Management of acute diverticulitis in a tertiary care institution.

BACKGROUND: Diverticular disease of the left colon is a common disease, mainly in the population over 50 years of age. The surgical management of acute diverticulitis is remains controversial, especially in severe forms. OBJECTIVE: This study aimed to evaluate the results of laparoscopic surgery for diverticular disease in a tertiary care institution with a specialist interest in minimally invasive surgery. DESIGN: All patients who had elective laparoscopic sigmoidectomy for diverticulitis within eight years at University Hospital of Luxembourg were selected from a retrospective database to evaluate laparoscopic benefit in moderate and severe disease. RESULTS: A total of 155 patients were divided in two groups: Moderate Acute Diverticulitis (MAD) and Severe Acute Diverticulitis (SAD) respectively. The short-term outcomes, after laparoscopic sigmoidectomy, were evaluated. There were not important differences between two groups. CONCLUSIONS: The laparoscopic management of diverticular disease after moderate and severe crisis gives same benefits and short-term outcomes are similar. Elective Laparoscopic surgery is actually the standard of care for moderate and severe diverticular disease in our institution.

Transjugular Intrahepatic Portosystemic Shunt and Laparoscopic Colorectal Resection: the ideal minimally-invasive management for the treatment of colorectal cancer in severe cirrhotic patients. A case report and literature review.

Surgical interventions on gastrointestinal tract are often not well tolerated by patients with cirrhosis and severe portal hypertension, impairing their prognosis if suffering from malignant disease. Combining the benefits of two minimally invasive techniques such as Transjugular intrahepatic portosystemic shunt (TIPS) and Laparoscopic Colorectal Resection (LCR), the complications related to surgical intervention might be reduced and thus, it allows patients with liver disease, to undergo a curative intervention. One patient with cirrhosis and portal hypertension diagnosed with a rectal cancer underwent a meticulous preoperative preparation through placement of TIPS before laparoscopic surgery. TIPS placement was performed without intraprocedure complications. The patient was successfully operated by laparoscopic technique 36 days after TIPS placement without intraoperative bleeding or postoperative complications. Our experience, despite being based on one case, allows us to conclude that decompression of portal system by TIPS, already used in open surgery, may be applicable as a preoperative laparoscopic procedure with equally satisfactory results.

Influence of obesity-susceptibility loci (MC4R and INSIG2) on the outcome of weight loss and amelioration of co-morbidity in obese patients treated by a gastric-bypass.

BACKGROUND: Genome-wide association and linkage studies have identified multiple susceptibility loci for obesity. OBJECTIVE: We hypothesized that such loci may affect weight loss and comorbidity amelioration outcomes following a gastric-bypass. DESIGN: A total of 200 obese patients who underwent a gastric bypass surgery were genotyped for single-nucleotide polymorphisms (SNPs) in insulin induced gene 2 (INSIG2) and melanocortin 4 receptor (MC4R) obesity genes. RESULTS: After a follow-up of 18 month, the patients (192) data of weight excess loss (72%) and co-morbidities (Hypertension -62- and Diabetes -39-) were analyzed and compared. 26 Patients with SNP were found (9 MC4R and 17 INSIG2). No significant differences in weight excess loss and amelioration of comorbidities were revealed. CONCLUSIONS: The data suggest no influence of weight excess loss and amelioration of co-morbidities after gastric-bypass by genetic susceptibility.

Somatostatin cell processes as pathways for paracrine secretion.

Somatostatin is produced by gastrointestinal endocrine cells that have long, nonluminal, cytoplasmic processes. Such processes terminate on other cell types, including gastrin-producing and hydrochloric acid-producing cells, whose functions are profoundly affected by somatostatin. The findings suggest that somatostatin cells control the functions of other cells through local release of the peptide by way of cytoplasmic processes. Also, certain other types of gastrointestinal endocrine cells have similar cytoplasmic prolongations, which may have analogous local (paracrine) regulatory functions.

Breath test for differential diagnosis between small intestinal bacterial overgrowth and irritable bowel disease: an observation on non-absorbable antibiotics.

