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Background/purpose: Cigarette smoking is the main risk factor for urothelial carcinoma of the bladder (UCB). Glutathione S-transferase omega 1 (GSTO1) and sulfotransferase 1A1 (SULT1A1) have been reported to be associated with the metabolism of polycyclic aromatic hydrocarbons (PAHs) and aromatic amines. The aim of the present study was to investigate the combined effects of polymorphisms in GSTO1 and SULT1A1 genes and cigarette smoking on UCB risk in a Taiwanese population., Methods: A total of 300 patients with histopathologically confirmed UCB and 233 cancer-free controls were recruited from the Department of Urology of Tung's Taichung Metro Harbor Hospital and Taipei Medical University Hospital. A comprehensive interview was conducted to collect personal information, including demographic characteristics and cigarette smoking status. A multivariate-adjusted logistic regression was performed to estimate the risk of UCB., Results: A significantly increased risk of UCB was observed in ever smokers [odds ratio (OR) = 2.3]. The Ala/Ala genotype of the GSTO1 gene and the Arg/Arg genotype of the SULT1A1 gene were associated with a significantly increased risk of UCB, with ORs of 1.8 [95% confidence interval (CI) = 1.2-2.6] and 2.1 (95% CI = 1.6-4.5), respectively. Significantly increased UCB risks were found in heavy smokers with the Ala/Ala genotype of the GSTO1 gene (OR = 4.2) and the Arg/Arg genotype of the SULT1A1 gene (OR = 6.8). Furthermore, a significant synergistic effect in an additive model (OR = 3.5) between the GSTO1 Ala/Ala genotype and the SULT1A1 Arg/Arg genotype on UCB risk was observed., Conclusion: The present study provided epidemiological evidence for a significantly increased risk of UCB in ever smokers with the Ala/Ala genotype of the GSTO1 gene and the Arg/Arg genotype of the SULT1A1 gene., (Copyright © 2012. Published by Elsevier B.V.)

Pleomorphic hyalinizing angiectatic tumor (PHAT) of soft parts is a rare, nonmetastasizing tumor of uncertain lineage which was first reported in 1996. Here, we report a case of PHAT and review the literature. A 49-year-old man presented with a soft and progressively enlarging mass over the right buttock for several years. On suspicion that the mass was a right gluteal lipoma, he underwent surgical excision. The excised lesion measured 14 x 6 x 3.5 cm. It had a variegated appearance with a white-tan to yellowish color on the cut surface. Some punctate hemorrhage and vessel thrombosis were seen. Microscopically, the tumor was a PHAT characterized by clusters of ectatic, fibrin-lined, thin-walled vessels, which were surrounded by a mitotically inert, spindled, pleomorphic, neoplastic stroma that contained a variable inflammatory component. Immunohistochemical study showed that the tumor cells were positive for CD34, and negative for S-100, HMB45 and actin. The patient experienced local recurrence 6 months later. The recurrent tumor was widely excised. No evidence of metastasis was found during the 18 months after the second operation. The recurrent lesion had a microscopic appearance that was similar to the initial lesion., (2010 Formosan Medical Association & Elsevier. Published by Elsevier B.V. All rights reserved.)

Background/purpose: Laparoscopic adjustable gastric banding (LAGB) is a newly developed minimally invasive surgical procedure for the treatment of morbid obesity. This study was conducted to evaluate body weight loss, surgical complications, and comorbidities after LAGB surgery., Methods: Ninety-one morbidly obese patients (mean age, 31.2 years; mean preoperative weight, 120.8 kg) underwent LAGB in a private Taiwan hospital setting within a comprehensive multidisciplinary bariatric program. Patients were followed up to 36 months. Comorbidities were assessed in 55 patients who completed more than 12 months of follow-up by comparing each comorbid condition before surgery and during follow-up., Results: All procedures were performed laparoscopically with no conversion. Mean operation time was 88.7 +/- 32.9 minutes. There were no intraoperative or major postoperative complications. Minor complication of stoma stenos is occurred in three (3.3%) patients. At 36 months after surgery, mean body mass index had decreased from 42.7 to 33.9 kg/m2, and mean percentage of excess weight loss was 44.8%. Late complications were as follows: intractable vomiting requiring band removal in one (1.1%) patient, tubing problems requiring revision surgery in four (4.3%), and stoma obstruction in two (2.1%). There was no mortality. Resolution or improvement of comorbidities was significant for hyperglycemia and diabetes-related index, dyslipidemia, abnormal liver function, hyperuricemia, sleep apnea, and arthralgia, but not for hypertension., Conclusion: LAGB provides good weight loss and significant reduction in comorbidities with few minor complications.

