Correction of distal limb prolapse of a diverting colostomy by stapling under sedation.

AIM: To describe a surgical technique to treat colostomy prolapse as a day case procedure with the patient under sedation and analgesia. METHOD: A 60-mm GIA Universal Stapler is inserted into the lumen of the prolapsed colon at right angles to the contour of the abdominal wall. Several firings are then made to completely divide the prolapsed colon. The instrument is then placed parallel to the skin to remove the prolapsed portion leaving 1-2 cm of bowel above the level of the skin. RESULTS: Two patients underwent the procedure. The operation times were 30 and 13 min. Both took oral liquids 2 h after surgery and solids 2 h later. They were discharged at 24 and 4 h after surgery, respectively. No postoperative pain was reported in either case. At 14 and 6 months of follow-up there has been no recurrence. CONCLUSION: Stapling treatment of prolapsed colostomies has the advantage of being an extra-abdominal procedure. It is performed under sedation and analgesia, the operation time is very short, recovery to normal life is rapid and there is less likelihood of complications by avoiding a laparotomy.

Transgenic mice overexpressing insulin-like growth factor-II in beta cells develop type 2 diabetes.

During embryonic development, insulin-like growth factor-II (IGF-II) participates in the regulation of islet growth and differentiation. We generated transgenic mice (C57BL6/SJL) expressing IGF-II in beta cells under control of the rat Insulin I promoter in order to study the role of islet hyperplasia and hyperinsulinemia in the development of type 2 diabetes. In contrast to islets from control mice, islets from transgenic mice displayed high levels of IGF-II mRNA and protein. Pancreases from transgenic mice showed an increase in beta-cell mass (about 3-fold) and in insulin mRNA levels. However, the organization of cells within transgenic islets was disrupted, with glucagon-producing cells randomly distributed throughout the core. We also observed enhanced glucose-stimulated insulin secretion and glucose utilization in islets from transgenic mice. These mice displayed hyperinsulinemia, mild hyperglycemia, and altered glucose and insulin tolerance tests, and about 30% of these animals developed overt diabetes when fed a high-fat diet. Furthermore, transgenic mice obtained from the N1 backcross to C57KsJ mice showed high islet hyperplasia and insulin resistance, but they also developed fatty liver and obesity. These results indicate that local overexpression of IGF-II in islets might lead to type 2 diabetes and that islet hyperplasia and hypersecretion of insulin might occur early in the pathogenesis of this disease.

Randomized trial of adjuvant chemotherapy with mitomycin plus ftorafur versus mitomycin alone in resected locally advanced gastric cancer.

PURPOSE: We performed a clinical trial to determine whether postoperative adjuvant chemotherapy with two drugs versus one drug could prolong survival. PATIENTS AND METHODS: From 1985 to 1996, 85 patients with completely resected locally advanced gastric cancer were enrolled. The subjects were randomized into two treatment groups, as follows: mitomycin (MMC) 10 to 20 mg/m2 intravenously (i.v.) on day 1 every 6 weeks plus ftorafur (FT) 500 mg/m2/d for 36 consecutive days; or MMC alone, 10 to 20 mg/m2 i.v. every 6 weeks. All courses were repeated four times. RESULTS: After a median follow-up duration of 62 months, the overall 5-year survival rates were 67% for the MMC-FT group versus 44% for the MMC group (P = .04). Subgroup analysis to compare survival curves using the method of Mantel-Cox showed survival rates significantly in favor of the MMC-FT group in the subsets of patients with node-negative disease (P = .01) and those whose disease was stage IB or II (P = .008). CONCLUSION: Significantly better survival results were observed for MMC-FT versus MMC alone. Subset analysis suggest a strong benefit in patients with node-negative and early-stage resected gastric cancer.

One thousand liver transplants: the hospital clinic experience.