AIM: To estimate the prevalence of small intestine bacterial overgrowth (SIBO) among patients with an earlier diagnosis of irritable bowel disease (IBS) in our geographical area, and to collect information on the use of locally acting non-absorbable antibiotics in the management of SIBO. METHODS: A non-interventional study was conducted in 73 consecutive patients with a symptom-based diagnosis. RESULTS: When the patients underwent a "breath test", 33 (45.2%) showed the presence of a SIBO. After treatment with rifaximin 1,200 mg/d for seven days in 32 patients, 19 (59.4%) showed a negative "breath test" one week later as well as a significant reduction of symptoms, thus confirming the relationship between SIBO and many of the symptoms claimed by patients. In the other 13 patients, "breath test" remained positive, and a further cycle of treatment with ciprofloxacin 500 mg/d was given for 7 additional days, resulting in a negative "breath test" in one patient only. CONCLUSION: (1) about half of the patients with a symptomatic diagnosis of IBS have actually SIBO, which is responsible for most of the symptoms attributed to IBS; (2) only a "breath test" with lactulose (or with glucose in subjects with an intolerance to lactose) can provide a differential diagnosis between IBS and SIBO, with almost identical symptoms; and (3) the use of non-absorbable antibiotics may be useful to reduce the degree of SIBO and related symptoms; it must be accompanied, however, by the correction of the wrong alimentary habits underlying SIBO.

Effect of bombesin on plasma insulin, pancreatic glucagon, and gut glucagon in man.

The effect of bombesin on insulin, pancreatic glucagon, and gut glucagon was investigated in eight healthy volunteers and two pancreatectomized patients. Bombesin, infused iv at the constant rate of 5 ng kg-1 min-1, produced a sharp and statistically significant rise in the plasma insulin concentration. The peak was reached at 5 min (26 +/- 2.17 microU/ml; P less than 0.005 vs. basal values), followed by a prolonged and statistically significant (P less than 0.05) decrease in blood glucose. Pancreatic glucagon rapidly rose to a maximal value of 80.5 +/- 7.6 pmol/liter (P less than 0.005 vs. basal values). In contrast with the prompt increase in insulin and glucagon plasma levels, the peak in gut glucagon concentration (55.8 +/- 4.6 pmol/liter; P less than 0.005 vs. basal values) was reached 30 min after bombesin infusion was discontinued. In the two pancreatectomized patients, bombesin induced an increase in gut glucagon concentrations only. The results presented indicate that bombesin acts directly on the A and B cells of the pancreas, influencing glucose homeostasis; however, more complex mechanisms seem to be involved in gut glucagon secretion.

Zollinger-Ellison syndrome and antral G-cell hyperfunction in patients with resistant duodenal ulcer disease.

We measured basal and pentagastrin-stimulated acid secretion, as well as basal and meal-stimulated plasma gastrin concentration to determine, in 67 patients affected by resistant duodenal ulcer, whether their condition could be related to gastric acid secretion and/or gastrin-related syndromes. We then compared them to 46 duodenal ulcer control patients. The outpatients were investigated consecutively. The resistant duodenal ulcer patients differed from the controls only in their higher complication rates (bleeding or perforation, P < 0.05). We identified five patients in the resistant duodenal ulcer group with Zollinger-Ellison syndrome and 12 with antral G cell hyperfunction, whereas in the control group only one patient was affected by antral G cell hyperfunction. IgG anti-Helicobacter pylori antibodies were positive for the presence of infection in 7 of the hypergastrinaemic patients. When Zollinger-Ellison syndrome or antral G cell hyperfunction were excluded, no differences could be found in gastric acid secretion, or basal and meal-stimulated plasma gastrin levels, between the resistant and control duodenal ulcer patients, except for basal acid hypersecretion (resistant duodenal ulcer 16% vs duodenal ulcer 2% P = 0.0144). In the presence of duodenal ulcer disease resistant to H2-blockers, it is mandatory to measure basal plasma gastrin concentration since it was possible to diagnose the gastrin-related syndromes, Zollinger-Ellison syndrome and antral G cell hyperfunction, in 26% of this group of patients.

Peptides of the APUD system in amphibian skins.

Methanol extracted skins from 84 species of amphibia were screened, measuring by RIAs: gastrin-CCK, VIP, calcitonin, GIP, PP and motilin. G-CCK-like immunoreactivity was found in 97.6%; VIP-like immunoreactivity in 41%; CT-like immunoreactivity in 34%; GIP-like immunoreactivity in 10%; PP-like immunoreactivity in 40% and MT-like immunoreactivity in 60% of the samples. The use of a sequence-specific radioimmunoassay and of gel-chromatography confirmed the caerulein-CCK-8-like nature of the immunoreactive material. Detected amounts of the other peptides (VIP, CT, GIP, PP, MT) were too low for bioassay or chromatographic studies, thus leaving the question open if they are due to some kind of unspecific interferences or, most likely, to species-specificity differences of the used antisera.

Bombesin effects on human GI functions.

