Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view.

BACKGROUND & AIMS: Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN). METHODS: On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives. RESULTS: This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum. CONCLUSION: The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

[Late ischemic stricture following anterior rectal resection]. / Estenosis isquémica tardía tras resección anterior de recto.

A considerable incidence of colonic strictures after oncologic low anterior resections has been reported. The present paper describes a colonic stricture 5 years after the surgery, and not related to radiotherapy, that required a challenging differential diagnosis with local recurrence of rectal cancer. The role of endoscopy in the management of this condition is discussed.

Tumor necrosis factor-alpha-induced inhibition of phosphatidylcholine synthesis by human type II pneumocytes is partially mediated by prostaglandins.

TNF alpha seems to play an important role in the pathogenesis of adult respiratory distress syndrome. We studied the effect of TNF alpha on phospholipid synthesis by isolated type II pneumocytes and attempted to characterize the role of arachidonate metabolites and the influence of pentoxifylline on such an effect. Lung tissue obtained from both multiple organ donors (n = 14) and lung cancer patients (n = 11) was used for cell isolation. Surfactant synthesis was measured by the incorporation of D-[U-14C]glucose into phosphatidylcholine (PC). The basal PC synthesis was higher in the donor group than in the malignant group (3.44 +/- 0.19 vs 2.15 +/- 0.15 pmol/microgram protein x 120 min, P < 0.01), and, in the presence of 100 ng/ml of TNF alpha, the incorporation of labeled glucose into PC was reduced significantly in both donor (1.13 +/- 0.11 vs 3.44 +/- 0.19 pmol/microgram protein x 120 min, P < 0.01) and cancer (0.99 +/- 0.11 vs 2.15 +/- 0.15 pmol/microgram protein x 120 min, P < 0.01) groups. Indomethacin was able to completely block the cytokine-induced decrease in PC synthesis by pneumocytes from the malignant group and to attenuate the inhibitory effect of TNF alpha in those from donors, nordihydroguaiaretic acid having a similar effect. The TNF alpha effect can be blocked by pentoxifylline (100 micrograms/ml), a substance which can even succeed in reverting the basal secretory inhibition of cancer patients' pneumocytes to levels similar to those of the donor group. TNF alpha may contribute to the pathophysiology of adult respiratory distress syndrome by inhibiting the synthesis of surfactant. TNF alpha might be produced in lung tumors, resulting in chronic paracrine or systemic exposure of pneumocytes to low concentrations of the cytokine. The TNF alpha effect was not prevented completely by the blockage of the arachidonic acid metabolism, hence other mediators should also be implicated.

[Animal models in glucose intolerance and type-2 diabetes]. / Modelos animales de intolerancia a la glucosa y diabetes tipo 2.

There stilla are many unknown facts about the pathogenic mechanisms of such a prevalente disease nowadays as i type-2 diabetes mellitus (DM2). The advances in diabetes prevention and management will greatly depend on the understanding of these mechanisms; therefore, it will be essential to keep on using animal models on which carrying out experiments that would be urethical in humans. DM2 represents a heterogeneous group of diseases characterized by an increase in insulin resistance at periphera tissues and a deterioration in insulin secretion by pancreatic beta-cells, both abnormalities being highly interweaved. The mentioned heterogeneity of DM2 is also reflected by the high diversity of useful animal models for its study. The main DM2 models are reviewed, classifying them by their mechanism of action in spontaneous or induced. Also, two categories in each one of them are distinguiseed: analogous models, which try to imitate the human disease, and intrinsic models, with which we pretend to answer specific questions about the disease. The decision about which model to case for a particular experiment usually is multifactorial. Ideally, the experiments should be carried out in several different models, taking into account that none of them completely reflects the complexity of human DM2 and that precautions should be taken when trying to extrapolate the findings to the clinical practice.

Efficacy of albendazole against Anisakis simplex larvae in vitro.

BACKGROUND: The growing popularity in western countries of eating uncooked seafood has resulted in an increased incidence of anisakidosis. AIM: To study the in vitro activity of different concentrations of albendazole against Anisakis simplex larvae under different media pH. METHODS: A. simplex larvae were obtained from fresh hakes acquired from the fish market of Madrid. They were divided into groups and placed in culture dishes (15 larvae each) containing RPMI-1640, in the presence or absence of different concentrations of albendazole (300, 400 and 500 microg/mL). RESULTS: Albendazole dose-dependently reduced the survival of the larvae, its maximum activity being at 500 microg/mL when it killed almost all larvae at 48 h. Acidic medium pH significantly reduced the efficacy of albendazole. CONCLUSION: Albendazole is effective in killing A. simplex larvae at different pH in vitro, suggesting that this molecule could be useful in treating clinical manifestations of human anisakidosis.

