[Enteral nutrition with peri-surgery immunomodulating diet]. / Nutrición enteral con dieta inmunomoduladora perioperatoria.

OBJECTIVE: To assess the nutritional peri-surgical status of patients suffering from esophageal or gastric cancer, treated with esophagectomy and total gastrectomy, respectively, and to analyze the impact of an enteral immunomodulating diet on postsurgical complications. SETTING: Patients admitted to the Surgery Department of Hospital Clinico Universitario of Salamanca. PATIENTS AND METHODS: Patients submitted to esophagectomy and/or total gastrectomy to whom early enteral nutrition (EN) is provided with an immunomodulating diet. INTERVENTIONS: All patients were prescribed an immunomodulating diet of 1000 Kcal/day p.o. plus a normal grinded diet that they started on the 5th presurgical day and pursued during the immediate postsurgical period (within the first 24 hours) with EN through a jejunostomy catheter, in a progressive way until reaching 25 kcal/kg/day at days 4-5. EN was kept in place for at least the first 10 days after surgery and laboratory checkups were done before surgery and at days 5 and 10 after surgery. We also performed a prediction equation, with morbidity as the dependent variable and the remaining as independent variables. RESULTS: Sixty-eight patients were studied of whom 36 (35 men and 1 women) suffered from esophageal cancer and 32 (21 men and 11 women) from gastric cancer. Mean age of patients with esophageal cancer was 60 +/- 9.68 years, with a mean postsurgical stay of 36.97 +/- 62.37 days, and for gastric cancer patients mean age was 69.41 +/- 11.53 years and mean stay 24.41 +/- 13.77 days. The comparison of the means of the biochemical nutrition parameters showed a decrease in almost all values at the 5ht post-surgery day in relation to the presurgical determination, and an increase in the measurement at the 10th postsurgical day as compared to the 5th day values. In most of the cases, the differences are statistically significant. For morbimortality prediction, the variables cholesterol, related diseases, CRP, IgM, and male gender, were contributors. CONCLUSIONS: All the analyzed variables, but gender, seem to be appropriate indicators for the study of response to surgical aggression as well as of enteral nutrition. We believe that peri-surgical immunomodulating nutrition recovers the values of postsurgical nutrition parameters. Enteral nutrition through jejunostomy is well tolerated, and has a low and mild morbidity.

Tacrolimus (FK506) down-regulates free radical tissue levels, serum cytokines, and neutrophil infiltration after severe liver ischemia.

BACKGROUND: Liver ischemia and reperfusion injury is associated with activation of multiple inflammatory pathways, including free radicals, cytokines, and neutrophil-mediated tissue damage among others. Tacrolimus (FK506) has shown important regulatory effects on some inflammatory pathways, such as cytokines, neutrophils, and adhesion molecules. In this study, we explored a new potential protective mechanism for tacrolimus in the liver inflammatory response after ischemia and reperfusion, specifically its effect on liver tissue free radicals. METHODS: Total hepatic ischemia was produced in the rat for 90 min with an extracorporeal portosystemic shunt. Animals (n=96) were divided into four groups: group 1 comprised normal rats for reference values; group 2 comprised sham operated rats; in group 3, ischemic control rats received only the vehicle; and the experimental treatment group, group 4, received tacrolimus at a dose of 0.3 mg/kg, 4 hr before ischemia. Animal survival was followed up to 7 days. Liver function tests were performed and liver tissue free radicals and myeloperoxidase, serum cytokines (interleukin 1, tumor necrosis factor-alpha), and liver histology were measured 4 hr after reperfusion. RESULTS: Seven-day survival was significantly improved from only 20% in the control group to 55% in the tacrolimus group (P<0.01). Liver function tests, histology, and myeloperoxidase tissue values were significantly improved (P<0.05) with tacrolimus pretreatment. Furthermore, a significant (P<0.05) down-regulation of serum cytokines and liver tissue free radicals was observed. CONCLUSIONS: These data indicate a new and different protective mechanism for FK506 in regard to its ability to down-regulate free radical levels in livers subjected to severe ischemia and reperfusion. Tacrolimus, also confirmed to be a potent suppressor of the cytokine response, specifically interleukin 1 and tumor necrosis, decreased neutrophil tissue migration as well.

Protective effect of exogenous nitric oxide on the renal function and inflammatory response in a model of ischemia-reperfusion.