In this article some of the actions of amphibian skin peptide Bombesin (BBS) on human gastrointestinal and pancreatic functions are reviewed. BBS causes increases of lower esophageal sphincter pressure, delay of gastric emptying, inhibition of mechanical activity of duodenum and jejunum and gallbladder emptying. BBS also releases in man gastrin and stimulates gastric acid secretion. BBS administration induces release of insulin, glucagon and pancreatic polypeptide from human Islet of Langerhans and causes secretion of pancreatic bicarbonates and enzymes in duodenal juice and release of pancreatic enzymes in blood stream.

Sulfation of gastrin: effect on immunoreactivity.

The effect of sulfuric acid esterification of Tyr-12 in gastrin-17 on immunoreactivity was evaluated by the ability of seventeen antisera raised against non-sulfated gastrin-17 to bind sulfated gastrins in extracts of gastrinoma and antral tissue. Using non-sulfated Tyr-12 iodinated gastrin as tracer, and non-sulfated gastrin-17 as standard the antisera showed three different patterns of reactivity: Three antisera (Nos. 2602, 2605 and 4562) bound sulfated gastrins with low (4-23%) potency; four antisera (Nos. 2604, 2720, 4710 and 4713) measured sulfated gastrins with a potency similar to that of non-sulfated gastrins (81-100% crossreactivity); whereas ten antisera (Nos. 2601, 2606, 2609, 2716, 2717, 2718, 4556, 4559, 4560 and 4563) displayed enhanced reactivity with sulfated gastrins (130-373% crossreactivity). Using Gly-2 iodinated gastrin as tracer, the latter type of antisera reacted almost equally with sulfated and non-sulfated gastrins, suggesting that the apparent increase in binding of sulfated gastrins rather is due to increased displacement of Tyr-12 iodinated gastrin. The results show that derivatization of amino acid residues greatly influences antibody binding.

Evidence that bombesin releases extragastric gastrin in man.

Bombesin-induced gastrin release from extragastric sources has been investigated in two groups of patients without gastric antrum: 11 patients with total gastrectomy and 11 patients with subtotal (Billroth II) gastrectomy. A 30-min bombesin infusion (5 ng . kg-1 . min-1) caused a prompt significant gastrin increase (P less than 0.05) in both groups of patients. The gastrin response to bombesin was significantly (P less than 0.005) lower in patients without antral tissue than in the control group (n = 7). The individual peak gastrin responses, in totally (TG) and subtotally (SG) gastrectomized patients, were significantly over basal levels (TG: peak 100.3 +/- 12 vs. basal 62.8 +/- 9.1, P less than 0.005; SG: peak 96.9 +/- 9.4 vs. basal 72.4 +/- 6.8, P less than 0.001; pg/ml, mean +/- S.E.M.). These data indicate that bombesin acts not only on antral G cells, but on all gastrin cells in the gastrointestinal tract.

Dose-response effect of somatostatin-14 on human basal pancreatic hormones.

The effect of increased doses of Somatostatin-14 (3, 10, 30, 100, 300 micrograms/h) on basal release of insulin, pancreatic glucagon and pancreatic polypeptide (PP) was investigated on eight normal volunteers. Levels of Somatostatin-like immunoreactivity (SLI) was determined in order to correlate the increased SLI levels with the degree of islet hormone inhibition (r = 0.9947, p less than 0.01). By increasing the basal levels of SLI by one-third, a significant inhibition (p less than 0.01) of insulin, glucagon, and PP was noted (78.5, 78.6, 75.2%, respectively, on basal levels). The maximal effect was obtained with 300 micrograms/h for insulin, with 30 micrograms/h for glucagon and 100 micrograms/h for PP. In evaluating the relative inhibitory potency of somatostatin, expressed as ED50, the theoretic potency of somatostatin on each peptide had similar values, ranging from 30 to 10 micrograms/h. The present data show that a minimal peripheric increase in SLI is able to regulate basal islet pancreatic hormones.

Radioimmunochemical quantitation of sulfated and non-sulfated gastrins in serum.