[Body weight profile in acute mesenteric ischemia. Experimental study in New-Zealand rabbits]. / Perfil del peso corporal en la isquemia mesenterica aguda. Estudio experimental en conejos Nueva Zelanda.

INTRODUCTION AND OBJECTIVES: There are few investigation studies that relate acute mesenteric ischemia and body weight in animal experimentation. The aim is to studying whether initial weight loss is related to the magnitude of the aggression induced by clamps of the superior mesenteric artery for 30 and 60 minutes, and whether reperfusion ischemia may hinder weight recovery in surviving animals at the end of 11 weeks of experimental work with New Zealand rabbits through a valid experimental model. MATERIALS AND METHOD: 80 animals (rabbits) were distributed in four series of 20 each one: series I (control), animals were weighed for 11 weeks; series II (simulated surgery); series III (mesenteric ischemia for 30 minutes); series IV (mesenteric ischemia for 60 minutes). We induced ischemia by clamping the superior mesenteric artery. Animals from series II, III, and IV were weighed 24 hours before the surgical procedure and weekly after surgery along their survival, until completing 11 weeks. For weight analysis, an ANOVA test was used by confronting the percentage weight variation according to the series. All animals were necropsied to know the cause of death and histological lesions of the intestinal mucosa. RESULTS: Series I had a linear weight increase until the end of the observation period. Series II, III and IV had a significant initial decrease of the percentage weight during the first post-surgical week, with a recovery towards the end of the study, but significantly lower as compared to the control series. Significant differences have also been found in weight recovery at 11 weeks between series II and series III and IV, and between ischemic series. CONCLUSIONS: Animals in series II, III, and IV reached at the end of the study a percentage weight significantly lower to that obtained by series I. In the experimental animal mesenteric ischemia-reperfusion processes, the initial percentage weight loss in the postsurgical period is influenced not only by ischemia time but also by pre-and postsurgical manipulations; by contrast, the longer ischemia time is, the greater weight loss at the end of the study will be.

Effect of surfactant protein A (SP-A) on the production of cytokines by human pulmonary macrophages.

Surfactant protein A (SP-A) is thought to play a role in the modulation of lung inflammation during acute respiratory distress syndrome (ARDS). However, SP-A has been reported both to stimulate and to inhibit the proinflammatory activity of pulmonary macrophages (Mphi). Because of the interspecies differences and heterogeneity of Mphi subpopulations used may have influenced previous controversial results, in this study, we investigated the effect of human SP-A on the production of cytokines and other inflammatory mediators by two well-defined subpopulations of human pulmonary Mphi. Surfactant and both alveolar (aMphi) and interstitial (iMphi) macrophages were obtained from multiple organ donor lungs by bronchoalveolar lavage and enzymatic digestion. Donors with either recent history of tobacco smoking, more than 72 h on mechanical ventilation, or any radiological pulmonary infiltrate were discarded. SP-A was purified from isolated surfactant using sequential butanol and octyl glucoside extractions. After 24-h preculture, purified Mphi were cultured for 24 h in the presence or absence of LPS (10 microg/mL), SP-A (50 microg/mL), and combinations. Nitric oxide and carbon monoxide (CO) generation (pmol/microg protein), cell cGMP content (pmol/microg protein), and tumor necrosis factor alpha (TNFalpha), interleukin (IL)-1, and IL-6 release to the medium (pg/microg protein) were determined. SP-A inhibited the lipopolysaccharide (LPS)-induced TNFalpha response of both interstitial and alveolar human Mphi, as well as the IL-1 response in iMphi. The SP-A effect on TNFalpha production could be mediated by a suppression in the LPS-induced increase in intracellular cGMP. In iMphi but not in aMphi, SP-A also inhibited the LPS-induced IL-1 secretion and CO generation. These data lend further credit to a physiological function of SP-A in regulating alveolar host defense and inflammation by suggesting a fundamental role of this apoprotein in limiting excessive proinflammatory cytokine release in pulmonary Mphi during ARDS.