OBJECTIVES: Our goal was to study a consecutive series of 1000 liver transplants performed in our institution to evaluate the changes over time in donors, recipients, and results. PATIENTS AND METHODS: With the aim to evaluate differences between transplantation in the first period and the present period, the first consecutive 100 liver transplants performed from June 1988 to June 1990 (first period) were compared with the last consecutive 200 liver transplants performed from January 2001 to June 2003 (second period). RESULTS: Increased donor age, change in donor cerebral death etiology, and increasing numbers of grafts from alternative methods using cadaveric donors were observed in the second period. Piggy-back technique and the biliary anastomosis without a t-tube was also started in the second period. One-year actuarial patient survival was higher in the second period (84% vs 91.3%). The need for retransplantation in the overall series was 95%. One-, 5-, and 10-year actuarial retransplant survival was 67.7%, 51.3%, and 39.4%, respectively. CONCLUSIONS: Technical innovations, better understanding of donor and recipient aspects, and global improvements were the reasons for time-related improved results of liver transplantation.

Predictive factors of in-hospital CNS complications following liver transplantation.

We prospectively evaluated 84 consecutive adult patients with chronic liver disease before and after liver transplantation to define the type and frequency of post-transplant neurologic complications, and to assess possible pretransplant and operative variables associated with in-hospital CNS complications. There were 25 patients (30%) who presented 23 neurologic complications of the central and six of the peripheral nervous system. Seventy-five percent of the complications occurred in the first month post-transplant. The most frequent CNS complications included anoxic (six patients) and septic (five) encephalopathy, as well as brain hemorrhage (five). Patients who presented CNS complications had a higher mortality rate than those who did not (55% versus 17%, p = 0.002). Multiple logistic regression analysis showed abnormal pretransplant neurologic examination suggestive of chronic hepatic encephalopathy (p = 0.007) and noncholestatic liver disease (p = 0.012) to be independently associated with in-hospital CNS complications. These data indicate that CNS neurologic complications following liver transplant are common in patients with noncholestatic liver disease and are associated with increased mortality. The pretransplant neurologic examination is an important predictor of CNS complications that occur in the immediate post-transplant period.

Cyclosporine-associated mutism in liver transplant patients.

Four liver transplant recipients treated with cyclosporine developed a reversible neurologic syndrome characterized by a speech disorder leading to mutism. This complication, previously reported in a few liver transplant recipients treated with the immunosuppressive drug FK506, had not been described with cyclosporine. Recognition of this syndrome should prompt withdrawal of the drug and avoidance of unnecessary diagnostic procedures.

Prostacyclin, thromboxane, and oxygen free radicals and postoperative liver function in human liver transplantation.

The aim of this prospective study is to evaluate prostanoid (prostacyclin and thromboxane) and lipid peroxide levels at the portal and hepatic veins, and their relation to immediate postoperative liver function. Nineteen patients with liver cirrhosis undergoing orthotopic liver transplantation were prospectively studied. Blood samples were obtained within 5 min and 1 and 2 hr after reperfusion of the new liver, through a catheter placed at the portal vein in the recipient and another at the left hepatic vein in the donor liver. Plasma prostacyclin and thromboxane were analyzed by HPLC and RIA. The formation of lipid peroxides was determined and expressed in terms of thiobarbituric acid-reacting substances. Immediate postoperative liver function was evaluated using the transaminase levels within the first 48 hr and the early postoperative graft function score, as described previously. After reperfusion, only determinations at 5 min were related with liver function. Either prostacyclin (R = -0.61, P = 0.004) levels at the hepatic vein or prostacyclin production (subtraction between hepatic and portal vein levels) (R = -0.47, P = 0.04) correlated significantly with the early postoperative graft function score. Besides, there was a significant relationship between lipid peroxide production as measured by thiobarbituric acid-reacting substances and a worse early postoperative graft function score (R = 0.61, P = .005). These results suggest that prostacyclin released after liver grafting attenuates preservation and reperfusion damage of the liver, supporting the hypothesis that there is an imbalance of prostanoids within the microvasculature in patients with a compromised postoperative liver function. Our results agree with the involvement of some degree of lipid peroxidation products in the damage of hepatocytes during anoxia and reperfusion.

L-arginine reduces liver and biliary tract damage after liver transplantation from non-heart-beating donor pigs.

