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Intraductal papillary mucinous neoplasm (IPMN) is premalignant pancreatic lesion. International guidelines offer limited predictors of individual risk. A nomogram to predict individual IPMN malignancy risk was released, with good diagnostic performance based on a large cohort of Asian patients with IPMN. The present study validated a nomogram to predict malignancy risk and invasiveness of IPMN using both Eastern and Western cohorts.Clinicopathological and radiological data from patients who underwent pancreatic resection for IPMN at four centres each in Eastern and Western countries were collected. After excluding patients with missing data for at least one malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum carcinoembryonic antigen and carbohydrate antigen (CA) 19-9 levels, and age).In total, data from 393 patients who fit the criteria were analysed, of whom 265 were from Eastern and 128 from Western institutions. Although mean age, sex, log value of serum CA19-9 level, tumour location, main duct diameter, cyst size and presence of mural nodule differed between the Korean/Japanese, Eastern and Western cohorts, rates of malignancy and invasive cancer did not differ significantly. Areas under the receiver operating characteristic (ROC) curve values for the nomogram predicting malignancy were 0·745 for Eastern, 0·856 for Western and 0·776 for combined cohorts; respective values for the nomogram predicting invasiveness were 0·736, 0·891 and 0·788.External validation of the nomogram showed good performance in predicting cancer in both Eastern and Western patients with IPMN lesions.La neoplasia mucinosa papilar intraductal (intraductal papillary mucinous neoplasm, IPMN) es una lesión pancreática premaligna. Las guías internacionales incluyen un número limitado de factores predictivos de riesgo individual. Para predecir el riesgo individual de malignidad del IPMN se ha propuesto un nomograma con un buen rendimiento diagnóstico, basado en una gran cohorte de pacientes asiáticos con IPMN. Este estudio validó el nomograma para predecir el riesgo de cáncer y de invasión de la IPMN utilizando cohortes tanto orientales como occidentales. MÉTODOS: Se recogieron datos clínico-patológicos y radiológicos de pacientes en los que se realizó una resección de páncreas por IPMN en 4 centros en países orientales y en 4 centros de países occidentales. Se excluyeron los pacientes en los que en el nomograma faltaba ≥ 1 factor(es) predictivo(s) de malignidad (diámetro del conducto pancreático principal, tamaño del quiste, presencia de nódulo mural, niveles séricos de CEA y CA19-9, y edad).En total, se analizaron datos de 393 pacientes que cumplían con los criterios de inclusión, de los cuales 265 eran de centros orientales y 128 de centros occidentales. Aunque la edad media, el sexo, el valor logarítmico del nivel sérico de CA19-9, la localización del tumor, el diámetro del conducto principal, el tamaño del quiste y la presencia de un nódulo mural difirieron entre las cohortes de Corea/Japón y las cohortes oriental y occidental, las tasas de malignidad y de cáncer invasivo no fueron significativamente diferentes. Las áreas bajo la curva operativa del receptor (area under the receiver operating curve, AUC) que mostró el nomograma para predecir la malignidad fueron: cohorte oriental: 0,745; cohorte occidental: 0,856 y cohortes combinadas: 0,776; y para predecir la invasión tumoral fueron: cohorte oriental: 0,736; cohorte occidental: 0,891, y cohortes combinadas: 0,788. CONCLUSIÓN: La validación externa del nomograma mostró un buen rendimiento en la predicción de cáncer, tanto en pacientes orientales como occidentales con lesiones IPMN.

Purpose: Biological subtypes and age were well-known risk factors associated with the development of brain metastasis in breast cancer patients. However the impact of each biological subtype in different age group was less discussed. Patient and methods: Patients with invasive ductal carcinoma of breast diagnosed from January 2000 to December 2009 were divided by age of diagnosis into three groups: age below 35, age from 36–59 and age above 60. Four biological subtypes of breast cancer subtype were approximated as luminal A, luminal B, HER2 enriched and triple negative breast cancer by intergrading status of estrogen receptor, progesterone receptor and HER2 and grade. Result: With a median follow-up time of 54.2 months, there were 164 patients (7.3%) among the 2248 enrolled patients developed brain metastasis. Patients with HER2 enriched [hazard ratio (HR) 2.53; 95% confidence interval (CI): 1.57–4.07, p < 0.0001)], triple negative breast cancer (HR 4.42; 95% CI: 2.86–6.85, p < 0.0001) and diagnosed age younger than 35 years-old (HR 2.09; 95% CI: 1.15–3.81, p = 0.016) were strongly associated with higher incidence of brain metastasis. Table 1 showed the important characteritics according to different age group. Furthermore the influence of each biological subtype amoung different age group were investigated. For patient younger than 35 years-old, risk of the developement of brain metastasis was independent to biological subtype (p = 0.507); while the risk of brain metastasis was influenced by biological subtype in older age groups. For patients older than 35, patients with triple negative and HER2 enriched disease had significantly increased risk for brain metastasis compared to luminal A; but for patients with luminal B disease, such incremental risk for the development brain metastasis was only observed in patients older than 60 years-old. Conclusion: Our study found that each biological subtypes of breast cancer had distinct impact on the development of brain metastasis among different age group. Further studies were needed to disclose the biology underneath. Also the findings should be taken into consideration when developing strategy for brain metastasis prevention. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-12-10.