Carbon monoxide contributes to the cytokine-induced inhibition of surfactant synthesis by human type II pneumocytes.

BACKGROUND: An increase in cyclic guanosine 3',5'-monophosphate (cGMP) due to nitric oxide generation is known to participate in the mediation of the tumor necrosis factor alpha (TNF-alpha) effect in type II cells. Because guanylyl cyclase can be activated also by carbon monoxide (CO), in this study we examined the ability of human type II pneumocytes to produce CO in the presence of cytokines and the relative contribution of this molecule to the TNF-alpha and interleukin 1 effects. DESIGN: Type II pneumocytes were isolated from cadaveric multiple-organ donors by enzymatic digestion, adherence separation of macrophages, and gradient purification. After preculture for 24 hours, cells were cultured for 24 hours in the presence or absence of TNF-alpha, interleukin 1, sodium nitroprusside, N(omega)-nitro-1-arginine, CO, hemin, zinc-protoporphyrin type IX, deferoxamine mesylate, S-adenosyl-L-methionine, alpha-tocopherol, methylene blue (a guanylyl cyclase inhibitor), 8-bromine-cGMP, and combinations of these reagents. Both CO (picomole per microgram of protein) and nitric oxide release to the medium and the cGMP (picomole per microgram of protein) content of the cells were measured. In a different set of experiments, D-glucose labeled with radioactive carbon (14C) was added to the medium, and the labeling of several lipid fractions was determined (picomole per microgram of protein). RESULTS: D-[14C]glucose incorporation into phosphatidylcholine, the main surfactant component, was selectively inhibited in the presence of cytokines, CO, sodium nitroprusside, or 8-bromine-cGMP. The inhibitory effect of TNF-alpha was partially reversed by N(omega)-nitro-L-arginine, deferoxamine, or alpha-tocopherol and totally reversed by methylene blue. Tumor necrosis factor alpha induced an increase in cGMP cell content and in the CO and nitric oxide release to the medium. Hemin increased CO and cGMP production and decreased phosphatidylcholine synthesis. Zinc-protoporphyrin type IX, an inhibitor of heme oxygenase, and all 3 antioxidants, which inhibited CO production, also antagonized the TNF-alpha effect on cGMP and phosphatidylcholine synthesis. CONCLUSIONS: Intracellular cGMP increase due to an endogenous generation of both CO and nitric oxide mediates the cytokine-induced inhibition of surfactant synthesis by type II pneumocytes. Both lipid peroxidation and heme oxygenase activity are sources for the observed CO production.

Both prostaglandin E2 and nitric oxide sequentially mediate the tumor necrosis factor alpha-induced inhibition of surfactant synthesis by human type II pneumocytes.

BACKGROUND: Tumor necrosis factor alpha (TNF-alpha)-induced inhibition of surfactant synthesis seems to participate in the pathogenesis of the adult respiratory distress syndrome. OBJECTIVES: To examine the ability of human type II pneumocytes to produce nitric oxide (NO) in the presence of TNF-alpha and, in addition, to explore the role of this radical in the transduction of the cytokine signal. DESIGN: Multiple organ donors were the source of lung tissue specimens. Type II pneumocytes were isolated by enzymatic digestion, adherence separation of macrophages, and gradient purification. After 24-hour preculture, cells were cultured for 24 hours in the presence or absence of TNF-alpha (100 ng/mL), sodium nitroprusside (100 mumol/L), N omega-nitro-L-arginine methyl ester (NAME) (1 mmol/L), methylene blue (10 mumol/L),8-bromo-3',5'-cyclic guanosine monophosphate (8-Br-cGMP) (1 mmol/L), prostaglandin E2 (PGE2) (0.1 mumol/L), indomethacin (30 mumol/L), and combinations. The NO release to the medium and cGMP and PGE2 contents of the cells were measured. RESULTS: The incorporation of 14C-labeled glucose (D-[U-14C]glucose) into phosphatidylcholine and phosphatidylglycerol was selectively inhibited either by 8-Br-cGMP or in the presence of TNF-alpha, PGE2, or nitroprusside, all of which caused an increase in the intracellular levels of cGMP. The inhibitory effect of TNF-alpha was partially reverted by indomethacin, NAME, N-monomethyl arginine, or methylene blue. The inhibitory effect of PGE2 was partially reverted by NAME, while that of nitroprusside was reverted by methylene blue, but not by indomethacin. Tumor necrosis factor alpha induced an increase in PGE2 (4.31 +/- 0.27 vs 1.65 +/- 0.17-pg/microgram protein, n = 10, P < .01) and cGMP (0.238 +/- 0.012 vs 0.109 +/- 0.014-pmol/microgram protein, n = 10, P < .01) cell content and in the NO release to the medium (3.10 +/- 0.14 vs 1.19 +/- 0.11-nmol/microgram protein, n = 10, P < .01). The basal NO release to the medium was also increased in the presence of PGE2. The NAME, which blocked NO generation and cGMP increase, did not affect PGE2 production in response to TNF-alpha. However, indomethacin, which blocked PGE2 production, also blunted NO generation and cGMP increase. CONCLUSIONS: The NO generation, secondary to PGE2 production, seems responsible for the TNF-alpha-induced inhibition of phosphatidylcholine synthesis by human type II pneumocytes. Nitric oxide seems to exert this effect through activation of guanylyl cyclase.