BACKGROUND: Tissue subjected to a period of ischemia undergoes morphological and functional damage that increases during the reperfusion phase. The aim of the present work was to assess the possible improvement induced by exogenous administration of nitric oxide (NO) on renal injury and inflammatory reaction in an experimental animal model of renal ischemia-reperfusion (I-R). METHODS: Ischemia was achieved by ligation of the left arteria and vein for 60 min, followed first by contralateral nephrectomy and then reestablishment of blood flow. Molsidomine, used as an NO donor, was administered by systemic injection 30 min before reperfusion. The effect of molsidomine was compared with the effect of hydralazine, a non-NO donor hypotensive agent. RESULTS: Treatment with molsidomine improved the renal dysfunction (increase in plasma creatinine and urea levels) caused by I-R. Moreover, molsidomine blunted the enhanced production of proinflammatory cytokines (tumor necrosis factor [TNF]-alpha and interleukin [IL] 1alpha), the increase in tissular levels of superoxide anions and oxygen free radical scavengers, and the neutrophilic infiltration observed in the ischemic kidney. One hundred percent survival was achieved in the group of animals treated with the NO donor, whereas the groups of animals undergoing I-R that did not receive molsidomine showed a 40% mortality from the second day after reperfusion. CONCLUSIONS: The present work demonstrated that systemic treatment with an NO donor before reperfusion improved renal function and diminished inflammatory responses in a kidney subjected to an I-R process.

Levels of serum cathepsin L and several glycosidases in patients operated for colorectal cancer.

The activities of several glycosidases and cathepsin L were determined in the blood serum of a control group of ten healthy humans in comparison with a group (group I: 32 subjects) of preoperative colorectal cancer patients (1 week before surgical exeresis) and with another two groups: group II, comprising 18 operated subjects (1 week after surgery), and group III, of 15 operated subjects (4 months after surgery). All subjects were 48-88 years old. Both 'enzyme activity' and 'specific activity' determinations of serum beta-galactosidase, alpha-L-fucosidase and cathepsin L revealed peculiar profiles that differed from one another. Control values differed from those of some stages of the pathological groups, but not of others. These values were compared also with the levels of total, lipid- and glycoprotein-associated serum sialic acid. The usefulness of some assays (especially cathepsin L activity measurement) in the follow-up of the health status of humans operated for colorectal cancer is discussed.

Ruptured aneurysm of the deep femoral artery. Case report and historical review.

The exceptional characteristics of the case are put forward and commented on. The patient was a 96-year-old man with an arteriosclerotic aneurysm of the deep femoral artery, which became urgently apparent on bursting. The surgical resolution was simple and satisfactory. Later investigation showed that the aneurysm was unilateral and only in the deep femoral artery. Deep femoral artery continues to be an exceptional location of true arteriosclerotic aneurysms, above all when they arise in an isolated fashion. However, in recent years the available information has changed two substantial aspects: 1) these peripheral aneurysms have the greatest risk of rupture, and 2) on many occasions it is possible, when the superficial femoral artery is permeable, to give simple and satisfactory treatment (exclusion of the aneurysms without revascularization).

Double-blind, controlled, multicenter study of indobufen versus placebo in patients with intermittent claudication.

The objective of the study was to evaluate the efficacy and safety of indobufen compared with placebo in the treatment of moderately severe intermittent claudication. The study consisted of a four-week single-blind, placebo-controlled run-in phase, followed by a six-month double-blind randomized treatment period. A total of 302 patients were allocated to treatment with either placebo (154 patients) or indobufen (148) 200 mg twice daily. The results of the overall intention-to-treat analysis of the study population showed statistically significant superiority of indobufen over placebo after six months for both the initial (ICD) and absolute claudication distances (ACD). The ICD before treatment with indobufen or placebo averaged 137.9 +/- 68.2 and 136.6 +/- 63.2 m (mean +/- SD), respectively. After six months' treatment with active drug or placebo, this parameter reached 227.9 +/- 174.4 and 153.1 +/- 86.8 m (mean +/- SD), respectively (p < 0.01). Similar results were obtained on ACD. The reduction of lower limb symptoms also suggested a greater clinical benefit in the indobufen-treated patients. There was no significant change in either group in the ankle/arm pressure ratio at the end of treatment. Adverse events of any type were reported by 18 patients (12.2%) in the indobufen group and by 11 patients (7.2%) in the placebo group. The mechanism whereby the drug is effective in this clinical condition could be related to both its antiplatelet and hemorheologic effects.

Laboratory control of continuous intravenous heparin therapy with Howel time and activated partial thromboplastin time. A prospective, randomized and blind study.

Although heparin has been used extensively to treat Deep Venous Thrombosis (DVT) and arterial ischemia (AI), controversy still exists regarding optimal dosage and the need for monitoring. Different authors have employed various test with variable results. Others, however, persist in giving heparin without laboratory control. This study was made in order to compare, in a prospective, randomized and blind manner, two coagulation tests, namely: Howel Time (HT) and Activated Partial Thromboplastin Time (APTT), in controlling the dose of heparin given by continuous intravenous infusion in DVT and AI. Our results show no significant difference in complications and failures of the therapy with either test, although significantly higher doses of heparin were needed to maintain APTT within therapeutic range than those needed to keep HT within a similar range.

