Cellular mechanisms underlying the protective effects of preoperative feeding: a randomized study investigating muscle and liver glycogen content, mitochondrial function, gene and protein expression.

OBJECTIVE: To investigate the effects of preoperative feeding with a carbohydrate-based drink that also contained glutamine and antioxidants (oral nutritional supplement [ONS], Fresenuis Kabi, Germany) on glycogen reserves, mitochondrial function, and the expression of key metabolic genes and proteins. SUMMARY BACKGROUND DATA: Preoperative carbohydrate loading attenuates the decline in postoperative insulin sensitivity but the cellular mechanisms underlying this remain unclear. METHODS: Two groups of 20 patients undergoing laparoscopic cholecystectomy participated in this randomized placebo-controlled double-blind study. Patients received either 600 mL of ONS or placebo the evening before surgery, and again 300 mL 3 to 4 hours before anesthesia. A 300-mL aliquot of ONS contained 50 g of carbohydrate, 15 g of glutamine and antioxidants. Blood was sampled before ingestion of the evening drink, after induction of anesthesia, and on postoperative day 1 for measurement of concentrations of glucose, glutamine, and antioxidants. Rectus abdominis muscle and liver biopsies were performed intraoperatively to determine glycogen and glutamine concentrations, mitochondrial function, pyruvate dehydrogenase kinase (PDK4), forkhead transcription factor 1 (FOXO1), and metallothionein 1A (Mt1A) expression. RESULTS: There were no drink-related complications. ONS ingestion led to increased intraoperative liver glycogen reserves (44%, P < 0.001) and plasma glutamine and antioxidant concentrations, the latter 2 remaining elevated up to the first postoperative day. Muscle PDK4 mRNA, PDK4 protein expression, and Mt1A mRNA expression were 4-fold (P < 0.001), 44% (P < 0.05), and 1.5-fold (P < 0.001), respectively, lower in the ONS group. There were no differences in FOXO1 mRNA and protein expression. CONCLUSIONS: The changes in muscle PDK4 may explain the mechanism by which preoperative feeding with carbohydrate-based drinks attenuates the development of postoperative insulin resistance.

Immunohistochemical expression of mitochondrial membrane complexes (MMCs) I, III, IV and V in malignant and benign periampullary epithelium: a potential target for drug therapy of periampullary cancer?

BACKGROUND: Mitochondrial membrane complexes (MMCs) are key mediators of cellular oxidative phosphorylation, and inhibiting them could lead to cell death. No published data are available on the relative abundance of MMCs in different periampullary cancers. Therefore, we studied the expression profile of MMCs I, III, IV and V in periampullary cancers, reactive pancreatitis, normal pancreas and chronic pancreatitis. METHODS: This was a retrospective study on tissue microarrays constructed from formalin-fixed paraffin-embedded tissue from 126 consecutive patients (cancer = 104, chronic pancreatitis = 22) undergoing pancreatic resections between June 2001 and June 2006. 78 specimens of chronic pancreatitis tissue were obtained adjacent to areas of cancer. Normal pancreatic tissue was obtained from the resection specimens in a total of 30 patients. Metastatic tumours in 61 regional lymph nodes from 61 patients were also studied. RESULTS: MMCs I, III, IV and V were highly expressed (p < 0.05) in all primary periampullary cancers compared with metastatic lymph nodes and adjacent benign pancreas. MMCs III, IV and V were highly expressed in all cancers regardless of type compared with chronic pancreatitis (p < 0.05). Higher expression of MMCs I and V was associated with better survival and may, in part, relate to lower expression of these MMCs in poorly differentiated tumours compared with well and moderately differentiated tumours. CONCLUSIONS: Differential expression of MMCs III, IV and V in primary periampullary cancers compared with adjacent benign periampullary tissue and chronic pancreatitis is a novel finding, which may render them attractive anticancer targets.

Predictive value of tumor proliferative indices in periampullary cancers: Ki-67, mitotic activity index (MI) and volume corrected mitotic index (M/V) using tissue microarrays.