Evidence for a cyclic guanosine monophosphate-dependent, carbon monoxide-mediated, signaling system in the regulation of TNF-alpha production by human pulmonary macrophages.

BACKGROUND AND OBJECTIVES: The second messenger cyclic guanosine 3',5'-monophosphate (cGMP) seems to be implicated in the release of tumor necrosis factor alpha (TNF-alpha) by activated macrophages. There is controversy regarding the potential of human macrophages to produce nitric oxide (NO). Since guanylate cyclase can be activated also by carbon monoxide (CO) and this gas may be formed endogenously, we examined the ability of human pulmonary macrophages to produce CO in the presence of lipopolysaccharide (LPS) or LPS+interferon gamma (IFN-gamma). In addition, the source and the relative contribution of this molecule to the LPS-induced increase in cell cGMP content and TNF-alpha release were explored. DESIGN: Interstitial macrophages were obtained from multiple organ donor lungs by enzymatic digestion. After 24-hour preculture, purified macrophages were cultured for 24 hours in the presence or absence of LPS, LPS+IFN-gamma, CO (250 and 500 mumol/L), sodium nitroprusside, 8-Br-cGMP, hemoglobin, methylene blue, zinc-protoporphyrin IX, hemin, S-adenosylmethionine, deferoxamine mesylate, or combinations. The cGMP content of the cells and TNF-alpha, CO, and NO release to the medium were determined. RESULTS: In the presence of LPS, TNF-alpha production was not accompanied by any detectable increase in the NO release to the medium. However, an increase in medium CO concentration (mean +/- SEM) (5.81 +/- 0.20 vs 3.74 +/- 0.08 pmol/microgram protein; n = 11; P < .01) and cell cGMP content (0.273 +/- 0.021 vs 0.138 +/- 0.019 pmol/microgram protein; n = 10; P < .01) was observed. These changes were more pronounced in the presence of LPS+IFN-gamma. Release of TNF-alpha also was induced by both sodium nitroprusside and 8-Br-cGMP. In contrast, methylene blue, a guanylate cyclase inhibitor, inhibited LPS-, LPS+IFN-gamma-, and sodium nitroprusside-induced TNF-alpha production and cGMP increase; hemoglobin, which traps CO, had a similar effect. CONCLUSION: Intracellular cGMP increase, secondary to an endogenous production of CO, participates in the release of TNF-alpha by activated human pulmonary macrophages.

Cytokine-induced inhibition of lipid synthesis and hormone secretion by isolated human islets.

Interleukin-1, tumor necrosis factor, and interleukin-6 inhibit insulin release and may be cytotoxic to isolated pancreatic islets. These cytokines have been postulated to play an important role in the beta cell destruction characteristic of type 1 diabetes. The present study was designed to investigate the effect of the above cytokines on insulin, glucagon, somatostatin, and thyrotropin-releasing hormone secretion by isolated human islets. In addition, we have investigated if cytokine-induced modifications in hormone secretion are accompanied by modifications in the ab initio synthesis of any specific lipidic fraction. All three cytokines studied, although not modifying insulin and somatostatin release to glucose 5 mmol/L, inhibited the response of both hormones to glucose 20 mmol/L. On the other hand, the cytokines almost completely blocked islet basal glucagon release, without affecting thyrotropin-releasing hormone secretion. The added cytokines also suppressed 20 mmol/L [U-14C]glucose incorporation into both phospholipids and diacylglycerol. Our results demonstrate a beta-, alpha-, and delta-cell, sensitivity to cytokine action. Additionally, they suggest that ab initio lipid synthesis might be implicated in the mechanism of insulin release in human islets.