A radioimmunochemical procedure which distinguishes sulfated from non-sulfated gastrins has been developed. Two antisera raised against synthetic non-sulfated human hexadecapeptide gastrin were used. No. 2604 binds sulfated and non-sulfated gastrins with equimolar potency, whereas No. 2605 reacts poorly with sulfated gastrin (ID50 for non-sulfated gastrin: ID50 for sulfated gastrin = 0.06). Both antisera bind gastrins of different molecular length with equimolar potency using monoiodinated human gastrin-17 as tracer. The method was validated by fractionating gastrins in serum and in tissue extracts, and by recovery experiments. We found that Component I of gastrin--like the smaller gastrin components--was present in both, sulfated and non-sulfated form. In serum from normal fasting subjects the concentration of non-sulfated gastrin was 12.5 +/- 0.8 pmol/l (mean +/- SEM) with a total range of 0-44 pmol/l and the corresponding values for sulfated gastrin were 7.5 +/- 0.5 pmol/l (range 0-20 pmol/l). Sulfated gastrin accounted for more than half of the gastrins in only 21% of normal subjects. There was a parallel rise and fall in sulfated and non-sulfated gastrins after a meal and after stimulation with adrenaline.

Assessment of small intestinal damage in patients treated with pelvic radiotherapy.

Pelvic radiotherapy almost always induces intestinal symptoms. We investigated the radiation-induced damage to the small intestinal mucosa and evaluated its relationship with symptoms, using cellobiose/mannitol permeability test (CE/MA) and plasma postheparin diamine oxidase test (PHD) in 20 patients treated with pelvic radiotherapy. The symptoms developed during radiotherapy were noted. Intestinal permeability significantly (p=0.013) increased from 0.021 +/- 0.026 to 0.047 +/- 0.055 (mean +/- SD) after 15 days of radiotherapy, while it returned to normal values (0.010 0.015) at the end of radiotherapy. PHD values did not change. All patients developed intestinal symptoms. These findings indicate that pelvic radiotherapy induces an early small bowel mucosa damage followed by mucosal adaptation. Acute intestinal symptoms during pelvic radiotherapy may not depend only on small intestinal mucosal damage.

Intestinal permeability in Crohn's disease patients and their first degree relatives.

BACKGROUND: Family studies suggested that an altered intestinal permeability plays a role in the genesis of Crohn's disease. AIM: Aim of the present study was to investigate a possible genetic alteration of the mucosal barrier in Crohn's disease. SUBJECTS: 16 Crohn's disease patients and 26 of their cohabiting first degree relatives were studied. METHODS: To investigate intestinal permeability, Cellobiose/Mannitol test was administered to both groups. RESULTS: In the two groups, we found that the median intestinal permeability values were higher and statistically different from those obtained in 32 healthy control subjects as well as in five healthy control families. Six (37.5%) Crohn's disease patients and three (11.5%) of their first degree relatives showed increased individual intestinal permeability values. Intestinal permeability alteration in Crohn's disease patients was unrelated to sex, age, disease activity, localisation, duration, treatment schedule, as well as to serum anti-Saccharomyces cervisiae antibody positivity in a pilot study conducted in 7 Crohn's disease patients; anti-Saccharomyces cervisiae antibody values were negative in all 10 first degree relatives investigated. CONCLUSIONS: These findings demonstrate the increase in IP in 37% of the patients and in 11% of their relatives. More extensive investigation of the correlation between ASCA alterations and IP will be needed in both patients with Crohn's disease and their relatives.

Intestinal permeability and diabetes mellitus type 2.

BACKGROUND: Intestinal permeability can be investigated by means of molecular probes which are able to cross the intestinal wall through tight junctions of villi (smaller probes) and/or of crypts (larger probes). Intestinal permeability is altered in the majority of uncomplicated diabetes mellitus type 1 patients, due to the augmented absorption of the smaller probe. The aim of this work was to investigate if any similar alteration of intestinal permeability is present in diabetes mellitus type 2. METHODS: Intestinal permeability was studied by means of the Cellobiose/Mannitol test (CE/MA). The first and larger probe (Cellobiose) crosses tight junctions of crypts, the smaller (Mannitol) crosses those of villi. The CE/MA test was administered to 18 patients affected by diabetes mellitus type 2, with length of disease = 4.5+/-1.9 years (mean+/-SD) with no relevant intestinal pathologies. Results obtained in these 18 patients were compared with those of 25 healthy volunteers. RESULTS: Intestinal permeability to the CE/MA test was normal in all patients. All the investigated permeability parameters (%CE, %MA, CE/MA) overlapped, as a mean, with those of control subjects and were not statistically different. CONCLUSIONS: The present data confirm that diabetes mellitus type 2 has not pathophysiological components at intestinal level. This is different from what was demonstrated in diabetes mellitus type 1, the last being very well known to be associated with autoimmune diseases and celiac disease.

Intestinal permeability assessment before and after ileal pouch-anal anastomosis.

