Endotoxin challenge causes a proinflammatory state in obstructive jaundice.

The aim of this study was to investigate the relationship between the obstructive jaundice-induced cellular immune suppression and endotoxin challenge with respect to the levels of tumor necrosis factor (TNF), interleukin-10 (IL-10), and interleukin-2 (IL-2). Rats underwent either bile duct ligation or sham operation. At 21 days, all rats were challenged either with lipopolysaccharide (LPS) or saline. In the sham-operated group LPS injection significantly increased TNF levels at 90 min. The common bile duct ligated group showed a significant increase in TNF levels compared with all other groups, including the sham-operated, LPS-injected group, at 90 min. At 180 min following LPS challenge, TNF levels decreased, and there was no difference between any of the LPS-challenged groups at 180 min and any of the saline groups at either 90 or 180 min. In the sham-operated group, LPS injection significantly increased IL-10 levels at both 90 and 180 min. In the bile duct ligated group, LPS injection significantly increased IL-10 levels compared with saline injection at both 90 and 180 min. On the other hand, bile duct ligated animals had significantly less increase in IL-10 levels following LPS challenge at 90 min but not at 180 min. In common bile duct ligated rats, LPS challenge induced a significantly greater increase in IL-2 levels compared with all other groups. In conclusion, in the presence of obstructive jaundice, endotoxemia primes a more vigorous inflammatory response despite cellular immune depression.

Intestinal ischemia-reperfusion injury augments intestinal mucosal injury and bacterial translocation in jaundiced rats.

BACKGROUND/AIMS: The aim of this study was to evaluate local effects and degree of bacterial translocation related with intestinal ischemia-reperfusion injury in a rat obstructive jaundice model. METHODOLOGY: Thirty adult Sprague-Dawley rats (200-250 g) were divided into three groups; including Group 1 (jaundice group), Group 2 (jaundice-ischemia group) and Group 3 (ischemia group). All rats had 2 laparotomies. After experimental interventions, tissue samples for translocation; liver and ileum samples for histopathological examination, 25 cm of small intestine for mucosal myeloperoxidase and malondialdehyde levels and blood samples for biochemical analysis were obtained. RESULTS: Jaundiced rats had increased liver enzyme levels and total and direct bilirubin levels (p<0.05). Intestinal mucosal myeloperoxidase and malondialdehyde levels were found to be high in intestinal ischemia-reperfusion groups (p<0.05). Intestinal mucosal damage was more severe in rats with intestinal ischemia-reperfusion after bile duct ligation (p<0.05). Degree of bacterial translocation was also found to be significantly high in these rats (p<0.05). CONCLUSIONS: Intestinal mucosa is disturbed more severely in obstructive jaundice with the development of ischemia and reperfusion. Development of intestinal ischemia-reperfusion in obstructive jaundice increases bacterial translocation.

Using a risk score for conversion from laparoscopic to open cholecystectomy in resident training.

BACKGROUND: We previously developed a risk score for conversion from laparoscopic to open cholecystectomy (RSCLO). The aim of this study is to validate this scoring system in a new patient population and test its use in case selection for resident training. METHODS: The data of 1,000 laparoscopic cholecystectomies (LC) that had been performed in our clinic between 1992 and 1999 were analyzed retrospectively, and RSCLO was developed. Scores take values between -20 and 41; values below -3 represent low risk, and values over -3 represent high risk. Analyses in this group of patients showed that at least 15 cases have to be performed for adequate LC training. The current study is a clinical prospective study based on data of the previous study and evaluates RSCLO in a new patient population of 400 LCs. All patients were scored preoperatively; surgeons who had performed 15 or fewer LCs previously operated only patients with a score below -3. Patients with high scores (>values of -3) were operated only by surgeons who had performed at least 16 LCs. Results of the first 1,000 cases and later 400 cases (new patient population of the current study) were compared in terms of conversion to open cholecystectomy, complications, and operation times. RESULTS: Both in the first 1,000 patients and later in 400 patients, increasing scores resulted with higher conversion rates and complication rates and longer operation times (P<.05). In the later 400 patients, conversion rate (4.8% vs 3.0%, P=.08), complication rate (5.5% vs 3.5%, P=.07), and mean operation time (56.8 min vs 52.5 min, P=.004) were decreased when compared with the first 1,000 patients. In resident training cases, conversion and complication rates decreased to 0%, and mean operation time was shortened by nearly 10 minutes. In high-score difficult cases, conversion and complication rates decreased, and mean operation time was shortened by nearly 20 minutes. CONCLUSIONS: This risk score can predict the difficulty of LC cases reliably. Scoring patients preoperatively can decrease the problems in training cases, and management of difficult cases may be left to experienced surgeons.