Background and Purpose: The inverse relation between life expectancy and obesity is in large part due to multiple metabolic and cardiovascular comorbidities. Metabolic syndrome (MS) is defined as a cluster of these comorbidities. The prevalence of MS in obesity is not clear. This investigation assessed the prevalence and inter-relationships of MS with various demographic and clinical characteristics in patients with severe obesity., Methods: A total of 534 obese patients referred to a surgical center for weight reduction surgery were included in this retrospective study. Data collected included blood pressure, anthropometric measurements, and biochemical parameters associated with metabolic comorbidities and MS. The prevalence of MS in various subgroups was analyzed., Results: The frequency of metabolic comorbidities included hypertension in 29.8%, hyperglycemia in 29.0%, hyperlipidemia in 61.0%, hyperuricemia in 57.9%, and abnormal liver function in 60.9%. The presence of any of these 4 metabolic comorbidities in the absence of others was uncommon. Only 28 patients (5.2%) had no metabolic comorbidities. The criteria for MS were met by 217 patients (50.7%). Patients with MS were significantly older (32.9 years vs 29.5 years), more likely to be male (31.9% vs 20.5%) and more likely to have metabolic comorbidities compared with patients without MS. In the multivariate analysis, male gender, age, and abnormal liver function remained significantly associated with the development of MS, while body mass index (BMI) was not., Conclusions: Metabolic comorbidities were common in the obese patients referred for weight reduction surgery. The cluster of metabolic comorbidities in MS was significantly associated with male gender, and increased age but not with BMI.

Background and Purpose: Laparoscopic Heller cardiomyotomy for the treatment of achalasia can be performed safely. The application of this minimally invasive approach has not been reported in Taiwan. This study assessed the results obtained using this new method in Taiwanese patients., Methods: From January 1998 to December 2000, we recruited 10 patients (3 men, 7 women; average age 37.3 yr) with achalasia who underwent laparoscopic cardiomyotomy and fundoplication. Before and after surgery, the severity of three symptoms (dysphagia, regurgitation, chest pain) was evaluated by symptom scores (0 = symptom absent; 1 = occasional; 2 = every day; 3 = every meal). Barium swallow study and panendoscopy were performed in all patients. Esophageal manometry was performed before surgery in seven patients. Laparoscopic Heller myotomy and anterior (Dor) fundoplication was performed through five abdominal trocar sites. The myotomy extended 7 cm, 6 cm above and 1 cm below the gastroesophageal junction., Results: Barium swallow study showed that one patient had a normal or mildly dilated esophagus (< 3 cm) and nine patients had moderate esophageal dilatation (3-7 cm). Mean operative time was 162.5 +/- 29.7 minutes. Mean hospital stay was 5.1 +/- 1.6 days (range, 3-9 d). The mean follow-up time was 21.3 +/- 9.4 months, longer than 19 months in eight patients. Dysphagia was alleviated in all but one patient (90%). Regurgitation and chest pain also improved in all patients. No intraoperative complication occurred. Postoperative weight gain (> 4 kg) was noted in all patients., Conclusions: Laparoscopic Heller myotomy and anterior fundoplication result in significant symptomatic relief for patients with achalasia.