BACKGROUND: Morphometry [nuclear Ki-67 labelling, mitotic activity index (MI), and volume-corrected mitotic index (M/V)] for periampullary cancers using tissue microarrays has not been performed previously. The purpose of the study was to assess these indices on tissue microarray (TMA) sections constructed from patients with periampullary cancers and study their association with clinicopathological variables. METHODS: Immunohistochemical staining for Ki-67 was performed on formalin-fixed pancreatic TMA sections. Expression of Ki-67 was assessed as the percentage of cancer cell nuclei expressing MIB1, MI as the mean percentage of Ki-67 from 10 random high-power fields, and M/V was calculated after standardizing MI for connective tissue volume and microscope parameters in the tumor using established protocols. RESULTS: Patients > or =70 years with periampullary cancers had higher Ki-67 expression (>15) compared with patients <70 years of age (chi(2) = 3.9, P = 0.047). Ki-67 expression was higher in tumors > or =2 cm (chi(2) = 4.9, P = 0.028) compared with smaller tumors. Higher MI (>15) was clearly associated with worsening histological grade (chi(2) = 9.2, P = 0.010). The median survival for tumors of the pancreaticobiliary subtype (pancreatic ductal adenocarcinoma and cholangiocarcinoma) was 43 months in the group with an M/V score of <20, compared with 18 months for the group with a score > or =20 (P = 0.001). There was no statistically significant difference in survival, based on M/V score, for tumors of the intestinal subtype (ampullary and duodenal adenocarcinoma). CONCLUSIONS: In periampullary cancers, Ki-67 and MI are proliferative indices predictive of tumor behavior. M/V was predictive of survival in tumors of the pancreaticobiliary subtype.

Complete absence of M2-pyruvate kinase expression in benign pancreatic ductal epithelium and pancreaticobiliary and duodenal neoplasia.

BACKGROUND: Elevated serum concentrations of M2-pyruvate kinase (M2-PK) correlate with poor prognosis in patients with pancreaticobiliary and duodenal cancer, but the expression of M2-PK in formalin-fixed pancreatic tissue is unknown. We aimed to characterise the immunohistochemical expression of M2-PK in archived specimens of pancreaticobiliary and duodenal cancers, premalignant lesions, chronic pancreatitis, and normal pancreas. METHODS: Immunohistochemical staining was performed with mouse anti-M2-PK monoclonal antibody (clone DF-4) at an optimal dilution of 1:25 on tissue microarrays constructed from formalin-fixed paraffin-embedded pancreatic tissue of 126 consecutive patients undergoing pancreatic resections between June 2001 and June 2006. 104 underwent resection for cancer and 22 for chronic pancreatitis. 78 specimens of chronic pancreatitis tissue were obtained adjacent to areas of cancer. Normal pancreatic tissue was obtained from the resection specimens in a total of 30 patients. Metastatic tumours in 61 regional lymph nodes from 61 patients were also studied. A further 11 premalignant pancreaticobiliary and duodenal lesions were studied. M2-PK expression was quantified with the immunohistochemical score (IHS; Range 0-12). RESULTS: Benign non-ductal tissue in chronic pancreatitis and normal pancreas showed variable expression of M2-PK (IHS = 1 in 25%, IHS = 2-3 in 40%, IHS>3 in 40%). Benign pancreatic ductal epithelium, all primary pancreaticobiliary and duodenal premalignant lesions and cancers (and lymph node metastasis) showed complete lack of expression (IHS = 0). CONCLUSION: Complete lack of M2-PK expression was observed in benign pancreatic ducts, premalignant lesions and cancer. M2-PK is present only in benign non-ductal epithelium in normal pancreas and peri-tumoural tissue.

Significant immunomodulatory effects of Pseudomonas aeruginosa quorum-sensing signal molecules: possible link in human sepsis.