Influence of cryopreservation on the sensitivity of human islets to tumor necrosis factor.

Tumor necrosis factor (TNF alpha) has been shown to inhibit insulin release and it has been postulated to-be an important effector in islet rejection. We studied the effect of cryopreservation on glucose oxidation rate (GOR), lipid synthesis, hormone secretion (insulin, glucagon, somatostatin, thyrotropin-releasing hormone), and cyclic guanosine 3',5'-monophosphate (cGMP) content of human islets, in the presence or absence of TNF alpha, looking for changes that could explain a different susceptibility to rejection for cryopreserved islets. Islets were isolated from multiple organ donor pancreata by collagenase digestion. The islets were then cultured for 7 days, cryopreserved (-0.25 degrees C/min), and stored in liquid N2. After 24 h of culture, thawed islets were cultured for an other 24 h in the presence or absence of TNF alpha. Islets were then washed to remove the cytokine and incubated in Krebs-Ringer bicarbonate (5 or 20 mM glucose), and both the cGMP content of the islets and the hormone concentration in the medium were determined by radio-immunoassay. GOR was measured as the production of 14CO2 from 5 or 20 mM D-[U-14C]glucose, and de novo lipid synthesis was determined as D-[U-14C]glucose incorporation into different lipidic fractions. Cryopreservation did not significantly modify the hormone response to glucose but it partially reversed the TNF alpha-induced inhibitory effect on insulin release in the presence of 20 mM glucose. In addition, the inhibitory effect of TNF alpha on phosphatidylcholine labeling was attenuated in cryopreserved islets compared with noncryopreserved islets. TNF alpha significantly stimulated islet nitrite production and cGMP accumulation, both effects being of a similar magnitude in cryopreserved and noncryopreserved islets. Our results suggest that cryopreservation can modify the metabolic and hormone response of human islets to TNF alpha. This effect is not mediated by changes in the TNF alpha-induced islet nitric oxide production or cGMP accumulation.

NO2/NO3 and cytokine plasma profiles under different postoperative parenteral nutrition regimens.

Both nitric oxide and cytokines are considered mediators of the acute-phase response in humans, and their early postoperative period plasma levels have been found to be of prognostic value. On the other hand, it has been suggested that the fatty emulsions used in total parenteral nutrition (TPN) may induce changes in macrophage function. In the present study we investigated the postoperative evolution of tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), interleukin-6 (IL-6), and nitrate/nitrite plasma levels under three different TPN regimens. Twenty-one patients diagnosed with upper digestive tract neoplasm, without preoperative TPN, and having undergone radical surgery, were randomly assigned to three groups: Group I, all nonprotein calories supplied by hypertonic glucose solution: Group II, 55% of the nonprotein calories supplied by glucose and 45% by 20% long-chain triacylglycerides emulsion (LCT) (Intralipid 20%, Kabi-Pharmacia); Group III, same as Group II, but a 20% emulsion of a mixture of medium-chain and long-chain triacylglycerides (MCT/LCT) (Lipofundina MCT/LCT 20%, B. Braun) was used instead of LCT. Blood samples were obtained on postoperative Days 1-5 and 10, 3 h after ending the lipid infusion. In all the three groups IL-1, IL-6, and TNF-alpha levels rose after surgery, peaking at Day 2, whereas NO2/NO3 levels had their peak at Day 3. Day-to-day comparison of plasma levels of cytokines and NO2/NO3 between the investigated groups did not show any statistical significance. Differences between group means were not found when the areas under the curve over the first 5 postoperative days were compared (1.72 +/- 0.25, Group I; 1.88 +/- 0.34, Group II; and 2.52 +/- 0.50, Group III, for TNF-alpha; 1.79 +/- 0.12, Group I; 1.92 +/- 0.18, Group II; and 1.50 +/- 0.12, Group III, for NO2/NO3). We conclude that the different parenteral nutrition regimens studied do not evoke alterations in cytokine and NO2 + NO3 levels in the patient groups investigated in this study.