BACKGROUND: To evaluate whether L-arginine reduces liver and biliary tract damage after transplantation from non heart-beating donor pigs. METHODS: Twenty-five animals received an allograft from non-heart-beating donors. After 40 min of cardiac arrest, normothermic recirculation was run for 30 min. The animals were randomly treated with L-arginine (400 mg x kg(-1) during normothermic recirculation) or saline (control group). Then, the animals were cooled and their livers were transplanted after 6 hr of cold ischemia. The animals were killed on the 5th day, liver damage was assessed on wedged liver biopsies by a semiquantitative analysis and by morphometric analysis of the necrotic areas, and biliary tract damage by histological examination of the explanted liver. RESULTS: Seventeen animals survived the study period. The histological parameters assessed (sinusoidal congestion and dilatation, sinusoidal infiltration by polymorphonuclear cells and lymphocytes, endothelitis, dissociation of liver cell plates, and centrilobular necrosis) were significantly worse in the control group. The necrotic area affected 15.9 +/- 14.5% of the liver biopsies in the control group and 3.7 +/- 3.1% in the L-arginine group (P<0.05). Six of eight animal in the control group and only one of eight survivors in the L-arginine group developed ischemic cholangitis (P<0.01). L-Arginine administration was associated with higher portal blood flow (676.9 +/- 149.46 vs. 475.2 +/- 205.6 ml x min x m(-2); P<0.05), higher hepatic hialuronic acid extraction at normothermic recirculation (38.8 +/- 53.7% vs. -4.2 +/- 18.2%; P<0.05) and after reperfusion (28.6 +/- 55.5% vs. -10.9 +/- 15.5%; P<0.05) and lower levels of alpha-glutation-S-transferase at reperfusion (1325 +/- 1098% respect to baseline vs. 6488 +/- 5612%; P<0.02). CONCLUSIONS: L-Arginine administration during liver procurement from non heart beating donors prevents liver and biliary tract damage.

Hepatic xanthine levels as viability predictor of livers procured from non-heart-beating donor pigs.

BACKGROUND: The aim of the present study was to evaluate hepatic content of adenine nucleotides and their degradation products in non-heart-beating donor (NHBD) pigs and its relationship with recipient survival. METHODS: Thirty animals were transplanted with an allograft from NHBDs. After warm ischemia (WI) time (20, 30, or 40 min), cardiopulmonary bypass and normothermic recirculation (NR) were run for 30 min. Afterward, the animals were cooled to 15 degrees C and liver procurement was performed. RESULTS: Survival rate was 100% in the 20WI, 70% in the 30WI, and 50% in the 40WI. Livers from non-surviving animals had higher levels of xanthine after NR than livers from surviving animals. Logistic regression analysis revealed that xanthine at the end of NR was the only variable able to predict survival with a calculated sensitivity of 80% and a specificity of 60%. Prolongation of warm ischemic period leaded to a greater xanthine accumulation as well as increased plasma alpha-glutathione S-transferase levels at reperfusion. Xanthine at NR and alpha-glutathione S-transferase at reperfusion significantly correlated, indicating that donor xanthine contributes to some extent to the severity of the lesion by ischemia-reperfusion. CONCLUSIONS: It is suggested that xanthine content in the donor is able to predict survival after transplantation. Xanthine is significantly involved in the hepatic lesion elicited by warm ischemia and subsequent ischemia-reperfusion associated to liver transplantation from a NHBD.

Hepatic blood flow and oxygen extraction ratio during normothermic recirculation and total body cooling as viability predictors in non-heart-beating donor pigs.

BACKGROUND: Our aim was to evaluate the hepatic blood flows and oxygen metabolism of non-heart-beating donor (NHBD) pigs, with the use of cardiopulmonary bypass (CPB) and normothermic recirculation (NR) before total body cooling, and its relationship with recipient survival. METHODS: Thirty-five pigs were transplanted with an allograft from NHBDs. After warm ischemia (WI) time (20, 30, or 40 min), CPB and NR were run for 30 min. After this period, the animals were cooled to 15 degrees C. In the control group (20 min of WI), the period of NR was excluded. Liver procurement was then performed. RESULTS: Survival rate was 100% in the 20WI, 70% in the 30WI, and 50% in the 40WI. Control group survival rate was 0%. Hepatic artery blood flow and portal blood flow recovered during NR. Pump blood flow during CPB increased rapidly during NR and was significantly higher in the 20WI. When donors of the livers transplanted in "surviving pigs" (DSP) were compared with donors of the livers transplanted in "nonsurviving pigs" (DNSP), hepatic artery blood flow, portal blood flow, and pump blood flow were higher in the DSP. Hepatic oxygen extraction ratio increased in the three groups with respect to baseline values. Hepatic oxygen extraction ratio was lower in the 20WI than in the other groups and was lower in the DSP than in the DNSP. CONCLUSIONS: The use of a NR period before total body cooling improves survival of liver transplantation in NHBDs. Portal blood flow and pump blood flow measurements can predict the viability of the grafts.