Hand exercise effect in maturation and blood flow of dialysis arteriovenous fistulas ultrasound study.

With the help of the Doppler Ultrasound we have measured the radial artery blood flow of 20 healthy volunteers and the fistula flow of 40 uraemic patients. The measurements were made at rest and repeated one, three and five minutes after initiation of hand exercise, and one minute after the exercise had finished. Radial artery mean flow increased significantly with the exercise (p less than 0.001); radial arteries with greater baseline flow had less flow increase (p less than 0.002). However, we were not able to demonstrate any fistula flow increase with the hand exercise. Therefore, we conclude that there is no benefit in advising uraemic patients to squeeze a rubber ball which, otherwise, supposes an unnecessary preoccupation for these patients.

Hydatid mesoarteritis in the abdominal aorta: case report.

A rare case of hydatid disease, presenting as a 12 cm. cyst in the arterial wall of the abdominal aorta, with progressive chronic ischemia of the lower limbs and repeated episodes of shock is reported. The diagnostic problems, surgical procedure and follow-up are presented. This is the first reported case in the literature.

Multicriteria decision analysis for determining drug therapy for intermittent claudication.

Drugs of various classes are prescribed for intermittent claudication. However, there is some discrepancy between medical practice and the scientific basis for drug selection. We have developed a quantitative criteria-based decision analysis to evaluate all implications of drug treatment choices for intermittent claudication. Pentoxifylline, buflomedil, naftidrofuryl and ticlopidine were the drugs selected for analysis. The evaluation criteria were 1) therapeutic efficacy, 2) safety, 3) patient acceptance and 4) cost. A review panel of experts determined the relative importance of each criterion by assigning points (or utility values) to each one. The points were 48, 20, 14 and 18, respectively, for criteria 1, 2, 3 and 4. A probability value, or numerical estimate of how well a drug meets a criterion, was assigned to each drug for each of the 4 criteria. The probability value was multiplied by the utility value to determine the score for each drug and criterion. The criteria points for each drug were added for a total score for the drug. The drug with the highest overall score was pentoxifylline, with 69 points out of an ideal score of 100. The rank order for the other drugs was buflomedil, ticlopidine and naftidrofuryl. A sensitive analysis showed that the relative ranking of the drugs remained unchanged over a series of data modifications.

Phenol lumbar sympathectomy in severe arterial disease of the lower limbs: a hemodynamic study.

The indications, results and evaluation methods of lumbar sympathectomy are very controversial. The authors present their experience and results with phenol lumbar sympathectomy (PLS). PLS (Reid's technique) was carried out in 25 patients with severe peripheral arterial disease. Sympathetic tone abolition was achieved in 72% of the patients, with a beneficial clinical effect in 60%. In this group, the following measurements were made, before sympathectomy, and 24 hours, one week and one month after it: Doppler ankle-pressure, ankle-arm pressure index and calf and foot arterial flow measured with an impedance plethysmograph (IPG), at rest and after controlled exercise. The IPG-measured arterial flow in the resting foot was the only parameter to show a significant increase following PLS (p less than 0.05). Although the IPG calf flow, ankle-pressure and ankle-arm index showed increases, these were not significant. Lumbar sympathectomy by phenol injection is as effective as by surgery. Its beneficial effect is believed to be due to an increase in the resting flow in the foot.

Systemic prophylaxis with gentamicin-metronidazole in appendicectomy and colorectal surgery: a prospective controlled clinical study.

A prospective, randomized, clinical study was carried out in 188 patients undergoing appendicectomy or colorectal surgery to test the efficacy of prophylactic, parenterally-administered antibiotics in the prevention of infection. The results show the effectiveness of the association gentamicin-metronidazole (9.4% of infections), compared to the control group with no antibiotics (39.1% of infections), X2 = 14.1; P less than 0.001).

Multiseptate gallbladder.

Nine cases of multiseptate gallbladder have been reported in the English literature. Another case is presented. We consider cholecystectomy the treatment of choice because it relieves the symptoms and avoids chronic infection and stone formation.

A comparison of three different prophylactic parenteral antibiotic regimens in colorectal surgery: a prospective study.

A double-blind, prospective, randomized study was performed with 90 patients undergoing colorectal surgery, to ascertain the prophylactic effect of three different parenteral antibiotic programs. The patients were divided into three groups. The patients in group 1 received 80 mg Gentamycin and 600 mg Lincomycin intramuscularly, two hours preoperatively, and every eight hours postoperatively for three days. In group 2, the treatment was similar to group 1 but the Lincomycin was replaced by 600 mg Clindamycin. In Group 3, the treatment was also similar to group 1, but 500 mg Metronidazole given over 20 minutes replaced the Lincomycin. The present study, the first comparing three antianaerobic antibiotics and an aminoglycoside in the prophylaxis of infection in colorectal surgery, shows certain clinical and socioeconomic benefits, although not statistically significant to be found in the group 3 program (Gentamycin plus Metronidazole) as compared with the other programs. This advantage was no doubt due to the use of Metronidazole (used in group 3 only), because of its effectiveness against anaerobic bacteriae.