We tested the hypothesis that the ProSeal laryngeal mask airway (PLMA) is a more effective ventilatory device than the Classic laryngeal mask airway (LMA) for laparoscopic cholecystectomy.Eighty anaesthetized, paralyzed patients (ASA 1-2, aged 18-80 yr) were randomly allocated for airway management with the PLMA or LMA. Ease of insertion and efficacy of seal were determined. Peak airway pressures were recorded immediately before and after carboperitoneum to 2.0 kPa. The inspired oxygen concentration and/or the ventilatory variable were adjusted according to a protocol to maintain SpO2or = 95% and E'CO26.0 kPa. Oxygenation was considered suboptimal if SpO2 fell to 94-90% and failed if SpO2 was90%. Ventilation was considered suboptimal if E'CO2 was6.0-7.3 kPa and failed if E'CO2 was7.3 kPa.First-time insertion success rates were higher for the LMA (40/40 vs 33/40; P = 0.02). Seven patients required two attempts with the PLMA. Oropharyngeal leak pressure was higher for the PLMA [29 (SD 6) vs 19 (4) cm H2O; P0.001]. There was a similar, significant increase in peak airway pressure after carboperitoneum for both devices (P0.001). Before carboperitoneum, oxygenation and ventilation were optimal in all patients in both groups. After carboperitoneum, oxygenation was optimal in all patients in both groups, but ventilation was suboptimal more frequently with the LMA (8 vs 0; P = 0.01). In three of these eight patients, ventilation failed but was subsequently optimal with the PLMA.The PLMA is a more effective ventilatory device for laparoscopic cholecystectomy than the LMA. We do not recommend the use of the LMA for laparoscopic cholecystectomy.

In this study, we evaluated three PCR methods for epidemiological typing of Burkholderia (Pseudomonas) cepacia--PCR-ribotyping, arbitrarily primed PCR (AP-PCR) and enterobacterial repetitive intergenic consensus sequence PCR (ERIC-PCR)--and compared them with pulsed-field gel electrophoresis. The analysis was performed with 31 isolates of B. cepacia, comprising 23 epidemiologically unrelated isolates and 8 isolates collected from the same patient during two episodes of bacteremia. Pulsed-field gel electrophoresis, ERIC-PCR, and AP-PCR identified 23 distinct types among the 23 unrelated isolates, while PCR-ribotyping only identified 12 strain types, even after AluI digestion of the amplification products. Among the eight isolates collected from the same patient, all typing techniques revealed two clones of strains. The day-to-day reproducibilities of PCR-ribotyping and ERIC-PCR were good, while greater day-to-day variations were noted in the fingerprints obtained by AP-PCR. We conclude that all three PCR techniques are useful for rapid epidemiological typing of B. cepacia, but ERIC-PCR seems to be more reproducible and discriminative.

Flavimonas oryzihabitans has emerged as a potential nosocomial pathogen in recent years. The typing method for characterization of this species has never been reported before. Pulsed-field gel electrophoresis (PFGE) and enterobacterial repetitive intergenic consensus (ERIC)-based PCR were used to generate DNA fingerprints for 14F. oryzihabitans isolates obtained from eight episodes of nosocomial infections during a 2-year period. Both techniques successfully classified these clinical isolates into eight distinct genotypes, thus indicating that all of these episodes of infections were independent. In contrast, repeated isolates from the same patient were assigned to identical genotypes. The reproducibility of both techniques was good. Therefore, we conclude that both PFGE and ERIC-PCR have comparable reproducible and discriminatory powers for the typing of F. oryzihabitans and may be useful for clarifying the epidemiology of this species; however, ERIC-PCR has the advantages of both speed and simplicity.

