[The Devascularisation Procedure for the Treatment of Fundic and Oesophageal Varices in Portal Hypertension - a Retrospective Analysis of 55 Cases]. / Die Devaskularisationsoperation zur Behandlung von Fundus- und Ösophagusvarizen bei portaler Hypertension ­ eine retrospektive Analyse von 55 Fällen.

BACKGROUND: The most dangerous complication of portal hypertension is the formation of oesophageal varices, as the risk of bleeding is up to 80%. In order to reduce pressure reduction in the portosystemic circulation and as secondary prophylaxis, the TIPSS procedure has proven successful. In patients with portal vein thrombosis, portosystemic shunt surgery is possible to reduce the risk of variceal bleeding. However, if thrombosis of the mesentericoportal axis or hepatic encephalopathy is imminent, interventional or surgical creation of a portosystemic shunt is contraindicated. As a last resort to avoid recurrent bleeding or in case of inexorable bleeding, a devascularisation procedure may be indicated. The aim of this study was to investigate perioperative complications, morbidity and mortality, the incidence of postoperative recurrent bleeding, and patient survival after devascularisation surgery. PATIENTS AND METHODS: We retrospectively analysed 55 patients with a history of variceal haemorrhage or acute bleeding without the possibility of an invasive or operative portosystemic shunt for complication rate, recurrent variceal recurrence, rebleeding and survival. RESULTS: While complications for elective surgery were 61%, they increased significantly in emergency surgeries (75%, p = 0.002), especially for severe complications (Dindo/Clavien grade III - V° [14 vs. 58%, p = 0.002]). Devascularisation significantly reduced varicosis occurrence. Furthermore, only 16% of patients suffered recurrent bleeding in a follow-up period of up to 24 years. Median survival (MS) after devascularisation surgery was 169 ± 23 months. After elective surgery, MS was 194 ± 25 months, but after emergency surgery only 49 ± 16 months. No patient showed any hepatic encephalopathy during their hospital stay. DISCUSSION: Devascularisation surgery is well suited for secondary prophylaxis in patients with fundic and oesophageal varices and portal hypertension with no possibility of portosystemic shunt or with impending hepatic encephalopathy. However, if the operation is performed in an emergency situation, significantly more major complications occur and the outcome is significantly worse. Therefore, especially in the absence of an opportunity of lowering pressure in the portal venous system and with progressive varices, elective devascularisation should be considered at an early stage.

Chronic rhinosinusitis and cystic fibrosis: the interaction between sinus bacteria and mucosal immunity.

BACKGROUND: Chronic rhinosinusitis (CRS) is highly prevalent in cystic fibrosis (CF) patients, in whom a close correlation exists between the microbiology of the upper and lower respiratory tracts. We have reported intramucosal bacterial microcolonies in the sinus mucosa from idiopathic CRS patients and have made observations suggesting that these may result from mucosal immunotolerance secondary to altered macrophage function. In this study, we sought to determine whether intramucosal microcolonies exist in the mucosa of CF patients with CRS, and to investigate the associated mucosal immunology. METHODS: Mucus swabs and tissue biopsies were taken from 9 patients with CF undergoing functional endoscopic sinus surgery (FESS) for CRS, 11 with idiopathic CRS undergoing FESS, and 9 with normal sinuses having transnasal pituitary surgery. Microbiology samples were taken for culture and intramucosal microcolonies were sought using Gram staining. Mucosal immune cells were identified using fluorescent immunohistochemistry. RESULTS: Positive culture rates were similar between CRS patients and controls, but there were significantly more intramucosal microcolonies in the CRS groups (8/9 CF-CRS, 7/11 CRS), compared to controls (1/9). Furthermore, the biodensity of intramucosal microcolonies was significantly higher in CF-CRS than idiopathic CRS. Mirroring the microbiological observations, the number of CD163+ macrophages was significantly increased in CF-CRS compared to idiopathic CRS (p = 0.03). CONCLUSION: Intramucosal bacteria exist within the sinus mucosa of patients with CF, and in significantly greater numbers than in idiopathic CRS patients. We speculate that intramucosal microcolonies may also exist in the lower respiratory tract mucosa in CF and play a role in disease recalcitrance.

Smoking during pregnancy causes double-strand DNA break damage to the placenta.

Despite the adverse effects of smoking, many pregnancies are exposed to tobacco smoke. Recent studies have investigated whether smoking damages placental DNA by measuring DNA adducts. This study investigated whether a more severe lesion, double-strand DNA breaks, was also present in the tobacco smoking-exposed placenta. Term placentae from women who smoked during their entire pregnancies (n = 52), from those who had ceased smoking for at least 4 weeks before delivery (previous smokers, n = 34), and from nonsmoking women (n = 150) were examined using the DNA double-strand break marker phosphorylated γ H2AX. The extent of DNA damage was assessed according to cell type and additional markers were applied for cell fate (apoptosis and DNA repair), and function (human chorionic gonadotropin, human placental lactogen, and glucose transporter 1), to characterize the effect of the DNA damage on placental integrity. Marked phosphorylated γ H2AX-positive cells occurred in the villous syncytiotrophoblast and syncytial knot nuclei in placentae from smokers (P < .001). Phosphorylated γ H2AX foci did not colocalize with the DNA repair protein 53BP1, and damaged nuclei had a marked reduction in expression of human chorionic gonadotropin, human placental lactogen, and glucose transporter 1. Minimal DNA damage, similar to nonsmokers, was present in previous smokers including those that had ceased smoking for just over 4 weeks before delivery. In summary, smoking during pregnancy was associated with marked double-strand DNA break damage to the syncytiotrophoblast. We suggest that smoking cessation is important to prevent additional DNA damage and to facilitate DNA repair.