Pathogenic bacteria use quorum-sensing signal molecules to co-ordinate the expression of virulence genes. Animal-based studies have demonstrated the immunomodulatory effects of quorum-sensing signal molecules. In the present study, we have examined the impact of these molecules on normal human immune function in vitro and compared this with immune changes in patients with sepsis where quorum-sensing signal molecules were detected in the sera of patients. Quorum-sensing signal molecules inhibited normal dendritic cell and T-cell activation and proliferation, and down-regulated the expression of co-stimulatory molecules on dendritic cells; in MLDCRs (mixed lymphocyte dendritic cell reactions), secretion of IL (interleukin)-4 and IL-10 was enhanced, but TNF-alpha (tumour necrosis factor-alpha), IFN-gamma (interferon-gamma) and IL-6 was reduced. Quorum-sensing signal molecules induced apoptosis in dendritic cells and CD4(+) cells, but not CD8(+) cells. Dendritic cells from patients with sepsis were depleted and ex vivo showed defective expression of co-stimulatory molecules and dysfunctional stimulation of allogeneic T-lymphocytes. Enhanced apoptosis of dendritic cells and differential CD4(+) Th1/Th2 (T-helper 1/2) cell apoptotic rate, and modified Th1/Th2 cell cytokine profiles in MLDCRs were also demonstrated in patients with sepsis. The pattern of immunological changes in patients with sepsis mirrors the effects of quorum-sensing signal molecules on responses of immune cells from normal individuals in vitro, suggesting that quorum-sensing signal molecules should be investigated further as a cause of immune dysfunction in sepsis.

Combined antioxidant therapy reduces pain and improves quality of life in chronic pancreatitis.

Patients with chronic pancreatitis (CP) typically suffer intractable abdominal pain that is resistant to most analgesic strategies. Recent research indicates that the pain of CP may be in part due to oxygen free radical induced pancreatic damage. Using a randomized, double-blind, placebo-controlled crossover trial, we evaluated the efficacy of a combined antioxidant preparation in the management of CP. Patients with confirmed chronic pancreatitis (N = 36) were randomized to receive treatment with either Antox, which contains the antioxidants selenium, betacarotene, L-methionine, and vitamins C and E, or placebo for 10 weeks. Each group of patients then switched to receive the alternative treatment for a further 10 weeks. Markers of antioxidant status were measured by blood sampling, whereas quality of life and pain were assessed using the SF-36 questionnaire. Nineteen patients completed the full 20 weeks of treatment. Treatment with Antox was associated with significant improvements in quality of life in terms of pain (+17 antioxidant vs. -7 placebo), physical (+9 vs. -3) and social functioning (+8 vs. -7), and general health perception (+10 vs. -3). We conclude that treatment with antioxidants may improve quality of life and reduce pain in patients suffering from chronic pancreatitis.

Early postoperative jejunostomy feeding with an immune modulating diet in patients undergoing resectional surgery for upper gastrointestinal cancer: a prospective, randomized, controlled, double-blind study.

BACKGROUND: The provision of perioperative immune modulating enteral feeds after major surgery may result in reduced infective complications, but meta-analyses have not demonstrated a survival advantage. The aim of this study was to determine whether early postoperative immune modulating jejunostomy feeding results in reduced infective complications in patients undergoing resectional surgery for upper gastrointestinal cancer. METHODS: A total of 120 patients undergoing resection for cancers of the pancreas, oesophagus and stomach were randomized in a double-blind manner to receive jejunostomy feeding with an immune modulating diet (Stresson-Group A) or an isonitrogenous, isocaloric feed (1250 Calories and 75 g protein/l--Nutrison High Protein-Group B) for 10-15 days. Feeding was commenced 4h postoperatively and continued for 20 h/day. The target volume (ml/h) was 25 on day 0, 50 on day 1, and 75 thereafter. Outcome measures included complications, hospital stay and mortality. RESULTS: A total of 108 patients (54 in each group) were analysed. Feed delivery, although less than targeted, was similar in both groups. There were 6 (11%) deaths in each group. Median (IQR) postoperative hospital stay was 14.5 (12-23) days in Group A and 17.5 (13-23) days in Group B (P=0.48). A total of 24 (44%) patients in each group had infective complications (P=1.0). A total of 21 (39%) patients in Group A and 28 (52%) in Group B had non-infective complications (P=0.18). Jejunostomy-related complications occurred in 26 (48%) patients in Group A and 30 (56%) in Group B (P=0.3). CONCLUSION: Early postoperative feeding with an immune modulating diet conferred no outcome advantage when compared with a standard feed.

Squamous cell carcinoma of the pancreas: report of a case and review of the literature.

