α-Defensins and hsCRP levels in inflammatory response of standard and laparoendoscopic single-site cholecystectomy.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery is an evolution of laparoscopic surgery aiming at decreasing the patient's parietal trauma associated with abdominal operations. LESS has been found so far to be efficient and have the same good results as the standard four-port laparoscopic cholecystectomy. α-Defensins are antimicrobial peptides of the organism. They are the first cell components against pathogens. Cytokines are also mediators in the response to trauma. The aim of this study was to compare the inflammatory reaction in LESS and four-port laparoscopic cholecystectomy. METHODS: Forty patients with noncomplicated cholelithiasis were randomly assigned into one of two groups. Group A included the patients who would undergo four-port laparoscopic cholecystectomy and group B included the patients who would undergo LESS cholecystectomy. These patients had a BMI < 30, were ASA I or II, and had no previous upper-GI surgery. Blood was taken preoperatively and 6 and 24 h postoperatively. hsCRP (with automated analyzer) and α-defensins (using ELISA) were calculated for each sample. The same postoperative protocol was followed for both groups. Mann-Whitney U test was used to analyze the results. Pain was calculated with a visual analog scale (VAS) for shoulder and abdomen at 6 and 24 h. Hospital stay, nausea, and pain medication needed was noted. RESULTS: The α-defensins value was statistically significantly higher in the 24-h samples (P < 0.001) for LESS cholecystectomy. No statistically significant difference was shown for hsCRP, even though P = 0.05 for the 24-h samples with the values of LESS higher. No LESS was converted to a classical laparoscopic cholecystectomy, and none of the patients of either group needed conversion to open cholecystectomy. Pain was statistically significantly less for the LESS group at the 24-h interval (P < 0.0001). Less medication was needed for LESS patients after the 6th postoperative hour (P = 0.007). CONCLUSION: Higher inflammatory reaction in LESS cholecystectomy could be the result of greater tension on the tissues. More studies are needed to conclude if this has a significant clinical expression.

Xenotransplantation of hepatocytes in rats with acute liver failure using sirolimus for immunosuppression.

This study aimed to evaluate the effect of sirolimus (SRL; rapamycin) as an immunosuppressant during xeno transplantation (XT) of rabbit hepatocytes into male Wistar rats with acute liver failure (ALF; n = 72). Isolated rabbit hepatocytes were transplanted intrasplenically into rats within 24 h of chemically induced ALF. Treatment groups received monotherapy with either cyclosporine (CsA) 20 mg/kg or SRL 0.20 mg/kg, or combination therapy with CsA 20 mg/kg + SRL 0.20 mg/kg for 14 days post-transplant. One control group with ALF received no treatment and a second group with ALF received only XT. Surviving rats were euthanized after 14 days, with concurrent blood sampling and organ retrieval for morphological evaluation. Survival rates at 14 days were: no XT/no treatment, 0%; XT alone, 29%; XT + CsA, 79%; XT + SRL, 33%; and XT + CsA + SRL, 33%. Liver morphology showed statistically superior liver regeneration for groups on SRL therapy. It is concluded that, in this hepatocyte XT model, SRL offered no survival advantage for ALF management so CsA still maintains a central role in attempts to develop alternative solutions for ALF.

Recombinant leptin administration improves early angiogenesis in full-thickness skin flaps: an experimental study.