Pathological findings in a cat with cryptococcosis and feline immunodeficiency virus infection.

This report describes the gross, histopathological, immunocytochemical and electron microscopic findings in a cat with systemic cryptococcosis and feline immunodeficiency virus (FIV) infection. Lymphadenopathy and cloudiness of leptomeninges were the major gross findings. Numerous cryptococcal yeasts were found in lymph nodes, brain, and lung, and were less common in the kidney and the eye. The inflammatory reaction varied in intensity and cell type (mononuclear through granulomatous) depending on the organ involved. Yeasts were mainly within phagocytes as revealed by electron microscopy. Some inflammatory cells were immunocytochemically-stained with anti-CD3 antibodies.

Semicarbazide-sensitive amine oxidase (SSAO) from human and bovine cerebrovascular tissues: biochemical and immunohistological characterization.

Semicarbazide-sensitive amine oxidase (SSAO) is widely distributed in almost all tissues, especially in vascularized ones. However, its presence in brain microvessels is still controversial. We have investigated the presence of SSAO in human and bovine brain microvessels by biochemical and immunohistological techniques, and we have compared it with SSAO present in meninges from the same species. SSAO metabolizes benzylamine and methylamine in all tissues tested and possibly dopamine and octopamine as well, as shown in competition studies. Kynuramine inhibited the metabolism of benzylamine by SSAO with high affinity in a non-competitive manner. Western-blot analysis rendered a positive staining of a 100 kDa band, in tissues from both species. These results were confirmed by immunohistological studies: the tunica media and intima of the meninges from both species were positively stained, and so was the endothelial layer of microvessels. SSAO was absent in brain parenchyma. These results definitively confirm the presence of SSAO in human and bovine cerebrovascular tissues and they demonstrate for the first time, the presence of this amine oxidase in endothelial cells from microvessels, through biochemical and immunological approaches.

Scintisplenoportography in assessing patency of distal splenorenal shunts.

Scintisplenoportography was performed on 33 occasions in 28 cirrhotic patients who had bled from esophagogastric varices. In 17 cases scintisplenoportography was carried out after a retroperitoneal distal splenorenal shunt procedure and in the remaining 16 instances in patients without any surgical shunt. In four patients scintisplenoportography was performed before and after a surgical shunt procedure, and in one case, before and after the shunt thrombosed. Gammagraphic patterns and spleen-heart times helped determine which patients did not have a surgical shunt, which had a patent shunt, and which patients had a thrombosed shunt. A patent shunt pattern and a thrombosed shunt pattern have been defined. It is concluded that scintisplenoportography is a useful, reproducible, and safe method to assess the patency of distal splenorenal shunts.

Sclerosing cholangitis after surgical treatment of hepatic echinococcal cysts. Report of three cases.

Three patients with sclerosing cholangitis after surgical treatment of echinococcosis of the liver are described. Before surgery, they had clinical symptoms that suggested a communication between the cyst and the biliary tract and, in two of them, the communication was later demonstrated by cholangiography. In each case, the cyst was injected with formalin solution. Soon after operation chronic cholestasis developed, with operative, cholangiographic, and histologic data suggesting sclerosing cholangitis. The role of formalin in the pathogenesis of this condition is discussed herein.

Evidence for chronic morbillivirus infection in the Mediterranean striped dolphin (Stenella coeruleoalba).