A newly-designed gastrojejunostomy with duodenal partition was hypothesized to be a relatively easier and safer gastric bypass procedure in interrupting the "food reentry", as compared with antrectomy, for patients with unresectable periampullary cancer.Thirty patients with unresectable periampullary malignancy were randomized to receive gastrojejunostomy with either duodenal partition or antrectomy, in addition to biliary bypass, to compare surgical risk and efficacy of the gastric bypass between these two groups.Gastrojejunotomy with either duodenal partition or antrectomy could significantly shorten the gastric emptying time 6 weeks after operation. There was no significant difference between these two groups in gastric outlet obstruction (GOO) symptoms, gastric emptying time, and time for resuming oral diet intake after operation. The median operation time was shorter in the duodenal partition group (180 min) than in the antrectomy group (240 min), p0.01. The median blood loss was less in the duodenal partition group (250 ml) than in the antrectomy group (400 ml), (p = 0.01). Complications occurred in 3 (20%) patients with duodenal partition and in 7 (47%) patients with antrectomy, (p = 0.25). One duodenal stump leakage occurred in antrectomy group. Surgical mortality occurred in 2 patients with antrectomy.Duodenal partition, with shorter operation time and less blood loss, had similar efficacy with antrectomy in correction of GOO. Therefore, duodenal partition could be a relatively easier and safer alternative to antrectomy in interrupting the "food reentry" in gastrojejunostomy for patients with unresectable periampullary cancer.

Fifteen patients with splenic abscesses were evaluated between 1985 and 1995. The most common predisposing factors were remote infection, diabetes mellitus and heart disease. Common clinical presentations included leucocytosis, fever, left upper quadrant abdominal pain and left pleural effusion. Four patients with splenic abscesses smaller than 4 cm in diameter were treated with antibiotics alone, and 1 in this treatment group died. Among the 10 patients with splenic abscesses larger than 4 cm in diameter receiving percutaneous drainage, 9 (90%) were successfully cured, including 8 with unilocular abscesses and 1 with multilocular abscesses. Two patients underwent splenectomy. In conclusion, percutaneous drainage using ultrasound or computed tomography guidance may be recommended as the treatment of choice for splenic abscess larger than 4 cm in diameter. Antibiotics alone may sometimes be considered for splenic abscesses smaller than 4 cm in diameter. Splenectomy is reserved for those cases where medical treatment has failed.

Pancreaticoduodenectomy remains a high-risk and formidable challenge to many surgeons. This study reappraised the surgical risk and prognosis for periampullary lesions in patients undergoing pancreaticoduodenectomy before and after 1990.Data on 308 patients with periampullary lesions undergoing pancreaticoduodenectomy were analyzed. The surgical risk was assessed by a variety of factors. Prognoses for periampullary cancers were determined and compared.The overall surgical mortality, morbidity and pancreatic leakage were 12.7%, 47.7% and 14.9% respectively. Surgical morbidity (43.5% vs. 51.6%) and pancreatic leakage (12.9% vs. 16.8%) did not change significantly before 1990 and after 1990. Surgical mortality significantly decreased from 17.1% before 1990 to 8.7% after 1990 (p = 0.043). Surgeons having more experience in performing pancreaticoduodenectomy (count20) made significantly lowest rates of surgical mortality, pancreatic leakage and bile leakage, as compared with those having performed this surgery with medium count (10-20) or low count (10). Statistically, pancreatic leakage was highly associated with operative mortality, (p0.001). As analysed by multivariate logistic regression, the most independent risk factor of surgical mortality after pancreaticoduodenectomy was pancreatic leakage (odds ratio = 12.1), followed by date of operation (odds ratio = 2.5). The 5-year survival rate for overall periampullary cancers was 23.0%, with the highest in ampulla of Vater cancer (32.7%), followed by duodenal cancer (18.0%), distal common bile duct cancer (12.3%) and pancreatic head cancer (5.5%) (p0.001).Surgical morbidity following pancreaticoduodenectomy remains high and unchanged while surgical mortality has significantly reduced. Pancreatic leakage is the most independent risk factor of surgical mortality. Patients with periampullary lesions appear to benefit from the experience of surgeons. The overall 5-year survival is most favorable for ampulla of Vater cancer and worst for pancreatic head cancer.

