver transplantation, it is of interest to analyze patterns of integrin receptors and cell-matrix molecules in order to study the relation between immune cells and the stromal and parenchymal cells. In the present study, we demonstrated the expression of these molecules in chronic rejected human liver grafts using immunohistochemical techniques. The results showed a differential expression and induction of integrin receptors and cell-matrix molecules on resident liver cells, especially on sinusoids, reflecting a state of chronic inflammation and a specific interaction between integrin receptors and cell-matrix molecules. The patterns of induced integrin receptors on graft-infiltrating cells was closely related to the local production of cell-matrix molecules and reflected the final sequence of a stepwise progress of the inflammatory reaction.     

Gallstone recurrence after direct contact dissolution with methyltert-butyl ether

To determine the rate and characteristics of gallstone recurrence after direct contact dissolution with methyltert-butyl ether, 60 consecutive patients were followed for up to 4.5 years (median 2.2 years) after complete disappearance of all stone residues and debris and cessation of adjuvant bile acid therapy. Initial gallstones had been multiple in all but four patients. Twenty-eight of the 60 patients developed recurrent gallstones. The cumulative risk of gallstone recurrence (actuarial analysis) was 23±6%, 34±7%, 55±8%, and 70±9% at one, two, three, and four years, respectively. The recurrent stones were usually multiple and small (6±4 mm). Gallstone recurrence was associated with recurrent biliary pain in two patients, one of whom developed acute cholecystitis. Recurrent stones were cleared completely by bile acid medication with or without shock-wave lithotripsy in 61±15% of patients at one year (actuarial analysis). In conclusion, gallstone recurrence after successful contact dissolution of multiple stones with methyltert-butyl ether has to be expected in a high percentage of patients. Most patients, however, remain free of biliary pain during long-term follow-up.     

禁食疗法初步应用的不良反应分析

禁食疗法是在有限的时间内,机体利用自身储存的能量和物质,在保证人体正常生命活动需要的前提下,除了可以适量饮水和特别提供低糖、无脂和无蛋白营养液外,禁食日常食物,达到预防治疗某些疾病的一种方法.在欧美,禁食疗法作为一种成熟、常规的治疗方法,可治疗脂肪肝、高血压病、脂质紊乱、肥胖、2型糖尿病等多种疾病.     

Physiology and pathobiology of the microcirculation

The delivery of nutrients to the tissues and the removal of waste products from the tissues is made possible by forcing a stream of blood through an arborizing network of microscopic blood vessels that comprise the microcirculation. The rapidity of the flow stream and, therefore, the rate of nutrient delivery to the tissue, is regulated by the automatic adjustment of the caliber of the precapillary arterioles that serve as the primary loci of vascular resistance. Exchange between the blood stream and the parenchymal cells occurs in capillaries and pericytic venules. Pathologic processes such as inflammation, diabetes, ischemia, and hypertension are characterized by abnormalities in microvascular structure and function.     

Cross-cultural adaptation and reliability of the Arabic version of Children’s Hand-use Experience Questionnaire (CHEQ)

BackgroundValidated outcome measures are essential for assessment and treatment of children with disabilities. The Children’s Hand-use Experience Questionnaire (CHEQ) was developed and validated for use in Western countries for children with unilateral hand dysfunction. This study aimed to perform a cross-cultural adaptation and investigate reliability for the Arabic CHEQ.MethodsTranslation and cross-cultural adaptation were performed in four phases: (i) forward-translation and reconciliation with feedback from parents and typically developing children from Jordan (n = 14); (ii) backward-translation and review; (iii) cognitive debriefing with parents and/or their children with unilateral hand dysfunction (n = 17); and (iv) review and proofreading. In the psychometric analyses, 161 children from Jordan (mean age [SD] 10y 8 m [5y 8 m]; 88 males) participated. Internal consistency was evaluated with Cronbach’s alpha. Test-retest reliability was evaluated in 39 children with intraclass correlation coefficient (ICC) and weighted kappa (κ).ResultsSynonyms of four words were added to accommodate for different Arabic dialects. On average, 93% of children with unilateral hand dysfunction and their parents understood the CHEQ items. One response alternative, ‘Get help’, to the opening question was unclear for 70% of the respondents and need further explanation. Two items about using a knife and fork were difficult to comprehend and culturally irrelevant. High internal consistency was demonstrated (Cronbach’s alphas 0.94- 0.97) and moderate to excellent ICC (0.77–0.93). For 18 individual items, κ indicated poor to good agreement (κ between 0.28 and 0.66).ConclusionsAfter the suggested minor adjustments, the Arabic CHEQ will be comprehensible, culturally relevant and reliable for assessing children with unilateral hand dysfunction in Jordan.     

Economics and cigarettes

Economic facts on cigarette consumption and production are summarized, and the health consequences of cigarette smoking are reviewed. The magnitude and distribution of these health consequences among the population are discussed in economic terms, that is, in an "accounting framework" comprising such disparate elements as lost lives, lost livelihoods, pain, fear, discomfort, medical costs, excise taxes, and the costs of regulating smoking behaviors. The importance of these factors and their potential influence on public policy and individual behavior are considered. Difficulties include assigning a monetary value to an expected extension of life, the "voluntary" nature of smoking (even though most smokers wish they could quit), deciding what to include as economic consequences of smoking, and the attribution to smoking of some share of the costs for diseases known to be affected by smoking. "Transfers," or purely financial transactions, in contrast to expenditures for goods and services, are explained as one assessment component of the economic impact of smoking-related diseases. The issue of the economic benefit to the United States as a whole and to the population engaged in the cigarette industry, because of the earnings and employment generated by cigarette purchases, is examined, as is the issue of cigarette purchases as a significant source of federal and state revenue.     

Mastopathia cystica chronica im Hinblick auf krebsige Entartung

Zusammenfassung Als Beitrag zur Frage eines Überganges der Cystenmamma in Carcinom werden in der vorliegenden Arbeit 381 Fälle mit klinisch einwandfrei cystischen Veränderungen der Brustdrüse aus der Chirurgischen Universitätsklinik Jena der Jahre 1920–1946 zusammengestellt unddie histologisch bewiesenen Fälle (169) zu Besprechungen herangezogen. Dabei zeigte sich, daßin 7,1% der Fälle die Mastopathia cystica einenKrebs oder krebsartige Veränderungen aufweist. Nach diesem Häufigkeitsverhältnis können wir diese Erkrankung nicht als Präcarcinomatose oder als Erkrankung, auf deren Boden sich ein Krebs prädisponiert entwickelt, ansprechen. Die Tatsache aber allein der Krebsentwicklung mahnt zur Vorsicht und weist die damit sich ergebende Behandlung, die kurz aufgezeichnet wird. Nachuntersuchungen und Anfragen bestätigen das gefundene Ergebnis.     

Fehlerrechnung bei Biologischen Messungen

Ohne Zusammenfassung