In the summer of 1990 an epizootic infection caused by a morbillivirus (DMV) killed several thousand striped dolphins (Stenella coeruleoalba) in the Mediterranean Sea. In 1991 and 1992 the epizootic reached Italian and Greek waters. The infection by DMV in the acute period of the epizootic caused encephalitis, pneumonia and depletion of lymph nodes. After 1990, the systemic infection apparently disappeared from the Catalonian coast, giving way to cases of chronic infection of the CNS. Dolphins that died between 1991 and May 1994 were necropsied, and investigated for lesions due to DMV, and for the presence of morbillivirus antigen in tissues. Encephalitis occurred in 6 dolphins in which DMV antigen was demonstrated in the CNS and which were without lesions or antigen in other, non-nervous tissues. Inflammatory lesions, gliosis, and DMV antigen decreased in density and amount from cerebral grey matter, through the thalamic areas to the medulla oblongata. The cerebellum was usually spared. Lesions consisted of non-suppurative encephalitis, with diffuse gliosis and glial nodules and neuronophagia, and loss of neurons. Perivascular cuffing of lymphocytes and plasma cells was present in the cerebral cortex and the white matter beneath the cortex. Multinucleate syncytia were not detected in any of the dolphins. The haemagglutinin of DMV was detected mainly in neurons in the cerebral cortical areas. There was no clear relationship between the presence and amount of DMV antigen and the density or chronicity of lesions. Viral inclusions were seen in haematoxylin and eosin stained sections in 3/6 dolphins, principally in the nucleus and the cytoplasm of neurons. In the immunoperoxidase stained sections, dense granular deposits of chromogen, similar to viral inclusions, were evident in all 6 dolphins. The change in the distribution of lesions and of DMV antigen, from systemic to localized in the CNS, and the clustering of systemic DMV infections in the first four months of the epizootic, giving rise to sporadic occurrence of local CNS infection in the subsequent four years, as well as the chronic nature of the CNS lesions, which closely resembles subacute sclerosing panencephalitis, strongly support the existence of a chronic morbillivirus infection in the striped dolphin, as a delayed consequence of the 1990 epizootic.

Hand-assisted laparoscopic splenectomy (HALS) in cases of splenomegaly: a comparison analysis with conventional laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) is considerably more difficult to perform when the spleen is enlarged. The new technique of hand-assisted designed technique aimed to assist laparoscopic surgery allows the surgeon to insert his or her hand into the abdomen while maintaining the pneumoperitoneum, thus recovering the tactile sensation lost in conventional laparoscopic surgery. OBJECT: In this study, we compared the immediate results of conventional LS and hand-assisted LS (HALS) in cases of splenomegaly. METHODS: Between February 1993 and August 2001, 200 LS were attempted at two university hospitals. In 56 cases, splenomegaly (final spleen weight >700 g) was observed clinically or detected on radiological examination. We compared the first 36 patients operated on by conventional LS (group I) with the last consecutive 20 patients, who underwent HALS (group II). The study parameters were operative time, conversion rate, transfusion rate, morbidity and length of hospital stay. RESULTS: The groups were comparable in terms of age (58 +/- 13 [ranges, l9-82] vs 58 +/- 16 years [range, 44-84] (ns), diagnosis, and spleen weight (1425 +/- 884 [range, 700-3400]) vs 1753 +/- 1124 g [range, 720-4500] (ns). HALS was associated with less morbidity (36% vs 10%) (ns), a shorter operative time (177 +/- 52 [range, 95-300]) vs 135 +/- 53 min [range, 85-270] (p <0.009), and a shorter hospital stay (6.3 +/- 3.3 [range, 3-14]) vs 4 +/- 1.2 [range, 2-7] days (p <0.05). CONCLUSION: In cases of splenomegaly, HALS assisted laparoscopic surgery significantly facilitates the surgical maneuvers during LS while maintaining the advantages of a purely laparoscopic approach.

Could age be an indication for laparoscopic colectomy in colorectal cancer?

BACKGROUND: The incidence of colorectal carcinoma increases in the elderly. Regardless of age as an isolated factor, postoperative complications represent the main factor in increasing hospital mortality. METHODS: The aim of this study was to compare the short-term results (first 30 postoperative days) after laparoscopically assisted colectomy (LAC) and open segmental colectomy (OC) in colorectal carcinoma between two groups of patients, older than 70 and younger than 70 years of age. In the study from November 1993 to June 1998, 255 patients were evaluated to participate. RESULTS: Peristalsis, oral intake, and discharge from the hospital occurred earlier in LAC than in OC treated patients, in the two age groups. The mean operative time was significantly longer in the LAC than in the OC patients in the two age groups. No differences were observed in morbidity between LAC and OC in the group younger than 70 years of age. However, the overall morbidity was significantly lower in the LAC group in patients older than 70 years. One patient in the LAC group older than 70 years died. CONCLUSION: These results suggest that laparoscopically assisted colectomy may be particularly indicated in elderly patients.