CONTEXT: Although, squamous metaplasia of the ductal columnar cells can be observed during periods of inflammation, squamous cell pancreatic carcinoma is an extremely rare tumour. CASE REPORT: We present the case of a 72-year-old man who presented to our hospital with painless obstructive jaundice. After careful and adequate staging investigations that revealed a malignant mass in the head of pancreas he underwent a laparotomy which revealed an inoperable pancreatic cancer. Palliative bypass procedure was done. The biopsy specimens revealed a squamous cell cancer. CONCLUSION: Pure squamous cell carcinoma of the pancreas is a very rare malignancy. In most cases it is not possible to make a pre-operative histological diagnosis and curative resection is unlikely because of dissemination at the time of initial diagnosis or laparotomy.

Heterotopic pancreas in the spleen: malignant degeneration to mucinous cystadenocarcinoma.

We report the clinicopathological findings of a patient who presented with a primary splenic cystic tumour arising from heterotopic pancreatic tissue. The pancreas was normal on radiological and intraoperative examination. Histological analysis of the specimen demonstrated a mucinous cystadenocarcinoma with remnants of normal pancreatic tissue within the substance of the spleen. Immunohistochemistry characterized the tumour as being pancreatic in origin with overexpression of p53 protein. Five cases of primary mucinous cystadenocarcinoma of the spleen originating from heterotopic pancreatic tissue have been described; to our knowledge, this is the first case to provide conclusive immunohistochemical evidence to support this proposition.

Percutaneous biliary metal wall stenting in malignant obstructive jaundice.

BACKGROUND: Most patients with advanced stage malignant obstructive jaundice will be suitable for palliation only. Metallic stents are safe, effective and minimally invasive. DESIGN: A review of case notes of patients who had Wallstents inserted percutaneously from January 1996 to December 2000. RESULTS: Eighty-nine patients with a median age of 72 years underwent percutaneous insertion of biliary metal stents. The diagnoses were cholangiocarcinoma (41.5%), pancreatic carcinoma (40.5%), nodal metastases at the porta hepatis (14.6%) and gall bladder cancer (3.4%). Ninety-six per cent of patients improved their hyperbilirubinaemia to normal levels by 1 month. The median post-procedure hospital stay was 16 days. Early overall complications (within 30 days of stenting) occurred in 30% of patients (70% of these were disease related). The 30 day mortality rate was 20% (n = 18). Fifty (70%) patients were readmitted to hospital, most commonly because of carcinomatosis (16) or stent obstruction (12). The symptom-free period ranged from 2 weeks to 13 months. Median survival for all patients was 3.5 months. Survival correlated inversely with serum bilirubin at presentation (r = -0.34, P = 0.001), but not with other liver function tests. DISCUSSION: Metal wall stenting for malignant obstructive jaundice provides good palliation with low, procedure-related morbidity and mortality, but poor overall survival from disease-related morbidity. Survival significantly correlates with pre-stenting serum bilirubin levels. There is a need to identify the subgroup of patients in whom stenting has no beneficial effect.

Ethylene diamine tetraacetic acid-induced colonic crypt cell proliferation in rats.

AIM: To investigate the effect of ethylene diamine tetraacetic acid (EDTA) on proliferation of rat colonic cells. METHODS: EDTA was administered into Wistar rats, carcinogenesis induced by 1,2-dimethylhydrazine (DMH) in rats was studied with immunohistochemistry. RESULTS: Marked regional differences in cell proliferation were found in all groups. In EDTA-treated animals, total labelling indexes in both proximal (10.00 +/- 0.44 vs 7.20 +/- 0.45) and distal (11.05 +/- 0.45 vs 8.65 +/- 0.34) colon and proliferative zone size (21.67 +/- 1.13 vs 16.75 +/- 1.45, 27.73 +/- 1.46 vs 21.74 +/- 1.07) were significantly higher than that in normal controls (P<0.05) and lower than that in DMH group (10.00 +/- 0.44 vs 11.54 +/- 0.45, 11.05 +/- 0.45 vs 13.13 +/- 0.46, 21.67 +/- 1.13 vs 35.52 +/- 1.58, 27.73 +/- 1.46 vs 39.61 +/- 1.32, P<0.05). Cumulative frequency distributions showed a shift of the EDTA distal curve to the right (P<0.05) while the EDTA proximal curve did not change compared to normal controls. Despite the changes of proliferative parameters, tumours did not develop in EDTA treated animals. CONCLUSION: Hyperproliferation appears to be more easily induced by EDTA in distal colon than in proximal colon. Hyperproliferation may need to exceed a threshold to develop colonic tumours. EDTA may work as a co-factor in colonic tumorigenesis.