A susceptibility surveillance study of 276 isolates of Streptococcus pneumoniae, 301 of Haemophilus influenzae, and 110 of Moraxella catarrhalis was carried out from November 1998 to May 1999 in Taiwan. High rates of nonsusceptibility to penicillin (76%), extended-spectrum cephalosporins (56%), azithromycin (94%), clarithromycin (95%), and trimethoprim-sulfamethoxazole (TMP-SMX) (65%) for S. pneumoniae isolates and high rates of nonsusceptibility to amoxicillin (58%) and TMP-SMX (52%) for H. influenzae isolates were found. Higher percentages of S. pneumoniae isolates nonsusceptible to aminopenicillins, extended-spectrum cephalosporins, macrolides, and TMP-SMX were observed among penicillin-intermediate and -resistant isolates. All quinolones tested were active in vitro against these three organisms.

Hepatic cysts are not uncommon and are usually asymptomatic, while large cysts sometimes show clinical manifestations. The management of large symptomatic hepatic cysts includes both percutaneous aspiration and surgical intervention. Aspiration has a high recurrence rate and is not a curative treatment. Recently, laparoscopic unroofing or "fenestration" in selected patients with hepatic cysts has gained popularity, for it shortens hospital stay, involves minimal invasiveness and does not result in a high recurrence rate. We report three cases of symptomatic hepatic cysts successfully treated with laparoscopic surgery.

Cell kinetics are important indicators of the biological behavior of various human tumors. In this study, we evaluated the prognostic values of the proliferative factors including MIB-1 index, DNA ploidy and S-phase fraction, and further determined the independent prognostic factors in pancreatic head cancer after pancreatoduodenectomy.Patients with pancreatic head cancer undergoing pancreatoduodenectomy were included. Cell proliferative parameters including MIB-1 index, DNA ploidy and S-phase fraction measured by flow cytometry were evaluated and compared with the conventional clinicopathologic factors.There were 21 resectable pancreatic head cancers. By univariate analysis MIB-1 index, cell differentiation and lymphovascular invasion were significant prognostic factors. The 5-year survival rate was 22.2% for overall patients and 29.2% for patients with MIB-1or = 11%, while it was 0% for MIB-1 index11%, p=0.011. Tumors without lymphovascular invasion had significantly better prognosis than those with lymphovascular invasion (median survival: 38 vs. 10 months, p=0.009). The median survival was significantly longer for well-differentiated cancers than for moderately and poorly differentiated cancers (44 vs. 11 and 9 months, p=0.038). There was no correlation between the MIB-1 index and the other 2 conventional prognostic factors. After multivariate analysis, only the MIB-1 index emerged as the independent prognostic factor.MIB-1 index played a significant role in the prognosis of the resectable pancreatic head cancer and could potentially complement the conventional factors in predicting the prognosis and determining the optimal treatment strategy. MIB-1 index was also an important independent prognostic factor.

Although the relationship between prognosis and age of patients with gastric cancer is controversial, a poorer prognosis in young patients has been suggested by most investigators. To further examine the hypothesis, a retrospective study was undertaken to analyze a large series of patients with gastric cancer in Taiwan.A total of 1,642 consecutive patients diagnosed with gastric cancer and receiving further management at one medical center from 1988 to 1993 were reviewed. The gender, TNM tumor stage, rate of curative resection and survival of the patients were compared in the young age group (or = 39 years) and the old age group (39 years). Survival was estimated with the product-limit method and difference in survival was tested by the log-rank test. Multivariate analysis was done by the Cox proportional hazard model.Among the 1,642 patients, 61 patients were in the young age group and 1,581 patients were in the old age group. There was no significant difference for the 2 groups of patients in the distribution of TNM stage (stage I: 20%; II: 8%; III: 13%; IV: 59% vs. 19%, 11%, 25% and 45% respectively, in the old age group, p = 0.098) and rate of curative resection (38% vs 51% in the old age group, p = 0.059). The overall 5-year survival showed no significant difference between the 2 groups (25% vs. 29% in the old). Subgroup analyses showed that survival after curative resection and survival without curative treatment (including palliative resection and no resection) also had no difference in the 2 groups. Multivariate analysis also showed that age was not an independent factor.Although most reports suggested a dismal prognosis in young patients with gastric cancer, based on our findings, young patients (or = 39 years) do not have a worse prognosis than older patients.