BACKGROUND: Leptin is a potent direct angiogenic factor that stimulates endothelial cell migration and activation in vitro, and angiogenesis in vivo. In addition, leptin seems to play an important role in angiogenesis as it promotes the formation of new blood vessels. OBJECTIVE: To determine the effect of local application of exogenous leptin on the survival of full thickness skin flaps in an experimental animal model. MATERIALS AND METHODS: Ninety Sprague-Dawley rats were used in this study. A full thickness dorsal flap (10 cm x 2 cm) with the pedicle located at the level of the iliac crest was designed. Animals were divided into ten groups of nine animals each. In the distal two thirds of the flap and by means of subdermal injection at 8 different locations, rats were injected with 100 ng/ml leptin, 250 ng/ml leptin, 500 ng/ml leptin, 1000 ng/ml leptin (groups A, B, C and D), 1 microg/ml VEGF (group E), or 1 ml saline (control group), respectively. For each of the four leptin doses used, another animal group was injected with a combination of leptin/antileptin: 100 ng/ml leptin with 150 ng/ml antileptin, 250 ng/ml leptin with 375 ng/ml antileptin, 500 ng/ml leptin with 750 ng/ml antileptin or 1000 ng/ml leptin with 1500 ng/ml antileptin (groups A1, B1, C1 and D1, respectively), in order to study the inhibition of the leptin factor. Nine rats served as controls and were injected with 1 ml saline solution. Rats were sacrificed 3, 7 and 9 days postoperatively. After sacrifice of the animals, the skin was grossly arranged on its appearance, colour and texture. Full thickness skin flaps were dissected for histological examination. A qualitative analysis of angiogenesis in the flap was conducted following a standard hematoxylin and eosin stain. The wound tissue samples from each experimental group underwent immunohistochemical evaluation of microvessel density by endothelial cell staining with mouse anti-rat CD 34 monoclonal antibody. RESULTS: Immunohistochemical staining revealed that more granulation tissue and improved angiogenesis were observed in group D (1000 ng/ml leptin) flaps compared to those in the VEGF, leptin/antileptin and saline groups. In addition, skin flap survival rate in group D (1000 ng/ml leptin) and group E (1 microg/ml VEGF) were significantly better than those of the other groups. The most impressive formation of new blood vessels was noted in the groups with the higher leptin doses. Surgical wounds in the control, as well as in the leptin/antileptin groups, did not demonstrate any new vessels. CONCLUSION: Exogenous administration of recombinant leptin increases early skin flap angiogenesis in an experimental animal model. Local application of leptin could efficiently improve survival of ischemic skin flaps.

Catheter knots in the urinary tract.

The use of catheters in the urinary tract, both in children and adults, has not been without complications. Many procedures performed in the urinary tract, including urethral or suprapubic catheterization of the bladder, urethrography, and ureteral catheterization, have showed complications, one of which is the formation of catheter knots. This complication, although very rare, yet it is very annoying. In this study, we searched (in winter 2002, employing Medline) and reviewed published reports of urinary tract catheter knots, and present measures for prophylaxis, diagnosis and proper management of this rare complication.

Human subcutaneous dirofilariasis: a report of three cases manifesting as breast or axillary nodules.

Human subcutaneous dirofilariasis is a rare infection caused by filarial worms of the genus Dirofilaria. The parasites are transmitted to man by zooanthropophilic bloodsucking insects and the infection is manifested as subcutaneous nodules. Excisional biopsy is both diagnostic and therapeutic. We herein report three cases of human subcutaneous dirofilariasis diagnosed, over a period of ten years (1991-2000), in North East Greece. The patients, two women and one man, were all adults between 32 and 67 years of age. In two cases the infection was manifested as breast nodules, while in the third case as a painful nodule in the axillary region. The excisional biopsy showed the presence of an adult Dirofilaria, identified as Dirofilaria (Nochtiella) repens. It is emphasised that both clinicians and pathologists should have an increased awareness of this clinicopathologic entity and include dirofilariasis in the differential diagnosis in patients presenting with breast or subcutaneous nodules.

Leiomyomas of spermatic cord and testis presenting as hernia--chromosomal analysis.

We report a rare case of three leiomyomas of the permatic cord and testis in a 73-year-old man. Indirect, large, painful, non-reducible inguinal hernia was diagnosed at admission. During surgery, the hernia was revealed. Furthermore, two tumors were found, both attached on the spermatic cord, and a third tumor close to the testis. All the tumors were carefully removed and no orchidectomy was performed. Hernia repair was performed and the removed tumors were sent to the Pathology Department. All tumors were benign. At the first follow up, chromosomal analysis was also performed. Chromosomal lymphocyte analysis revealed increased fragility at site 4q31. Two years after surgery, the patient was admitted again with a new similar tumor, and underwent a new surgical treatment. In the case of large non-reducible inguinal hernias, surgeons have to consider tumors in the inguinal area in their differential diagnosis.