Background and Purpose: Juvenile rheumatoid arthritis (JRA) can result in disability, growth disturbance, and systemic complications. This study investigated the efficacy and adverse effects of oral methotrexate (MTX) therapy in Taiwanese children with JRA., Methods: The medical records of 52 Taiwanese children with JRA treated with oral MTX were retrospectively analyzed. The disease onset was polyarticular in 22 children, oligoarticular in 13, and systemic in 17. The indication for MTX therapy was lack of efficacy of previous drugs, including two or more nonsteroidal anti-inflammatory drugs, in all patients. In addition, three patients had received hydroxychloroquine and one had received sulfasalazine, without improvement. Corticosteroid dependency had developed in 27 patients prior to MTX therapy. The mean initial dose of MTX was 9.1 mg.m-2.wk-1 (range, 5-20 mg.m-2.wk-1), and the mean maximal dose was 10.2 mg.m-2.wk-1 (range, 5-20 mg.m-2.wk-1). The mean duration of treatment was 23 months (range, 6-96 mo), and the mean duration of follow-up was 52 months (range, 10-123 mo) from the start of MTX therapy., Results: Thirty-six children (69%) showed clinical improvement and 25 children (48%) achieved clinical remission. The administration of MTX resulted in more than a 50% reduction in required corticosteroid dosage in six children, and complete discontinuation of corticosteroid in 10 children. MTX was discontinued in 18 patients following a mean of 8 months (range, 2-34 mo) of clinical remission. Relapse occurred in nine (50%) of these patients. Thirteen patients (25%) suffered from adverse effects associated with MTX treatment. All of these adverse effects resolved spontaneously, or subsided within 4 weeks following dosage reduction or discontinuation of MTX., Conclusions: Oral MTX therapy is effective and well-tolerated in Taiwanese children with JRA. It can serve as the first choice of second-line therapy in JRA.

The success of mini-laparoscopic cholecystectomy and splenectomy has encouraged the application of this new technique in children with non-complicated intussusception. Here, we report on the use of this technique in two children, aged 21 and 24 months, respectively, who had failed saline enema reduction of ileocolic intussusception. Under a 2-mm videoscopic visualization, the intussuscepted bowel was identified and reduced with the assistance of a 2-mm working port placed at the right lower abdominal area and a 5- to 10-mm working port placed at the supraumbilical area. An intussuscepted lymph node at the ileocecal area, as the lead point, was removed at the time of the procedure in one child. Both patients experienced relief of symptoms the day after operation and resumed a regular diet on the first post-operative day. No recurrence or complications, including abscess and wound infection, occurred. These findings suggest that mini-laparoscopic reduction is a safe procedure for children with uncomplicated intussusception. Moreover, the procedure provides better cosmesis than conventional laparoscopic techniques.

Continuous hyperthermic peritoneal perfusion (CHPP) with anticancer agents in warm saline was performed in 10 patients with cancer of the digestive tract and peritoneal carcinomatosis after resection of primary and metastatic lesions or both. Eight patients had colorectal cancer and one patient had recurring gastric cancer. CHPP was performed using saline containing mitomycin-C and 5-flurouracil at 42 degrees C to 43 degrees C for 60 minutes. One patient with pancreatic cancer received CHPP twice. After CHPP, the preoperative ascites of three patients disappeared. Four patients died of malignancy within 1 year of CHPP and one patient died of respiratory failure 5 months post-CHPP. The remaining five patients survived for more than 1 year after CHPP. There were no significant immediate postoperative complications, except for transient changes in liver function, white blood cell count and serum albumin level. While CHPP treatment appears to be a safe method of treatment for peritoneal carcinomatosis, its long term benefits need further investigation.