Risk factors for death following liver retransplantation.

AIM: Our goal was to retrospectively analyze graft loss and mortality risk factors using multi-centre data on liver retransplantation. MATERIAL AND METHODS: Between 1991-1995, 640 patients underwent 718 liver transplants in Barcelona. Mean age of the 74 patients receiving a second transplant was 47.6 years (range 19-65). Causes of retransplantation were immunologic in 26 patients (35.1%), technical in 23 (31.1%), primary dysfunction in 12 (16.2%), recurrent original disease in 7 (9.5%), and other causes in 6 (8.1%). Mean time between first and second transplant was less than 7 days in 20 patients (27%), between 8 and 30 days in 4 (5.4%) and more than 30 days in 50 patients (67.6%). Recipient, donor, and operative variables were analyzed using univariate (Kaplan-Meier curves) and multivariate techniques (Cox regression) to identify risk factors. RESULTS: Retransplant patient survival at 1 and 5 years was 60.8% and 49.5%, respectively, compared to 75.6% and 64.8% in a series of 640 first transplant patients. Mortality risk factors identified by multivariate analysis were bilirubin >12 mg/dL (RR 2.3; P=.010), recipient age (RR increase 0.04 for each additional year; P=.02), cause for retransplant (immunologic RR 4.01, technical RR 2.7 and other causes RR 6.9; compared to primary dysfunction RR 1; P=.020). Urea >54 mg/dL (0.02) and multiple transfusions >15 units red blood cells (0.001) were only significant in the univariate analysis. CONCLUSIONS: In our experience, retransplantation for primary dysfunction is the setting that has the best prognosis. Of the other causes, retransplantation should be performed before the total bilirubin reaches >12 mg/dL or before the appearance of variables indicative of severe renal insufficiency.

The modified distal splenorenal shunt in the elective treatment of variceal hemorrhage.

We report on our experience with a modified version of the distal splenorenal shunt (DSRS) initially described by Warren. Since 1976 more than 150 shunts have been done in the department. The first part of this study shows the long-term results of a series of 100 consecutive patients treated electively. The estimated survival at 80 months was around 30%. On the other hand, the median survival rate (68 months) and the five-year survival (52%) of Child's A patients differed significantly from those of Child's B patients (8 months and 15%, respectively). These results suggested that the modified DSRS was an effective and relatively safe procedure for the elective treatment of variceal bleeding and warranted a prospective and randomized trial to compare DSRS and endoscopic sclerotherapy (ES). In the second part of the study, in which ES was compared with DSRS, both modalities showed a similar survival rate, although patients in the DSRS group had a higher incidence of encephalopathy and patients in the ES group were more prone to rebleed. It was concluded that ES was a good alternative to DSRS for the elective treatment of esophageal variceal bleeding. If orthotopic liver transplant is considered the only definitive mode of treatment for the elective management of portal hypertension, the DSRS should be reserved for patients in whom ES has not been totally effective, or varices are located predominantly in the fundus of the stomach.

Peripheral blood lymphocyte changes after benign gastrointestinal surgery. Role of thymostimulin in reversing the postoperative immunodepression seen in humans.

A generalized state of immunosuppression during surgery has been implicated in the development of septic complications postoperatively. We studied 18 patients operated upon for benign diseases, to examine the influence of surgical trauma on circulating lymphocyte subpopulations in man. Additionally, we evaluated the effect of thymostimulin on these changes, in another group of 10 patients. Our results suggest that the total number of lymphocytes, as well as lymphocyte subpopulations CD3+ and CD4+, fell significantly following surgery. This reduction in cell number is more pronounced on the helper/inducer lymphocytes. The CD4+/CD8+ ratio decreases significantly after operation. For patients with no complications, the immunosuppression in terms of peripheral lymphocyte population, seen in the postoperative period is usually reversible around the seventh day. On the other hand, peripheral blood lymphocyte changes in the postoperative period were less pronounced in patients treated with thymostimulin. Thymostimulin's action is predominantly on T lymphocytes, and within these, on the T helper/-inducer subpopulation. And finally, thymostimulin is capable of maintaining a normal relationship between helper/inducer and suppressor/cytotoxic cells (CD4+/CD8+ ratio) during the postoperative period, suggesting a better immune state.