Publications in vascular journals: contribution by country.

The geographical origin of all published papers in four major vascular journals as well as the "vascular papers" in two high impact "general" surgical journals during a four year period (2003-2006) were examined by search of their electronic editions. As an index of high quality papers, the randomized controlled trials (RCT's) by country were also examined. A total of 3422 papers were searched in the four vascular journals (115 RCT's) while 144 "vascular" papers (19 RCT's) were located in the two "general" surgical journals. It was not surprising that USA and western European countries were having the largest contribution to the vascular literature.

Primary adrenal hydatid cyst: a case report.

A rare case of primary adrenal hydatid cyst is reported in a 56-year-old male. The cyst was discovered incidentally. The only symptom was hypertension. Partial excision of the gland and pericystectomy were performed. Surgical treatment was also therapeutic for the hypertension.

Penetration of clarithromycin in experimental pleural empyema model fluid.

BACKGROUND: The degree of penetration of clarithromycin into the pleural fluid has not been studied. OBJECTIVE: To determine the degree to which clarithromycin penetrates into empyemic pleural fluid using a new rabbit model of empyema. METHODS: An empyema was created via the intrapleural injection of 1 ml turpentine followed 24 h later by instillation of 5 ml (10(10)) Escherichia coli bacteria (ATCC 35218) into the pleural space of New Zealand white rabbits. After an empyema was verified by thoracentesis and pleural fluid analysis, clarithromycin 30 mg/kg was administered intravenously. Antibiotic levels were determined on samples of pleural fluid and blood samples collected serially over 12 h. Antibiotic levels were estimated using HPLC. RESULTS: The antibiotic penetrated well into the empyemic pleural fluid (AUC(PF)/AUC(serum) ratio of 1.57). The time to equilibration between the pleural fluid and blood antibiotic levels was 8 h. The peak pleural fluid level (Cmax(PF) of 2.88 microg/ml) occurred 1 h (Tmax(PF) of 1 h) after infusion and decreased thereafter. The Cmax(serum) was 3.53 microg/ml at 1 h after administration. CONCLUSION: The levels of clarithromycin in the pleural fluid after intravenous administration are inhibitory for most of the usual pathogens causing empyema. The degree of penetration of clarithromycin should be considered when macrolides are selected for the treatment of patients with empyema.

Patency of autologous and prosthetic arteriovenous fistulas in elderly patients.

OBJECTIVE: To compare the patency of autologous and graft-bridging (prosthetic) arteriovenous (AV) fistulas in patients 70 years of age or more. DESIGN: Non-randomised comparative study. SETTING: University hospital, Greece. PATIENTS: 114 patients aged 70 years or more (mean 78) who required 135 consecutive angioaccess procedures during the 8-year period January 1990-December 1997. INTERVENTIONS: 68 autologous and 67 prosthetic procedures, 64 of the prosthetic procedures being proximal brachioaxillary AV arm grafts. MAIN OUTCOME MEASURES: Primary and secondary cumulative patency rates and cumulative survival. RESULTS: Life table analysis showed that the 3-year secondary patency (medium term patency) was significantly superior in the prosthetic group (58% compared with 44%, p = 0.04). Cumulative survival at 3-years was 21%. CONCLUSIONS: A proximal brachioaxillary prosthetic AV graft is a good alternative as initial primary access in elderly patients who are not suitable for an autologous proximal AV fistula. At this age long term patency and conservation of proximal access sites are of minimum importance because of their limited life expectancy.

Removal of knotted intravascular devices. Case report and review of the literature.