Non-heart-beating donation: current state of the art.

The use of non-heart-beating donors (NHBD) helps us to deal with the problem of the organ shortage. In addition to difficulties with legal and ethical acceptability, there are concerns regarding medical safety, which prevent the widespread use of these donors. To make optimum use of this potential organ supply, the ischemic injury that occurs after a period of warm ischemia needs to be reversed. To minimize the warm ischemia time, once the subject is declared dead, most centers commence in situ cold perfusion via a femoral access or a rapid aortic cannulation. This usually occurs within minutes of arriving at the emergency department, before the next of kin have been notified of the patient's death. The European experience of kidney transplantation from NHBD shows promising results. The long-term outcomes are similar to HBD kidneys notwithstanding a higher rate of delayed graft function, which seems not to affect the long-term survival of these kidneys. In summary, NHBD may have an important impact on the large discrepancy that exists between the organ supply and the demand. Current data suggest that the results may be further improved by better patient selection and retrieval team organization.

Evaluation of surgical and anesthetic strategy as a key factor in the postoperative results of liver transplant.

Since the inauguration of our liver transplant program two years ago, retrospectively we can distinguish two different periods as regards postoperative results. The patients studied were distributed in two groups by chronological order and date of introduction of an improved surgical and anesthetic strategy: retrohepatic dissection during the veno-venous bypass phase and meticulous hemostasis in the anhepatic phase: Group A: 11 transplants in 10 patients and Group B: 22 transplants in 21 patients. Preoperatively, both groups were homogeneous with respect to the clinical situation. During the operation, significantly larger transfusion volumes were given in group A (25.4 +/- 10.5 ml/kg/hr) than in group B (10.0 +/- 5.7 ml/kg/hr) (p less than 0.01). The anhepatic phase lasted 1'50" +/- 20" in group B (p less than 0.05). The postoperative outcome of group B was better than that of A as regards hemodynamic and respiratory parameters, functional impairment of the graft and mortality (p less than 0.05). We conclude that the realization of retrohepatic dissection and careful hemostasis during the anhepatic phase, which prolongs the duration of venovenous by-pass but does not increase intraoperative morbidity, reduces the need for blood transfusion, and yields better postoperative results.

Results of surgical treatment of esophageal achalasia. Multicenter retrospective study of 1,856 cases. GEEMO (Groupe Européen Etude Maladies Oesophagéennes) Multicentric Retrospective Study.

A retrospective analysis of 1,856 patients treated by esophageal achalasia in 23 different surgical departments from seven countries is reported. The predominant symptom was dysphagia (100%), pain, vomiting and weight loss (76.1%). The most useful diagnostic methods were: barium meal (85%), manometry (100%), endoscopy (100%) and 99mTc (100%). Conservative treatment (5.45%) was useful in 5.8% only. Dilatation (16.9%) produced amelioration in 65.9%. Thoracotomy was used in 20.9% and middle line laparotomy in 79.2%. Heller esophagomyotomy was performed in 99.52% associated with anterior fundoplasty in 79.8% and postero-lateral (Mark IV) in 9.75%. Most of the patients were controlled through barium meal, esophagoscopy, esophageal manometry, pHmetry and 99mTc ingestion. Good results after Heller's myotomy with anterior fundoplication were 81.7% and poor 7.2%. Recurrence of achalasia was present in 184 patients. A new esophagomyotomy was performed on 58.6% and distal esophageal resection in 62 (35.3%). In total, 988 patients were reviewed once a year. Absence of gastroesophageal reflux was shown in 73.9% of the explored patients.

[Major abdominal surgery and the clearance of lipid emulsions]. / Cirugía abdominal mayor y aclaramiento de emulsiones lipídicas.