Glucagonoma is a very rare islet cell tumor of the pancreas. We present a case of pancreatic tail tumor with the typical glucagonoma syndrome of necrolytic migratory erythema (NME), diabetes mellitus (DM), anemia, weight loss and glossitis. After complete resection of the pancreatic tumor, the glucagonoma syndrome subsided. In reviewing 120 cases of glucagonoma in the literature, the average tumor diameter was 3.6 cm. Most (68.1%) of the tumors occurred in the pancreatic tail. Two-thirds of the reported glucagonomas were malignant and 53.5% metastasized to other organs. The curative resection rate was 45.8%. A triad of pancreatic tumor, NME and DM should lead to the diagnosis of glucagonoma.

The aim of this paper is to reevaluate the factors responsible for hospital morbidity, mortality and post-operative survival following pancreaticoduodenectomy for ampullary cancer.Peri-operative data on 132 patients undergoing pancreaticoduodenectomy for ampullary cancer were correlated with post-operative morbidity, mortality and long-term survival.Three factors were found to correlate well with post-operative morbidity; however, only intraabdominal or wound sepsis was an independently significant variable. Four parameters correlated well with hospital mortality, while multivariate analysis revealed age75 y/o, positive blood culture and albuminor = 3.0 g% to be independently significant in predicting post-operative mortality. Univariate analysis identified seven significant factors: 1) ageor = 75 y/o, 2) hematocrit30%, 3) blood urea nitrogen20 mg%, 4) earlier TNM staging, 5) smaller tumor size, 6) negative nodal status and 7) well-differentiated tumors, which were associated with longer survival. However, multivariate analysis disclosed nodal status and hematocrit to be the two most significant independent variables.Although radical resection for ampullary cancer can be performed with a low mortality in recent years, the justification for performing this major operation in a patient over 75 years of age should be reevaluated for prohibitively high mortality (10x) and shorter survival (median 6.0 months). Pre-operative nutritional support and careful surgical technique to prevent post-operative sepsis are mandatory to reduce operative morbidity and mortality. Correction of anemia and adequate lymph node dissection will clarify the patient's survival benefit following this operation.

The authors present their recent experience with the treatment of periampullary lesions to compare the surgical technique, safety and prognosis between pylorus-preserving pancreaticoduodenectomy (PPPD) and classic pancreaticoduodenectomy (CPD).Prospective data from 100 patients with periampullary lesions treated with either PPPD or CPD between January, 1991, and June, 1997, were evaluated, including demographic data, surgical technique, surgical risk and prognosis.There were 35 patients treated with PPPD and 65 treated with CPD. The operating time was significantly shorter in the PPPD group (9.3 +/- 0.3 hours) than in CPD (10.4 +/- 0.3 hours). The average overall blood loss was 1,275 +/- 71 ml, with no statistical difference between PPPD and CPD groups. The overall complication rate was 56%, with 54% in the PPPD group and 57% in the CPD group (p = 0.755). The overall mortality was 4%, with 0% in the PPPD group and 6.2% in CPD (p = 0.655). There was no statistical difference in survival time for overall periampullary cancers between the PPPD and CPD groups (median = 28.0 vs 26.5 months, p = 0.393). The difference in survival time was still of no significance between the PPPD and CPD groups when the periampullary cancers were further stratified into pancreatic head cancer and nonpancreatic periampullary cancer.Morbidity and mortality of PPPD did not exceed that of CPD, and the prognosis after PPPD was not compromised in patients with periampullary cancer. PPPD, with a shorter operating time, can be a safe and effective alternative to CPD in the treatment of periampullary lesions.