A prognostic score for colorectal cancer.

BACKGROUND/AIMS: Scoring systems are generally used for predicting prognosis in critically ill patients, but not frequently for predicting prognosis in cancer. Our aim was to develop a prognostic score for colorectal cancer. METHODOLOGY: Demographic, clinical, laboratory, radiologic, histopathologic and operative data of 112 patients who had resection for colorectal cancer, were analyzed for their effect on survival. Eight variables (invasion depth of tumor, nodal status, presence of metastasis, CEA level, differentiation, resectability, tumor location, presence of blood transfusion), which have the most significant effect on survival in univariate analysis and multivariate analysis, were chosen. Coefficients were calculated and the Prognostic Score for Colorectal Cancer (PSCRC) was designed. All patients were scored using this system and staged according to TNM, Dukes and Astler-Coller systems. RESULTS: The score range is between -49 and 80. Patients were grouped as Group 1 (score < -30), Group 2 (score -30 to -6), Group 3 (score -5 to 19), Group 4 (score > 19). Survival rates decreased and recurrence rates increased significantly with increasing scores. The associations of PSCRC and staging systems with survival and recurrence rates were determined by logistic and Cox regression analyses. PSCRC was proved to have the most significant association with survival and recurrence rates. Furthermore, PSCRC had better correlation with survival and recurrence rates when compared with staging systems according to Pearson correlation analysis. CONCLUSIONS: Inclusion of more variables in PSCRC seems to make it superior to the staging systems. PSCRC may be a practical and useful scoring system in clinical practice and is easily adapted to different patient populations.

Effect of topically applied charged particles on healing of colonic anastomoses.

HYPOTHESIS: Various forms of electrical stimulation can improve wound healing in different tissues, but their application to gastrointestinal tract healing has not been investigated. We assumed that positively charged diethylaminoethyl cross-linked dextran bead (diethylaminoethyl Sephadex [DEAE-S]) particles would have a beneficial effect on the healing of colonic anastomoses. DESIGN: Experimental animal study. SETTING: Animal research laboratory of a university hospital. ANIMALS: Forty female Wistar albino rats. INTERVENTIONS: Right colonic transection and anastomosis was performed in 5 animal groups. The control group received no treatment; the placebo group, methylcellulose gel; and the DEAE-S group, DEAE-S in methyl cellulose gel applied topically around the anastomoses. The fecal peritonitis (FP) group underwent cecal ligation and perforation simultaneously with the anastomosis to cause FP; the FP + DEAE-S group also received DEAE-S applied around the anastomoses. MAIN OUTCOME MEASURES: After the completion of postoperative day 4, all rats were killed. Anastomotic bursting pressures and hydroxyproline concentrations in perianastomotic tissue were measured and compared. RESULTS: Mean bursting pressures were 115.1 mm Hg in the control group, 113.6 mm Hg in the placebo group, 159.4 mm Hg in the DEAE-S group, 62.8 mm Hg in the FP group, and 121.1 mm Hg in the FP + DEAE-S group (P =.001, 1-way analysis of variance [ANOVA]). The differences between the control vs DEAE-S groups, placebo vs DEAE-S groups, and FP vs FP + DEAE-S groups were significant (P<.05, t test). Mean hydroxyproline concentrations were 5.2 microg/mg in the control group, 4.9 microg/mg in the placebo group, 5.6 microg/mg in the DEAE-S group, 4.5 microg/mg in the FP group, and 5.4 microg/mg in the FP + DEAE-S group (P =.09, 1-way ANOVA). The difference between the FP and FP + DEAE-S groups was significant (P =.04, t test). CONCLUSIONS: A positively charged particle, DEAE-S, improves healing of colonic anastomoses in healthy rats and in rats with FP. This inexpensive, nontoxic material is easily applied and deserves further evaluation in gastrointestinal tract healing.