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The Mechanical Massage O! The Abdomen Decreases Postoperative Pain And Ileus: A Randomized Study Isabelle Le Blanc Louvry, C Boulon, Anne Marie Leroi, Philippe Denis, Philippe Ducrotte, ADEN, Hosp C Nicolle, Rouen France

The aim of this study was to determine the action of an abdominal mechanical massage on postoperative pain and ileus after colectomy. Our hypothesis was that parietal abdominal stimulation could counteract, through common spinal sensitive pathways, with nociceptive visceral inputs involved in postoperative pain and ileus. Methods: After preoperative randomiza- tion and informed consent, 25 patients (52 + 5 years) had active mechanical massage (AMM) in the entire abdominal wall using Cellu M50 device (LPG Valence - France), and 24 patients (60 + 6 years) had non AMM (placebo group) started the first day after colectomy. None of the patients had postoperative morbidity. Mechanical massage was performed by delivering an intermittent negative pressure on the abdominal wall resulting in aspiration. In the AMM group, the amplitude and the frequency of the rhythmic abdominal stimulation were those effective on muscular pain, when in placebo group uneffective parameters were used. Duration of each massage session was 15 min. Massage was performed daily until the 7th postoperative day. Visual analogic scale (VAS) pain score, doses of analgesics and delay between surgery and the time to first passage of flatus were assessed by an another observer than those performing massages and those performing randomization. Results: Nor anaesthetic drugs (Diprivan, Fentanyl, Norcuron) used during surgery, nor their doses, nor the duration of the surgical procedure (AMM : 154 _+ 46 min vs placebo : 143 -+ 14, p > 0.05) were different between the AMM and placebo groups. After the 2 t" and the 3 fd postoperative days respectively, VAS pain scale (p<O.O01) and doses of analgesics (p<O.05) were significantly lower in the AMM group than in placebo group. Time to first passage of flatus was also significantly shorter in AMM group ( Day 1.6 -+ 0.3 vs Day 3.6 -+ 0.4 - p<O.01). No adverse effect was observed, Conclusions: These results show that the mechanical massage of the abdomen wall decreases postoperative pain and reduced the duration of ileus after colectomy.

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One Hundred Consecutive Cases Of Sentinel Lymph Node Mapping In Early Colorectal Carcinoma: Detection Of Missed Micrometastases Thomas F. Wood, John Wayne Cancer Institute, Santa Monica, CA; Sukamal Saha, Michigan State Univ, Flint, MI; Donald L. Morton, George J. Tsioulias, Roderick R. Turner, Decio Rangel, William Hutchinson, Jr., Anton J. Bilchik, John Wayne Cancer Institute, Santa Monica, CA

Background: Almost one-third of patients with node-negative colorectal carcinoma (CRC) develop systemic disease. This implies that these patients have occult disease that is inade- quately treated by surgery alone. We have coupled sentinel lymph node (SN) mapping and a focused pathologic examination to detect occult nodal micrometastases in CRC. Methods: Since 1996, SN mapping was performed in 100 consecutive patients undergoing colectomy for CRC. Peritumoral injection of 0.5-1.0 cc of isosulfan blue dye was performed to demonstrate the SN(s). All lymph nodes in the resection specimen were examined by routine hematoxylin and eosin (H&E) staining. In addition, a focused examination of multiple sections of the SNs was performed using both H&E and cytokeratin immunohistochemistry (CK-IHC). Results: Overall, SN mapping successfully demonstrated 1-4 SNs in 97/100 cases (97%). These SNs accurately reflected the status of the nodal basin as a whole in 92/97 patients (95%). All five of the false-negative cases occurred in T3/T4 tumors and 3 of the 5 occurred during the first 30 cases in the experience. Unexpected lymphatic drainage was encountered in 7 patients (7%) altering the operative approach. Twenty-six patients were node positive by routine H&E staining. An additional eighteen patients (18%) were upstaged by identification of occult nodal micrometastases missed on routine H&E sections but detected by multiple sections (5) or CK-IHC (13). The SNs were the only positive nodes in 19 cases. Conclusions: Sentinel lymph node mapping may be performed in CRC with a high degree of success and accuracy. A focused pathologic examination of the SN detects micrometastetic disease missed by conventional techniques in a significant proportion of patients with early CRC and may be useful to stratify those who might benefit from adjuvant therapy.