Well-differentiated thyroid cancers (WDTC) are usually slow-growing neoplasm with an indolent clinical course. Assessment of treatment modalities for them requires a long-term follow-up in a large population, and is still of much debate. A systematic analysis of the history, prognosis and therapy for this disease in Taiwan is lacking.A retrospective analysis of clinical and pathological records was conducted on 488 patients (149 male and 339 female, male: females = 1:2.28) treated for WDTC in the Veterans General Hospital-Taipei from 1971 to 1991 with subsequently follow-up until December 1994 (Mean follow-up: 8.5 years). Factors influencing recurrence, survival and different treatment were analyzed.Papillary thyroid cancer increased obviously as compared to our experience from 1959-1976. Changing tumor behaviors, including increasing female/male ratio, higher percentage of papillary cancer, decreasing primary tumor size and lower distant metastatic rate at the time of initial diagnosis, were noted. Factors influencing survival, as determined by univariate analysis, included age, gender, distant metastasis, extrathyroidal invasion, tumor size, nodal involvement, histological type, extent of surgical therapy and use of postoperative radioactive iodine. Those patients aged more than 45 at initial diagnosis, with primary tumors larger than 4 cm, with extrathyroidal invasion, and with distant metastasis at initial diagnosis were classified as being at high risk. The others were at low risk. Total or near total thyroidectomy (TTx), depending on the judgement of each surgeon, had much higher complication rate than lobectomy with/without isthmusectomy, but offered no benefit effect on disease-free survival or overall survival rates. Postoperative radioactive iodine ablation treatment and thyroxine replacement in suppressive dose after TTX improved survival among high risk patients. Lobectomy with/without isthmusectomy in low risk patients, followed by thyroxine suppression therapy, was adequate to improve the postoperative outcome and with low complication rate. Lymph node resection in patients with clinically palpable nodes improved longterm prognosis.Changing tumor behavior of WDTC leading to favorable prognosis has been noticed since 1971. Total or near total thyroidectomy is worthwhile in high risk patients with WDTC but does not appear necessary in low-risk patients. Lymph node dissection for metastatic lymph node could improve the survival rate.

Concerned about the inactivation of piperacillin by beta-lactamase and the risk of aminoglycoside-induced nephrotoxicity and clindamycin-induced enterocolitis, we conducted the following phase III clinical trial.Between November 1991 and March 1993, 77 surgical patients with intraabdominal infections were enrolled and randomly assigned in a 3:2 ratio to receive either piperacillin/tazobactam or clindamycin plus gentamicin to compare safety, tolerance and efficacy between both two treatment groups.There were 76 clinically and 50 bacteriologically evaluable patients with 80 isolated pathogens. The demographic data were comparable in both groups. There was no statistically significant difference of clinical response at any time-point of treatment, with 97.8% favorable clinical response rate in piperacillin tazobactam group and 96.6% in clindamycin plus gentamicin group at endpoint. The bacteriological eradication rates were similar, with 97.7% in piperacillin/tazobactam group and 94.4% in clindamycin plus gentamicin group at pathogen level, and 96.7% in piperacillin/tazobactam group and 95.0% in clindamycin plus gentamicin group at patient level. By susceptibility tests, only 3 (4%) isolated pathogens were resistant to piperacillin/tazobactam, which was much superior to the use of piperacillin, clindamycin or gentamicin alone in antimicrobial activity. The piperacillin tazobactam-related adverse experiences included 1 (2.1%) urticaria and 2 (4.3%) diarrhea. However, there were no significant differences in the adverse experiences between these two groups.This study has demonstrated that piperacillin/tazobactam is comparable with clindamycin plus gentamicin in efficacy, safety and tolerance in the treatment of surgical patients with intra-abdominal infections. The combination of piperacillin/tazobactam could potentially be the treatment of choice in adjunt to surgical management in intra-abdominal infection.

The technique of continuous ambulatory peritoneal dialysis (CAPD) catheterization is critical to patient success. To clarify how important a surgeon's experience to CAPD is, the experience exclusively from a single surgeon was presented and compared with those from a group of surgeons. The roles of intraoperative fluoroscopy and laparoscopy in CAPD catheterization and the rescue of tube migration in the authors' experience would also be introduced.Fifty-five patients followed for a total of 668 patient-months between July 1990 and July 1993 were included for analysis. All of the catheterization procedures were done by one surgeon.The overall complication rate was 56%. Twenty-two percent of the patients had peritonitis, with an incidence of 0.56/patient-year, and 25% of the patients had exit-site infection, with an incidence of 0.36/patient-year. Tube migration occurred in two patients (4%). There was no dialysate leakage or incisional hernia. These incidences were much lower than previous reports by groups of surgeons. Laparoscopy successfully rescued a migrated tube. The cumulative 1-year, 2-year and 3-year catheter survival rates were 81%, 75% and 63% respectively. The previous abdominal operation, catheter type and catheterization site were not the prognostic factors of catheter survival.Based on this favorable outcomes, an experienced CAPD-surgeon may be one of the factors in minimizing the complications and improving the catheter survival in CAPD. Intraoperative fluoroscopy for every catheterization procedure and laparoscopy for the migrated or dysfunctional tube are highly recommended.