OBJECTIVE: to review published reports on knotted intravascular devices/catheters. METHOD: report of two cases and systematic review of the literature. RESULTS: a total of 113 reported cases of knotted intravascular devices/catheters were located. Pulmonary artery catheters (Swan-Ganz) were responsible for more than two thirds of the total reported intravascular knots. In 62% (70/113) of the cases withdrawal of the knotted catheters was achieved successfully with different interventional radiological techniques, avoiding the need for surgical exploration. In 32% (36/113) of the patients surgical removal was favoured. Capture with one of the interventional techniques and pulling down the knot into an easily accessible vein to be removed through an open venotomy, was the most common surgical procedure. However, in five cases, an open cardiotomy was required. In seven cases the patient's condition was critical and precluded any surgical procedure, so the knotted catheter was left in situ. The mortality of this event was 8% (9/113). CONCLUSIONS: interventional radiological techniques have largely replaced open surgical removal. Knotted catheters may need to be surgically removed when (a) the knot is large in size with many loops, or (b) intracardiac fixing of the knot is encountered.

Penetration of newer quinolones in the empyema fluid.

The degree of penetration of newer quinolones into the pleural fluid has not been studied. The objective of the present study was to determine the degree to which moxifloxacin and levofloxacin penetrate into empyemic pleural fluid using a new rabbit model of empyema. An empyema was created via the intrapleural injection of turpentine (1 mL), followed 24 h later by instillation of 2 mL (1 x 10(10)) Escherichia coli bacteria (ATCC 35218) into the pleural space of New Zealand white rabbits. After an empyema was verified by thoracentesis and pleural fluid analysis, moxifloxacin and levofloxacin (25 mg.kg(-1) for both, i.v.) were administered. Antibiotic levels were determined in samples of pleural fluid and in blood collected serially over 12 h. Antibiotic levels were measured using HPLC. Each of the antibiotics penetrated well into the empyemic pleural fluid. Antibiotic penetration was the greatest for moxifloxacin (area under the curve (AUC) for pleural fluid/blood (AUCPF/AUCblood) ratio=1.37) followed by levofloxacin (ratio=1.13). The time to equilibration between the pleural fluid and blood antibiotic levels was more rapid for moxifloxacin (3.9 h) than for levofloxacin (4.4 h). With moxifloxacin, the peak pleural fluid concentration (Cmax,PF) was 2.77 microg.mL(-1) and occurred at a time to maximum pleural fluid concentration (Tmax,PF) of 6 h after infusion and decreased thereafter. The peak blood concentration (Cmax,blood) was 4.81 microg.mL(-1) at 1 h after administration. With levofloxacin, the peak pleural fluid level (Cmax,PF=1.39 microg.mL(-1)) occurred at 6 h (Tmax,PF=6 h) after infusion. The Cmax,blood was 1.88 microg.mL(-1) at 1 h after administration. In conclusion, differences were found in the degree of penetration of the two quinolones into infected pleural fluid in rabbits. The clinical significance of these differences is unknown. More studies are needed to evaluate the pharmacokinetic parameters in the pleural space in humans.

Influence of surgeons' specialty on the selection of vascular access for hemodialysis treatment.

BACKGROUND/AIMS: Various patient-related factors could not explain the variability of access types across facilities in the published literature. The aim of this study was to investigate the influence of surgeons' specialty on access type selection for hemodialysis treatment. METHODS: The directors (nephrologists) of all renal units in Greece (n = 92) were surveyed by a closed questionnaire. RESULTS: The response rate was 75%. There was no statistically significant difference in the percentage of patients predominantly with autologous arteriovenous fistulae between units where only vascular surgeons were performing access surgery and those where either general surgeons or transplant surgeons were operating (mean value in all renal units 80.8%, range 43-97%). However, the difference between the three groups of renal units regarding their surgeons' ability to create complex access procedures and to correct complications (as an index of surgeons' skill) was statistically significant (p < 0.001). CONCLUSION: The general surgeons of the new generation are not often using vascular surgical techniques and may have less opportunities to develop expertise in vascular access creation.