Recurrent aspiration pneumonia after laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding is a popular therapeutic option for morbid obesity. Band slippage, pouch enlargement and esophageal dilatation are occasional late complications of this procedure. There are rare reports of recurrent aspiration after banding. We report a 44-year-old female suffering from dysphagia and aspiration pneumonia 2 years after adjustable banding. Her esophagus was dilated to 6 cm, and videocinematography showed a severe achalasia-like disorder. Withdrawal of fluid from the band should be immediate, and relieved the stomal obstruction in this patient. Aspiration pneumonia is a serious late complication, which is easily treated by deflation of the band.

Impact of weight loss on inflammatory proteins and their association with the insulin resistance syndrome in morbidly obese patients.

OBJECTIVE: Obesity is closely linked to the insulin resistance syndrome (IRS), type 2 diabetes, and cardiovascular disease, the primary cause of morbidity and mortality in these patients. Elevated levels of C-reactive protein (CRP) and interleukin-6 (IL-6), indicating chronic subclinical inflammation, have been associated with features of the IRS and incident cardiovascular disease. METHODS AND RESULTS: We studied the cross-sectional and longitudinal relation of CRP, IL-6, and tumor necrosis factor-alpha (TNF-alpha) with features of the IRS in 37 morbidly obese patients with different stages of glucose tolerance before and 14 months after gastric surgery. Weight loss after gastric surgery induced a significant shift from diabetes (37% vs 3%) to impaired glucose tolerance (40% vs 33%) and normal glucose tolerance (23% vs 64%). The baseline concentration of IL-6 was correlated with TNF-alpha (r=0.59, P<0.01) and CRP (r=0.44, P<0.05) levels. TNF-alpha, IL-6, and CRP were significantly correlated with insulin resistance estimated by the homeostatic model assessment (r=0.48, P<0.05; r=0.56, P<0.01; and r=0.35, P<0.05, respectively). Concentrations of CRP and IL-6 decreased after weight loss (median, 8.6 and interquartile range, 2.7/14.5 vs 2.5 and 1.2/4.1 mg/L; P<0.006, and 5.13 and 2.72/12.15 vs 3.95 and 1.97/5.64 pg/mL, P<0.02, respectively), whereas serum levels of TNF-alpha remained unchanged (8.6 and 6.3/18.8 vs 11.7 and 5.8/17.2 pg/mL; NS.). Multiple regression analysis revealed that the decrease in insulin resistance remained independently and significantly correlated with the decrease in IL-6 concentrations (P<0.01) and the decrease in body mass index with the decrease in CRP (P<0.05), respectively. CONCLUSIONS: Weight loss in morbidly obese patients induces a significant decrease of CRP and IL-6 concentrations in association with an improvement of the IRS.

Immunocytochemical localization of the extracellular calcium-sensing receptor in normal and malignant human large intestinal mucosa.

We identified the parathyroid type Ca(2+)-sensing receptor (CaR) in normal human colon mucosa and in cancerous lesions at the mRNA and protein level. Polymerase chain reaction produced an amplification product from reverse-transcribed large intestinal RNA which corresponded in size and length to a 537-bp sequence from exon 7 of the CaR gene. With a specific antiserum against its extracellular domain, the CaR could be detected by immunostaining in normal human colon mucosa in cells preferentially located at the crypt base. The CaR protein was also expressed in tumors of the large bowel in all 20 patients examined. However, the great majority of CaR-positive cells in the adenocarcinomas inspected were confined to more differentiated areas exhibiting glandular-tubular structures. Poorly or undifferentiated regions were either devoid of specific immunoreactivity or contained only isolated CaR-positive cells. In the normal mucosa and in glandular-tubular structures of cancerous lesions, the CaR was exclusively expressed in chromogranin A-positive enteroendocrine cells and in only a small fraction of PCNA-positive cells.

Dietary changes after vertical banded gastroplasty.