AIM: Intestinal permeability is considered an index of anatomic and functional integrity of the small intestine mucosa. Altered intestinal permeability has been suggested to be a possible cause of pouchitis. Aim of this paper was to assess variations in intestinal permeability during the first year of a pouch reconstruction. METHODS: Intestinal permeability (IP) was investigated in 8 ulcerative colitis patients before and after total proctocolectomy, with ileal pouch-anal anastomosis (IPAA), by means of the cellobiose/mannitol test. To each patient a basal test (before surgery) and 3 more tests during a 1 year follow-up were administered. RESULTS: Individual data were altered despite clinical findings in 9 of 30 IP measured values. An overall pattern of unaffected permeability was however shown and none of our patients, during the first year follow-up, has developed pouchitis. CONCLUSIONS: Six of the 8 investigated patients presented at least 1 altered IP value. A longer follow-up aimed to further investigate patients beyond the first year after IPAA confection as to the occurrence of pouchitis and its possible correlation with a previous permeability alteration of the pouch mucosa is in progress.

[Physical training of patients with ischemic heart disease. Effects on diastolic time]. / L'allenamento fisico in pazienti affetti da cardiopatia ischemica. Effetti sul tempo diastolico.

In patients (pt) with coronary artery disease diastolic duration is an important determinant of myocardial oxygen supply. To assess the effects of physical training on diastolic duration, twelve male pt with previous infarction were studied. During 12 month training program the physical exercise was of progressively increasing intensity, duration and frequency. Training induced a significant reduction in heart rate. Both systolic and diastolic blood pressure were unchanged. The mean values of electromechanical systole were lower after training. On the contrary, the training induced a lengthening of diastolic duration expressed as percentage of cardiac cycle (% diastole) from 51.4 +/- 2.6 to 57.5 +/- 3.8% (p < 0.001). Thus, this results validate the hypothesis that physical exercise training can improve myocardial perfusion through an increase in diastolic duration, partially independent of bradycardia.

[Thrombosis of an aorto-iliac stent graft used for treating an iliocaval arteriovenous fistula following lumbar disc surgery]. / Thrombose d'une endoprothèse couverte aorto-bi-iliaque posée en cure d'une fistule artério-veineuse après chirurgie discale lombaire.

OBJECTIVES: Major vessel injury is a rare complication of spinal surgery. Iliac artery injury is the most common. Frequently, a chronic arteriovenous fistula develops. METHODS: We describe the case of a 63-year-old woman who had developed a chronic arteriovenous fistula following lumbar disc hernia surgery. The patient was treated using an Anaconda™ stent graft (Vascutek Terumo). After 2years, the prothesis thrombosed and an aorto-iliac bypass was performed. RESULTS: A gel soft prosthesis 18/9 (Vascutek Terumo) was implanted by laparotomy. The postoperative period was uneventful. A month later, the patient had recovered good lower limb function. CONCLUSION: The choice between endovascular versus open surgery must take into account the patient's age, the risk of long-term complications, and the need for radiographic surveillance. Curative open surgery remains a valid option for young patients.

Right colectomy: value of the totally laparoscopic approach.

UNLABELLED: The role of laparoscopy for right colectomy remains controversial - largely because of a lack of standardization of the operative procedure, including a diversity of techniques including laparoscopy-assisted cases with extra-corporeal anastomosis and totally laparoscopic procedures with intra-corporeal anastomosis. METHODS: The charts of all patients who underwent right colectomy by a totally laparoscopic approach in our service since 2004 were reviewed and pre-, intra-, and postoperative data were collected. RESULTS: Eighty-two patients underwent totally laparoscopic right colectomy; of these, 32 had a BMI greater than 20 kg/m2 (39%). The mean operative duration was 113 minutes. In most cases, the operative specimen was extracted through a supra-pubic Pfannenstiel incision measuring 4-6 cm in length. Three cases were converted to a laparoscopy-assisted technique (in order to control the ileo-cecal vascular pedicle because of extensive nodal invasion in two cases, and to evaluate a hepatic flexure polyp in the third case). Overall morbidity was 29.3% and parietal morbidity was only 9.8%; there was no difference in morbidity between obese patients (BMI>30 kg/m2) and non-obese patients (BMI<30 kg/m2). The mean duration of hospitalization was 9 days and two patients developed ventral hernia in the extraction incision in long-term follow-up. CONCLUSION: These satisfactory results show that the totally laparoscopic approach to right colectomy is technically feasible and safe, even in obese patients. In addition, the very low rate of parietal complications is an argument in favor of this approach.