Justification of pancreatoduodenectomy for highly malignant periampullary cancers with regional lymph node involvement is questioned. Attempting to clarify the therapeutic dilemma, we compared the prognoses of resectable periampullary cancers with and without lymph node involvement, as well as unresectable cancers with lymph node involvement. The medical records of surgical patients with periampullary adenocarcinoma were reviewed. We compared the survival times of resectable cancers with (resectable TanyN1M0) and without (resectable TanyN0M0) regional lymph node involvement, and the survival times of resectable cancers with lymph node involvement (resectable TanyN1M0) and unresectable cancers with lymph node involvement (unresectable TanyN1M0). There were 138 resectable and 115 unresectable periampullary cancers including 117 cancers of the pancreatic head, 117 cancers of ampulla of Vater, 7 cancers of duodenum, and 12 cancers of distal common bile duct. The prognosis was very poor in cancer of the pancreatic head. Neither resectability nor status of lymph node involvement could influence the survival time of the cancer of pancreatic head. In resectable non-pancreatic periampullary cancers, the prognosis was significantly better in the group without lymph node involvement. However, once the lymph node was involved, the outcomes were the same in the resectable and unresectable groups. Although pancreatoduodenectomy does not seem to be justified for periampullary cancers with regional lymph node involvement, this procedure should be considered for periampullary cancers without nodal involvement.

Reproducibility of the so-called "mucolytic effect" of the 2%-10% dextrose-water solution is questioned. To test the mucolytic effect of 5% and 10% dextrose-water solutions and to determine what could be a true mucolytic agent, in vitro and in vivo studies were undertaken in two proven pseudomyxoma peritonei cases. In vitro study: Immediately after the mucin jelly was taken out of the peritoneal cavity, the jelly was immersed in various 40 cc solutions including: 1) 5% dextrose-water; 2) 10% dextrose-water; 3) normal saline; 4) lactated Ringer; 5) distilled water. The mucolytic effects of these solutions were observed once every hour after vigorous mixing. In vivo study: After completion of the operation, the peritoneal cavity was repeatedly irrigated with massive warm 5% dextrose-water and normal saline solutions in an attempt to dissolve the residual mucin cake and jelly. Neither 5% and 10% dextrose-water solution nor control solutions of normal saline, lactated Ringer, and distilled water could dissolve the mucin jelly in test tubes at 0, 1, 2, and 3 hours. The "claimed" mucolytic agent, 5% dextrose-water solution could not facilitate the removal of both mucin jelly and cake in the peritoneal cavity. The 5% dextrose-water solution was not superior to the normal saline solution in terms of mucolytic effect. In the present study, a true mucolytic agent does not exist. Currently, multiple laparotomy for aggressive cytoreduction remains the treatment of choice for pseudomyxoma peritonei.

Since Whipple's successful resection of the head of the pancreas and duodenum in 1935, pancreaticoduodenectomy has become a standard operation for periampullary malignancies. Although the operative mortality has decreased dramatically in the recent years, it continues to be associated with high morbidity; with anastomotic leakage remaining a major problem.One hundred and seventy-six pancreaticoduodenectomies performed for periampullary lesions during the past 27 years were reviewed. These included 171 Whipple operations, 4 total pancreatectomies and 1 pylorus-preserving pancreaticoduodenectomy. Among them, 40 cases were complicated with anastomotic leakage following pancreaticoduodenectomy. Their management strategy and outcome were reevaluated. Furthermore, the factors suggested to affect pancreaticojejunostomy leakage were also analyzed.The overall operative mortality was 15.3%, which decreased to 6.7% in recent two years. However, a high complication rate of 50% remained. Among the complications of the whole series (46.6%), anastomotic leakage accounted for 22.7% (40/176). Leakage occurred in 28 pancreaticojejunostomies (16.3%), 9 hepaticojejunostomies (5.1%) and 6 gastrojejunostomies (3.4%). Twelve patients required reoperation for ongoing sepsis or bleeding. This experience disclosed that in most cases hepaticojejunostomy leakage (8/9) could be successfully managed without operation. While three of the six gastrojejunostomy leaks survived after conservative treatment, two of the remaining three patients operated died of sepsis. Among cases with pancreaticojejunostomy leakage, 12 survived after conservative treatment, whereas 6 died of sepsis. Among 10 operated patients, only 3 patients survived. Earlier reexploration for uncontrolled leakage, probably within the first eight postoperative days, seemed to be the only chance for life saving. As far as the risk factors of pancreaticojejunostomy leakage are concerned, there seemed to exert no significant influence in terms of intraoperative blood loss, type and sequence of anastomosis as well as pancreatic stenting. The only clue that may affect the surgical outcome is technical; more experienced (or = 10 Whipple operations) surgeons tended to render less morbidity and mortality.The retrospective analysis of our experience in pancreaticoduodenectomy discloses a trend toward decreased mortality rates in the recent years but operative complications remain high. Among the possible complications, anastomotic leakage is still a troublesome concern. Although conservative treatment can benefit most patients, earlier reexploration for uncontrolled sepsis should be considered. If a good result is anticipated, this complicated procedure should only be performed by an experienced surgeon.