BACKGROUND: Gastric restriction surgery relies on obstruction to oral intake by formation of a gastric pouch. Therefore, the therapeutic effect is closely related to intolerance for different types of food, and an ingestion of an unbalanced diet. We investigated dietary changes after VBG and their associations with therapeutic success. METHODS: 70 patients (4 men, 66 women, median age 32) with a median preoperative BMI of 44.6 were examined > or =3 years after VBG. Weight reduction, nutritional changes (type of diet, number of daily meals, amount of food that could be ingested, intolerance for different types of food, frequency of vomiting), satisfaction with results, and willingness to undergo the operation once again were investigated. RESULTS: The average reduction of the BMI was 13, with sufficient weight loss in 80%. 36% were eating a solid, 43% a soft, and 21% a liquid diet. Weight reduction did not depend on the type of diet eaten but on the ingestion of sweets. 93% indicated they could take only small amounts of food. The average number of daily meals was 3.76% reported an intolerance for some type of food (most often meat, fruit, or vegetable). Vomiting was the most common problem and occurred in 71%. 71% indicated a high level of satisfaction with the results of the operation, and 96% said they would undergo the operation again. CONCLUSIONS: The investigation demonstrated successful weight reduction despite dietary changes in 80% of patients after VBG. Weight reduction was not influenced by type of, diet but depended on consumption of sweets.

In situ mRNA hybridization analysis and immunolocalization of the vitamin D receptor in normal and carcinomatous human colonic mucosa: relation to epidermal growth factor receptor expression.

There is evidence that vitamin D receptor (VDR)-mediated action of 1 alpha,25-dihydroxyvitamin D3 (1 alpha,25-(OH)2D3) could limit colon cancer cell growth particularly when induced by activation of the epidermal growth factor receptor (EGFR). We therefore wanted to ascertain the relevance of this observation for human colon cancerogenesis. Utilizing in situ mRNA hybridization and immunocytochemical techniques, we analyzed cell-specific expression of VDR and EGFR in normal and malignant human colonic mucosa. In normal mucosa, VDR positivity is weak and observed only in a small number of luminal surface colonocytes. In contrast, EGFR expression at a relatively high level is also found in cells at the crypt base. The number of VDR-positive colonocytes increases remarkably during tumor progression. It reaches its maximum in low grade adenocarcinomas and returns to lower levels in highly malignant cancers. In both low- and high grade carcinomas, the great majority of tumor cells contain the EGFR message. The relative abundance of EGFR over VDR in normal mucosa and in high grade carcinomas would create a situation in which mitogenic effects from EGFR activation are only ineffectively counteracted by signaling from 1 alpha,25-(OH)2D3/VDR. In contrast, in well to moderately differentiated tumors, upregulation of VDR could retard further tumor progression.

Long-term outcome after open treatment of severe intra-abdominal infection and pancreatic necrosis.

BACKGROUND: Outcome assessment after surgical treatment of intra-abdominal infections and pancreatic necrosis has concentrated on postoperative complications and survival, while long-term results have received little attention. OBJECTIVES: To evaluate hospital costs and long-term outcome for patients undergoing open treatment of intra-abdominal infection or pancreatic necrosis and to determine whether results justify costs. DESIGN: Cohort study and cost-effectiveness analysis. SETTING: Referral center. PATIENTS: From January 1, 1988, through June 30, 1996, we used open treatment for 147 patients with pancreatic necrosis (n=75; group 1), severe intra-abdominal infections due to benign diseases (n=50; group 2), and infections due to malignant neoplasm (n=22; group 3). All surviving patients (n=92) were followed up. Fifty-seven patients in group 1, 25 patients in group 2, and 10 patients in group 3 survived. INTERVENTIONS: The effective costs of treatment per surviving patient (including restorative surgery) were calculated. The patients were interviewed, and the residence location, medical treatment, degree of recovery, functional state, and employment status were assessed. We assessed the quality of life by using the short general health survey (SF-36). MAIN OUTCOME MEASURES: Costs, survival, and long-term outcome. RESULTS: The effective costs per survivor studied were $175000 (group 1) and $232400 (groups 2 and 3). Most patients experienced good long-term results, ie, employment status was unchanged for 69 (75%) of the patients, and the functional state was unchanged for 81 (88%) of the patients. Readmission to a hospital was necessary for 14 (15%) of the patients, and 5 (6%) required care in nursing homes. Of the patients studied, 75% described their quality of life as good. Patients in group 3 had significantly worse results for survival, functional status, and quality of life (P<.01, log-rank test). CONCLUSIONS: Our study demonstrated that open treatment of severe intra-abdominal infection and pancreatic necrosis is a cost-effective treatment with good long-term results for most patients. However, patients with malignant neoplasms did not benefit from this therapy and, therefore, should not be treated by laparostomy.

Therapy of cervical esophageal carcinoma.