Fifty-three patients with bleeding esophageal varices received a non-shunting operation--esophageal transection and devascularization of the proximal stomach with splenectomy--from March 1977 to October 1986. The ages of these patients ranged from 26 to 69 years with a mean of 49.70 +/- 10.03 years (+/- SD). Thirty-six patients were male and 17 were female. The pathology of the liver was post-necrotic liver cirrhosis in 39 cases, alcoholic liver cirrhosis in seven cases, liver cirrhosis with hepatocellular carcinoma in six cases and non-cirrhotic in one case. The operative mortality was 26.4% (14/53); major causes of operative death were due to liver failure (six cases) and recurrent bleeding (five cases). The operative mortality was 10% in Child's Class A, 37.5% in Class B, and 73% in Class C (p < 0.05 by Fisher's exact test). The operative mortality was 18.5% in the elective group and 40% in the emergent group, but the difference was not statistically significant. The absolute overall five-year survival rate was 61.1%, but the expected 10-year survival was only 46.4%. The major causes of death during long-term follow-up were liver failure (nine cases) and recurrent bleeding (seven cases). The incidence of recurrent bleeding of esophageal varices was 44.4% in long-term follow-up. Two patients developed hepatocellular carcinoma 22 and 37 months after their operations; this incidence was much lower than that of our previous report.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of complete transection of the common bile duct due to abdominal blunt injury in a 49-year-old man is presented. The rarity of this injury and its initial presentation as a pancreatic pseudocyst warrant its description. This patient was diagnosed as having bile duct injury following ascites aspiration. Common bile duct transection was documented and a choledochostomy was done. However, bile leaked into the peritoneal cavity one week after the operation. A Roux-en-Y choledochojejunostomy was done successfully in a second operation. Delayed diagnosis is common in these kinds of injuries, but it should be considered when a patient has bile ascites, abdominal distention and jaundice after a blunt abdominal injury. A review of the literature, methods of diagnosis and the technique of surgical repair are described.

Postoperative management of kidney allograft recipients requires a reliable and rapid diagnostic method so that proper therapy can be initiated. In this study, we tried to correlate serum neopterin levels with different conditions after transplantation. Serial serum neopterin levels were assessed after operation. Serum neopterin levels of uremic patients were significantly higher than those of healthy persons (239.9 +/- 177.7 nmole/L, n = 33 vs 6.14 +/- 2.78 nmole/L, n = 10, p < 0.001). In recipients with a stable post-transplant course, the serum neopterin level was low. On the contrary, acute rejection episodes were associated with a high level of serum neopterin which declined after successful treatment, although the difference was not significant (96.2 +/- 57.7 nmole/L vs 56 +/- 38.1 nmole/L, p > 0.05). The serum neopterin level was also high in post-transplant acute tubular necrosis (ATN, 256.6 nmole/L), which gradually declined parallel to the resolution of ATN. The neopterin level was low in patients with cyclosporine nephrotoxicity (17.8 +/- 7.6 nmole/L). In summary, the serum neopterin levels were persistently high in uremic and post-transplant ATN patients. Acute rejection episodes were correlated with an increased level of neopterin. It appears that daily measurement of the serum neopterin level may be useful for biochemical detection of immunologic complications in allograft recipients.

Interleukin-2 (IL-2) and soluble interleukin-2 receptor (sIL-2R), released during T-lymphocyte activation, were measured in serial samples of serum from 32 patients with renal allografts and other uremic patients. Patients undergoing chronic hemodialysis had elevated sIL-2R levels (1,801.93 +/- 753.23 U/mL) which dropped after stable renal transplantation (822 +/- 438 u/mL). However, these values were higher than those of a normal control group (397.3 +/- 84.5 u/mL, p < 0.01). Marked elevation of sIL-2R (1,503.78 +/- 640 u/mL) was noted in patients with acute rejection episodes compared to those in a stable allograft condition (p < 0.02) and those with cyclosporine nephrotoxicity (793.2 +/- 245.2 u/mL, p < 0.01), but returned to a stable level after successful anti-rejection treatment (745.91 +/- 345.8 u/mL, p < 0.01). Acute tubular necrosis and infection also showed a comparable rise in the sIL-2R level. The increase in sIL-2R with rejection was found one to four days earlier than the clinical diagnosis of acute rejection. There was a marked rise in the serum IL-2 level of uremic and post-transplant patients when compared to normal subjects (34.76 +/- 32.16 u/mL and 9.3 +/- 12.7 u/mL vs 4.38 +/- 3.38 u/mL, p < 0.001), but no significant differences were found between the IL-2 level of patients with acute rejection and cyclosporine nephrotoxicity or acute tubular necrosis (3.74 +/- 4.51 u/mL, 1.57 +/- 1.25 u/mL and 6.73 +/- 6.3 u/mL, p > 0.05). The diagnostic value of sIL-2R assay was more meaningful than that of IL-2.(ABSTRACT TRUNCATED AT 250 WORDS)