Effects of pharmacological doses of synthetic salmon calcitonin on wound healing in rats.

The effect of pharmacological doses of synthetic salmon calcitonin (CT) on the healing of experimental wounds in rats is studied. Subcutaneous administration of 20 IU/Kg body weight/day induces a significant increase in collagen content in the scars of treated animals at five, eight, ten and 15 days, as compared with the scars of non-treated animals. The scars of the treated animals also showed a greater tensile strength (TS) than those of the control group, except on day 8.

Effect of intestinal ischemia on pulmonary surfactant. An experimental study.

The infective factor seems to be very important in the physiopathology of intestinal ischaemia syndrome, as we suggested in previous research works, and is probably responsible for the disturbances observed in pulmonary surfactant. In the present research project, 48 mongrel dogs were studied under different situations of experimental intestinal ischaemia (arterial, venous and revascularization) after laparotomy and the pulmonary surfactant was determined in all cases. We conclude that the observed changes in phospholipids (phosphatidylglycerol and phosphatidylinositol particularly) can be directly related to the infective factor and important enough to induce physicochemical alterations of the surfactant and subsequently pulmonary function.

Peri-incisional and preoperative administration of cefmetazole for the prophylaxis of wound infection after appendicectomy.

The tissue and blood levels of Cefmetazole are compared after preoperative administration of a single dose of 30 mg/K body weight of the antibiotic administered intravenously (15 patients) and peri-incisionally (30 patients) to patients scheduled for emergency appendicectomy. Local and general tolerance to the antibiotic was good by both routes. No local or general complications arose in any of the patients. As expected, the tissue concentrations achieved with peri-incisional infiltration were significantly higher than those obtained by the intravenous route. With the blood levels, exactly the opposite happens at the start of the operation whereas at the end, there were no significant differences between the two routes employed. The prophylactic administration by peri-incisional infiltration is an easy and safe method which provides high tissue concentrations simultaneously with adequate blood levels and should be considered as useful in the preoperative administration of antibiotics for prophylaxis.

[Perfusion of donor tissue improves the preservation of graft in heterotopic tracheal transplantation]. / La perfusión tisular del donante mejora la conservación del injerto en el transplante traqueal heterotópico.

To assess the effect on tracheal graft preservation of perfusion of donor tissue with a Collins solution before extraction and immunosuppression of the recipient. An experimental study was performed in 36 albino rabbits with revascularized heterotopic cervical reconstruction of the trachea with omentum. The animals were distributed in four groups. Groups I (n = 9) and III (n = 9) were transplanted with non perfused donor tissue. Animals in groups II (n = 9) and IV (n = 9) received grafts perfused with Collins solution. Immunosuppression with steroids and cyclosporin was continued for 21 days in groups III and IV. In a mid portion of the trachea viewed under optical microscope, the degree of inflammation or circumferential necrosis was assessed on a scale of 0 to 9 by adding the scores for mucosa, submucosa and cartilage. The mean score for tracheal lesion was lower in group IV, with a likelihood of random difference of less than 5%. Perfusion of peritracheal tissues with Collins solution in the donor, in addition to immunosuppression decreases the extent of tissue damage in the tracheal graft.

[Nutrition and bacterial translocation]. / Nutrición y translocación bacteriana.

The present work is part of a presentation given at the Scientific Meeting of the Association for Surgical Nutrition and Metabolism, during the XX National Congress for Surgery (Madrid, November 1994). The authors, prior to presenting their experiences, define and high light the importance of the phenomenon of "Bacterial Translocation" (BT). Afterwards, and based on several experimental studies performed by them, they attempt to answer two questions: 1) Is the term BT correct? 2) Is BT a physiological or a pathological state? Finally they review the relationship which exists between bacterial translocation and nutrition, both from a causative point of view as from the prevention and therapy of the same.

[An experimental model of bacterial translocation]. / Modelo experimental sobre translocación bacteriana.

The authors submit an experimental model for bacterial translocation (administering OF-1 mice Zymosan intra-peritoneally at a dose of 1 mg/kg weight). The existence is confirmed of this new mechanism of infection (0% of translocation in control groups, as against 80% in the trial group -p < 0.001). The bacteria in the translocated organs coincide with those present in the fecal flora of the experimental animal. This study is the point of departure for subsequent research to study the physiopathological mechanisms of the phenomenon, which will enable us subsequently to reach better preventive and/or therapeutic decisions.