Variability of cell proliferation in the proximal and distal colon of normal rats and rats with dimethylhydrazine induced carcinogenesis.

AIM: To investigate the patterns of cell proliferation in proximal and distal colons in normal rats and rats with 1,2-dimethylhydrazine (DMH) induced carcinogenesis using the thymidine analogue bromodeoxyuridine. METHODS: Colonic crypt cell proliferation was immunohistochemically detected using the anti-bromodeoxyuridine Bu20a monoclonal antibody. RESULTS: Marked regional differences were found in both groups. Total labelling index (LI) and proliferative zone size in both normal (8.65+/-0.34 vs 7.2+/-0.45, 27.74+/-1.07 vs 16.75+/-1.45) and DMH groups (13.13+/-0.46 vs 11.55+/-0.45, 39.60+/-1.32 vs 35.52+/-1.58) were significantly higher in distal than in proximal colon (P<0.05), although the number of cells per proximal crypt was greater (31.45+/-0.20 vs 34.45 +/-0.39, 42.68+/-0.53 vs 49.09+/-0.65, P<0.0001). Crypt length, total LI and proliferative zone size all increased in both proximal and distal regions of DMH rats compared to normal controls (P<0.0001). In DMH-treated rat colon a shift of labelled cells to higher crypt cell positions was demonstrated distally whilst a bi-directional shift was evident proximally (P<0.05). CONCLUSION: Our results show that changes in cell proliferation patterns, as assessed by bromodeoxyuridine uptake, can act as a reliable intermediate marker of colonic cancer formation. Observed differences between proliferation patterns in distal and proximal colon may be associated with the higher incidence of tumors in the distal colon.

Transduodenal sphincteroplasty and transampullary septectomy for sphincter of Oddi dysfunction.

BACKGROUND: The diagnosis and management of sphincter of Oddi dysfunction are controversial issues. Both surgical and endoscopic series report modest success in the treatment of this condition. There is evidence from endoscopic series that the Milwaukee classification could predict the clinical outcome after sphincterotomy. We reviewed our long-term results of surgical sphincter ablation for sphincter of Oddi dysfunction, in order to correlate outcome with underlining pathology (biliary versus pancreatic) and Milwaukee biliary group classification. PATIENTS AND METHODS: During a 10 year period (1987-1996), 36 patients with either biliary (n = 26) or pancreatic (n = 10) presentation of suspected sphincter of Oddi dysfunction were selected for surgery according to a standard protocol of investigation and management. All patients were classified according to the Milwaukee classification for the biliary group or its version for the pancreatic group and had transduodenal sphincteroplasty and transampullary septectomy. RESULTS: Despite a trend towards a better outcome in the biliary group (good result 62%, moderate 23%, poor 15%) compared to the pancreatic (good result 40%, moderate 40%, poor 20%) the difference was not statistically significant (P = 0.48). Milwaukee classification for the biliary group correlated well with a favourable outcome (P < 0.05). CONCLUSIONS: The modest outcome despite careful patient selection for surgery emphasises the need for more objective diagnostic tools. Milwaukee classification appears to be of good predictive value, and a good result can be anticipated in type I or even type II patients. The trend towards a better outcome in the biliary group may reflect the weakness of a drainage procedure to treat patients with parenchymal pancreatic disease.

An international multicenter randomized controlled trial of G17DT in patients with pancreatic cancer.