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Downstream Apoptosis Effectors APAF-1 and CLARP Are Markedly Reduced in Colon Cancer Sergio Huerta, David Heber, Julio Licinio, Ma-Li Wong, Jonas Hannestad, Edward H. Livingston, UCLA Ctr for Human Nutrition, Los Angeles, CA

Background/Objectives: Loss of apoptosis is associated with the development of malignant cancers and apoptosis induction a possible approach for cancer treatment. Each major apop- tosis mediator has been shown to contribute in some way to the pathogenesis of colon cancer, however, the relative importance of individual mediators remains unknown. Only simultaneous analysis of them in a model of colon cancer progression can resolve which has the greatest potential impact on apoptosis. Utilizing a cell line system representing a primary tumor and subsequent metastatic lesion we simultaneously analyzed 9,600 cONKs for apop- tosis-related gene expression. Methods: Cell lines SW480 (primary colon cancer) and SW620 (metastatic lesion from the same patient) were obtained from the ATCC and grown under standard conditions, mRNA was extracted as previously described (Roesler et al. Am. J. Surg 174:251-257, 1997.), converted to cDNA then hybridized to a GeneChip as per standard protocol for the device. Results: See Table. Expression was also reduced in SW620 relative to SW480 for: TNF-related apoptosis inducing ligand, TNFR-related death receptor-6, apoptosis- related protein TFAR15, CSE1, and apoptosis inhibitor surviving genes. Conclusion: Bcl-2 was the most highly expressed apoptosis regulatory molecule in SW480 and its expression markedly reduced in the metastatic SW620 cell line. The apoptosis facilitator 6AX had slightly increased expression in SW620. However, the downstream effector molecules APAF-1 and Caspase-like spoptosis regulatory protein (CLARP) were markedly reduced in both cell lines. BCL-2 and BAX act reciprocally at the initiation stage for apoptosis. The BCL-APAF-cytochrome

c-caspase complex activates down stream caspases that enzymatically break down cell compo- nent during apoptosis. Loss of the downstream-effector molecules predominated in both cell lines. Downstream APAF and Caspase systems should be targeted for increased expression if enhanced apoptosis is desired as a cancer therapy.

Expression of Apoptotic mediators (% Relative Expression Compared to GAPDH)

CellLine BC~2 1~33 BAX p~ Cytoch.C APAF. CLARP t

SW~0 87,2 13.7 2.8 3.4 12.0 0.3 2.5 SW6~ 12,2 2.7 3.9 0.4 10.9 0.0 0.9

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mRNA Ouantitatiou of Thymidylate Synthase and Dihydropyrimidine Dehydrogenase Can Predict Disease-Free Survival in Stage lib and III Colon and Stage II and III Rectal Cancer Marko Kornmann, Karl H. Link, Univ of UIm, Ulm Germany; Wolfgang Schwabe, Peter Haeussler, Oncoscreen Research Institute, Jena Germany; Joern Straeter, Sucan Polat, Univ of Ulm, UIm Germany; Peter D. Danenberg, Univ of Southern CA, Los Angeles, CA; Detlet Behnke, Oncoscreen Research Institute, Jena Germany; Hans G. Beger, Univ of UIm, UIm Germany