One-hundred-and-forty fresh frozen breast tissue samples from Chinese patients collected from May 1991 to October 1992 were evaluated for DNA content by flow cytometric analysis. None of the 12 benign tumors displayed aneuploidy. One-hundred-and-twenty-eight of the 140 specimens were histologically proven to be malignant. Ploidy was compared to the clinical characteristics which included age, tumor size, lymph node involvement, menopausal status, steroid receptor status, histological grading and pathological staging. After univariate and multivariate analyses, aneuploidy was more frequently identified in progesterone receptor negative and high grade tumors. This study suggests that an aneuploid DNA content in a breast cancer specimen may indicate more aggressive cancer.

Two hundred and fifty-eight patients with pathologically proved periampullary carcinomas who underwent surgical treatment between the years 1965 and 1992 were evaluated. Comparison was carried out between the resectable and unresectable groups. Carcinoma of the pancreatic head occurred in less than one-half (47 percent) of the patients, and only 23 percent were resectable. In contrast, carcinoma of the ampulla of Vater had a similar rate of occurrence, but a much higher resectable rate (86 percent). Thus, carcinoma of the pancreatic head was the minor group (19 percent) in the resectable patients we studied. The main clinical presentations and durations of symptoms before diagnosis did not differ in the resectable and unresectable groups, so it was impossible to predict the resectability by symptoms. Incidences of diabetes mellitus and diarrhea increased twofold in the unresectable group. Preoperative biopsy was difficult to perform for those with carcinoma of the pancreatic head. Comparing pancreatoduodenectomy and palliative operation, pancreatoduodenectomy resulted in a higher complication rate (43 versus 13 percent), a higher surgical mortality rate (17 versus 9 percent) and a longer hospitalization period (31 versus 20 days), but there was no statistical difference in the median survival time between the resectable and unresectable carcinomas of the pancreatic head (seven and one-half versus five months). Most of the patients (81 percent in the resectable group and 70 percent in the unresectable group) we studied died of cachexia with tumor recurrence. Although the advantage of pancreatoduodenectomy for resectable carcinoma of the pancreatic head was questioned, we still recommend this procedure for all periampullary carcinomas to avoid depriving the occasional patients with pancreatic carcinomas of long term survival and forfeiting the chance of cure for some misdiagnosed patients with other more favorable periampullary carcinomas.

Angiograms and clinical data for 249 patients with hepatoma were evaluated, with particular attention paid to the arteriovenous (A-V) shunt and venous thrombosis (including occlusion). There were 43 cases (17.3%) with A-V shunt and 140 cases (56.2%) with venous thrombosis. A statistically significant difference in survival was noted among the unresectable patients with and without these vascular changes. Furthermore, in the resectable patients, presence of venous thrombosis also showed a poor prognosis. A-V shunt did not influence the survival in the unresectable patients with venous thrombosis, and 93.0% of A-V shunt was associated with venous thrombosis. This seemed to imply that these two vascular changes might be the same entity. In the presence of either A-V shunt or venous thrombosis, the survival rate in the surgical group was still better than that of medical groups treated by either transarterial embolization (TAE) or conservative methods. Most of the A-V shunt (81.4%) and venous thrombosis (56.4%) occurred in the diffuse type of hepatoma, and the prognosis for unresectable patients was the worst in this type, with a mean survival time of 3 months. Since A-V shunt and venous thrombosis are factors in poor prognosis and occur frequently, careful preoperative evaluation of these vascular changes is mandatory. However, in patients with localized tumor, coexisting with such vascular involvement, surgical resection is still recommended.