The use of lipid emulsions for TPN remains controversial. Although experimental studies show that medium chain triglycerides (MCT) are beneficial over long chain triglycerides (LCT) clinical studies are contradictory. With the aim to study the clearance of two lipid emulsions a prospective study was designed. 21 patients, submitted to resective surgery because of upper gastrointestinal tract malignancy were randomized in three groups. In group I (without lipids): all caloric intake was supplied by hypertonic glucose solution. In group II (LCT group) 55% of caloric intake was supplied by glucose and 45% by a LCT 20% emulsion (Intralip[id 20%, Kabi-Pharmacia). In group III (MCT group) 55% of caloric intake was supplied by hypertonic glucose solution and 45% by a physical mixture of LCT and MCT at 20% concentration (Lipofundina MCT, B. Braun). Our results show that in postoperative period of major abdominal surgery both lipid emulsions are cleared of in a similar way. When these emulsions are administered during 12 hours per day plasmatic triglycerides are completely cleared before to start the next-day infusion of lipid emulsion. Differences in total cholesterol were not found between groups. Nevertheless LDL-cholesterol rose significatively between first and tenth postoperative day in LCT group.

[Lymphocyte subpopulations and surgery. The role of postoperative parenteral nutrition]. / Subpoblaciones linfocitarias y cirugía. Papel de la nutrición parenteral postoperatoria.

The effects of LCT-based lipid emulsions used in TPN on immune system remains controversial. In this prospective study we research the effects of three types of TPN on T-lymphocyte subsets and NK cells. 21 patients diagnosed because of upper gastrointestinal carcinoma (UGIC), and amenable of curative surgery were included in the study. TPN support was maintained 10 postoperative days at least. All patients received 35 non-proteic Kcal/KG BW/day. Group I (without lipid): received 100% of caloric intake (CI) by glucose. Group II (LCT): received 55% of CI by glucose and 45% by LCT at 20% emulsion. Group III (MCT/LCT): received 55% of CI by glucose and 45% by MCT/LCT at 20% mixture. T-lymphocyte subsets were determined by flow cytometry preoperatively and in first and tenth postoperative days. Our results suggest that patients diagnosed of UGIC present alterations of cellular immunity. These alterations are increased by the age and by surgical act. The changes found are independent of the type of TPN. LCT-based emulsions have similar effects on T-lymphocyte subsets that MCT/LCT-based emulsions.

[Indications and results of surgical treatment of cavernous hemangioma of the liver]. / Indikationen und Resultate der chirurgischen Behandlung von cavernösen Hämangiomen der Leber.

Over a period of 6.5 years, 29 patients with liver hemangiomas have been examined. In 8 patients, the most frequent symptom was pain; in 11, a tumor was found. The diagnosis was made by means of scintigraphy with 99mTc, followed by real-time sonography, computed tomography using a contrast medium, and selective arteriography. In 16 patients (15 women, 1 man), the tumor radius was more than 6 cm and in 9 of these, more than 10 cm. In 3 patients, a left lobectomy was carried out, and in 5 a right lobectomy; in an additional 5 patients, a extended right lobectomy (three segments excised) was done. In the rest, a medial lobectomy, a segmentectomy on the left side, or a segmentectomy on the right was performed. The only complications observed in the whole series were: pleural effusion (1 case), subphrenic abscess (1), and transitory biliary fistula (1). All hemangiomas with a radius of more than 10 cm should be removed operatively, as should smaller symptomatic hemangiomas and tumors that are not clearly benign.

[Early and late results of orthotopic liver transplantation]. / Früh- und Spätresultate nach orthotoper Lebertransplantation.

Between 4/1986 to 1/1989, 74 orthotopic liver transplantation were performed in 62 patients (62 first liver transplants, 10 as second graft and two as a third graft); 57 in adults and 17 in children. The main indication for the operation was liver cirrhosis (61.4%) (the most frequent etiology was alcoholic cirrhosis, 28.5%). Six cirrhotic patients had a hepatocarcinoma (9.6%). Two received a liver and kidney transplant due to terminal renal insufficiency and hemodialysis. The most frequent indication in children was biliary atresia (33.3%). Six patients had a fulminal liver failure (9.6%). AB0 blood group compatibility was identical in 87.5%, compatible in six and incompatible in three patients. Total orthotopic liver transplantation was performed in 67 patients, and size-reduced liver was indicated in 7 patients. Extracorporeal veno-venous bypass was used in adults but never in children. In 93.1% of the transplants a single hepatic artery was anastomosed to the recipient and in 6.9% a double anastomosis was performed. In 62.5% of the patients a end-to-end choledocho-choledochostomy was performed and in 34.8% hepatico-jejunostomy was indicated. Three months postoperative mortality rate was 12.9%. Arterial stenosis and thrombosis were the most frequent complication.