OBJECTIVES: This study aimed to investigate G17DT, an immunogen producing neutralizing antibodies against the tumor growth factors amidated and glycine-extended forms of gastrin-17, in the treatment of pancreatic cancer. METHODS: A randomized, double-blind, placebo-controlled, group-sequential multicenter trial of G17DT in patients with advanced pancreatic cancer unsuitable for or unwilling to take chemotherapy. Inclusion criteria were a Karnofsky performance score of 60 or higher and a life expectancy of more than 2 months. Patients received G17DT or placebo emulsion at weeks 0, 1, 3, 24, and 52. The primary end point was survival, and secondary end points were tolerability, Karnofsky performance. RESULTS: A total of 154 patients were recruited: 79 G17DT and 75 placebo. A final analysis of the intention-to-treat population, using a proportional hazards model, stratifying by disease stage and adjusting for interim analysis, gave a hazard ratio for mortality of 0.75 (95% confidence interval, 0.51-1.10, P = 0.138; G17DT/placebo). A conventional analysis without adjustment for disease stage or interim analysis, censoring for chemotherapy and excluding protocol violators, gave median survival periods of 151 (G17DT) and 82 days (placebo) (log-rank test, P = 0.03).Patients developing anti-G17DT responses (73.8%) survived longer than nonresponders or those on placebo (median survival, 176 vs 63 vs 83; log-rank test, P = 0.003). G17DT was well tolerated.

Vacuum-assisted closure of postoperative abdominal wounds: a prospective study.

BACKGROUND: We aimed to study outcome in patients with an open abdomen in whom the abdominal vacuum-assisted closure system (V.A.C.((R)) Therapy()) was used to provide temporary cover and achieve wound closure. METHODS: All patients in whom V.A.C. Therapy was used to manage laparotomy wounds between February 2006 and May 2007 at a University Teaching Hospital were followed up prospectively until successful completion or stoppage of V.A.C. Therapy. RESULTS: Of the 51 consecutive patients (33 male), V.A.C. Therapy was used to manage a laparostomy in 10 patients and abdominal wound dehiscence in 41. Median (IQR) duration of V.A.C. Therapy was 17 (7-26) days. Wound healing was achieved in 31 (61%) patients, four of whom had additional surgery to assist wound closure. The rest healed by secondary intention. Treatment was withdrawn due to therapy-related complications in nine patients and due to medical or logistical reasons in seven. Four patients died while on therapy. While most V.A.C. Therapy-related problems were minor, two patients developed enteric fistulae that necessitated surgical repair. At a median (IQR) follow-up of 8 (4-13) months, 18 patients had stable cutaneous coverage with no incisional hernia, 12 developed an incisional hernia, 9 were lost to follow-up, and 12 died. CONCLUSIONS: V.A.C. Therapy is a useful adjunct in the management of the open abdomen and should be considered in the treatment of this problem. Restoration of cutaneous and fascial integrity of the abdominal wall, the risk of fistulisation, and the cost-effectiveness of this therapy require further evaluation.

Is a T-tube necessary after common bile duct exploration?

BACKGROUND: T-tube drainage used to be standard practice after surgical choledocholithotomy, but there is now a tendency in some centers to close the common bile duct (CBD) primarily. This study was designed to review the complications associated with T-tube drainage after CBD exploration and to determine whether primary closure of the bile duct reduces postoperative morbidity. METHODS: A retrospective audit was performed on patients undergoing CBD exploration between July 1997 and March 2007, who were identified from the theatre database of one teaching hospital. Intraoperative findings and postoperative complications were recorded from the clinical notes. RESULTS: During the study period, 158 patients (97 women; median age 65 (range, 25-90) years) underwent CBD exploration. A T-tube was inserted in 91 patients (group I) and the CBD was closed primarily in 67 (group II). One or more biliary complications occurred in 26 patients (16.5%): 20 (22.0%) in group I and 6 (8.9%) in group II (p = 0.03). In group I, 15 had a biliary leak (3 needed reoperation), 2 had accidental slippage of the tube, 2 an entrapped T-tube, and 1 a retained stone. In group II, six patients had biliary leakage, two of whom were re-explored. Six patients in group I also had peritubal infection, necessitating the use of antibiotics. There were three deaths: two in group I (1 T-tube-related) and 1 in group II (p = 1, not significant). CONCLUSION: There is a lower biliary complication rate associated with primary closure of the CBD than after T-tube drainage.