Background: Patients (pts) with UICC stage lib and III colon and stage II and III rectal cancer (CRC) may receive adjuvant chemotherapy with 5-fluorouracil (5-FU) and levamisol. Despite the treatment 30-40% of the patients develop local or distant tumor recurrence. Thymidylate syntbase (TS) is a key enzyme in DNA synthesis and targeted by 5-FU, whereas dihydropyrimid- ine dehydrogenase (DPD) is the key enzyme for the inactivation and catabolism of 5-FU. High intratumoral levels of both enzymes have been associated with 5-FU resistance in advanced colorectal cancer (CRC). Aim: To investigate the value of TS and DPD as a predictive marker for disease-free survival (DFS) in pts with CRC receiving adjuvant 5-FU chemotherapy. Methods: So far, primary tumor tissue of 348 pts with CRC, which were entered from 1992 to 1999 in our randomized adjuvant trials of colon and rectal cancer (5-FU/levamisol vs. 5-FU/levamisol with folinic acid vs, 5-FU/levamisol with interferon--/), respectively, was used for this retrospec- tive analysis. TS and DPD mRNA quantitation was performed using an reverse transcription polymerase chain reaction technique with ~actin as internal standard. Results: Neither TS or DPD predicted tumor recurrence nor survival in all 348 pts. However, in the subgroup of pts with tumor recurrence (130/348 = 37%) TS alone predicted DFS. Thus, pts with low TS levels (u = 64) had a median DFS of 19.4 months (range: 3.0-55.7 months) and pts with high TS levels (n = 46) of 11.7 months (range: 1.7-53.1 months; (p < 0.0001). There was also a trend for longer median DFS in pts with low DPD levels, however the difference was statistically not significant. Conclusion: TS can predict the time to tumor recurrence in pts with CRC receiving adjuvant 5-FU treatment. It is possible that future adjuvant treatment of CRC is performed according to individual TS mRNA levels. Pts with low TS may receive adjuvant 5-FU according to current protocols, whereas pts with high TS may receive other 5-FU regimens or other agents for adjuvant chemotherapy.

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Role of Extrinsic Innervation in Jejunal Adaptation to Total Ileal Resection Karen D. Libsch, Nicholas J. Zyromski, Toshiyuki Tanaka, Louis J. Kost, Michael G. Sarr, Daniela Peia, Jaime Haidenberg, Mathias Worni, Mayo Clin, Rochester, MN

Segmental small bowel transplantation (SBT) offers theoretic advantages over total jejunoileal transplantation, but regional ability of the transplanted segment to adapt has not been well investigated. AIM: To investigate extrinsic neural mechanisms mediating jejunal adaptation to total ileal resection. HYPOTHESIS: Adaptive response is blunted in denervated bowel METHODS: 14 dogs were implanted with cannulae in proximal jejunum to measure absorption in an 80-cm segment via a triple lumen perfusion technique. After 2 wk, separate studies measuring baseline absorption of water, electrolytes, and 4 3H-labelled nutrients (glucose, glutamine, oleic acid and taumcholic acid) were performed (2 studies per dog with each solution). Control dogs (CON, n=6) then had the distal 50% of small bowel resected, preserving ileocecal valve. Experimental dogs (EXP, n = 8), underwent distal 50% enterectomy and extrinsic denervation of jejunoileum; this validated model of (auto)transplantation avoids immune rejection and ischemia/reperfusion. Absorptive studies were repeated in both groups 2 and 12 wk later. RESULTS: All dogs developed diarrhea which resolved in all but 1 CON dog but persisted in all 8 EXP dogs. Maximal weight loss was greater in EXP (3.7_+0.2 vs 2.1 _+02 kg; p<O.05). Glucose and oleate absorption was decreased at 2 wk after ileal resection in both CON and EXP; glutamine absorption was decreased at 2 wk in EXP only. All values returned to baseline at 12 wk (Table). Net fluxes of tauro-cholate and water were unchanged in both groups. Summary: Distal 50% enterectomy induces a short bowel syndrome worsened by extrinsic denervation. Despite more weight loss and persistent diarrhea, there were no differences in absorptive fluxes 12 wk after denervation. CONCLUSION: Extrinsic denervation as necessitated by SBT does not blunt the jejunal adaptive response to total ileal resection. (Support NIH R01 DK39337-MGS)

Glucose Glutamine Oleic acid CON EXP CON EXP CON EXP

Baseline 4.~0.5 4.~0.4 4.0_+0.4 4.1_+0,2 9.7_+1.0 0.2_+0.5 2 wk 2.7_+0.6* 2.5_+0.8* 3.5~0.7 2.6_+0.4* 6.3_+0.5* 5.8~0.8" 122k 3,7±0.3 4.0_+1.1 4.4_+1.0 3,6-+0,6 8.0±1.6 7.5_+1.5

Absorptive fluxes (pM cm -1 • 10 -2) are ~SEM, *p<O.05 vs baseline.

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