Surgical treatment of cervical esophageal cancer is influenced by special problems arising from the anatomical characteristics of this organ. The cervical and thoracic extension of these tumors makes an extensive lymphadenectomy necessary, and radical resections often may only be achieved by laryngectomy. The extent of the resections performed determines the type of intestinal restoration by gastric or colonic interposition and small bowel transplantation. The patient's voice may be preserved by means of tracheopharyngeal shunts with intestinal interposition. The advances of radiation therapy and chemotherapy will enable less extended resections with greater rates of laryngeal preservation.

25-Hydroxyvitamin D(3)-1alpha-hydroxylase and vitamin D receptor gene expression in human colonic mucosa is elevated during early cancerogenesis.

Human colorectal cancer cells not only express the nuclear vitamin D receptor (VDR) but are also endowed with 25-hydroxy-vitamin D(3)-1alpha-hydroxylase activity and therefore are able to produce the specific ligand for the VDR, the hormonally active steroid 1alpha,25-dihydroxyvitamin D(3) (1alpha,25(OH)(2)D(3)). In the present study we show by semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR) as well as by Western blotting and immunohistochemical methods, that in human large intestinal carcinomas expression of the genes encoding the 25-(OH)D(3)-1alpha-hydroxylase as well as the VDR increases in parallel with ongoing dedifferentiation in the early phase of cancerogenesis, whereas in poorly differentiated late stage carcinomas only low levels of the respective mRNAs can be detected. This indicates that, through up-regulation of this intrinsic 1alpha,25(OH)(2)D(3)/VDR system which mediates the anti-mitotic effects of the steroid hormone, colorectal cancer cells are apparently able to increase their potential for an autocrine counter-regulatory response to neoplastic cell growth, particularly in the early stages of malignancy.

Video-assisted resection of pulsative midesophagus diverticula.

BACKGROUND: Pulsative diverticula located in the midesophagus occur rarely. Surgical treatment is indicated for symptomatic diverticula. This study evaluated a new minimally invasive method of treatment. METHODS: Three women, ages 69 to 73 years, underwent resections of diverticula via a thoracoscopic access. No major complications were observed. Preoperative symptoms such as dysphagia, regurgitation, aspiration, loss of weight, and retrosternal pain were not reported at follow-up assessment 3 to 60 months after surgery. The patients were highly satisfied with the functional results. CONCLUSIONS: According to our results, minimally invasive treatment of midesophagus diverticula by thoracoscopic resections may be performed with excellent outcome.

Functional impairment of the abdominal wall following laparoscopic and open cholecystectomy.

BACKGROUND: Subcostal incisions for open cholecystectomy (OC) denervate the right upper and middle abdomen. METHODS: Sensory and abdominal muscle function (Janda's muscle function test, Cybex 6000) was evaluated. Healthy volunteers (10 women, 12 men) were compared with 13 women and 12 men after OC and 11 women and 11 men after laparoscopic cholecystectomy (LC). For computed tomography (CT) studies, a spiral scanner was used. RESULTS: Of the OC patients, 21 (95.5%) complained of dys- and anesthesias below the incision. Of the LC patients, only nine (2.4%) reported anesthesias around the port sites. Normal subjects scored significantly higher in muscle strength (p <.01). LC patients scored higher than OC patients at 10 degrees and 20 degrees trunk flexion (p <.05). Depending on the flexion angles, the men in all groups developed 30-114% more muscle power than the women. Denervation of the abdominal muscles was confirmed by CT. CONCLUSION: OC reduced skin sensitivity and abdominal muscle function. Although the procedure is minimally invasive, LC also causes sensory and functional losses, albeit minor ones.

Vitamin D receptor activity and prevention of colonic hyperproliferation and oxidative stress.

Unimpaired vitamin D action has been implicated in human cancer prevention. We have previously demonstrated the effectiveness of 1 alpha-dihydroxyvitamin D3 (1,25-D3) to reduce proliferation and increase differentiation in human colon cancer cells. The aim of this study was to investigate, on the one hand, expression of the vitamin D receptor (VDR) and of 25-hydroxyvitamin D(3)-1 alpha-hydroxylase (1 alpha-hydroxylase) in human normal and malignant colonic tissue and, on the other hand, to determine consequences of reduced or lacking VDR action in a VDR knockout mouse model. In low-grade malignancies of the human colon we found increased VDR and 1 alpha-hydroxylase mRNA expression. However, in late-stage high-grade tumors the vitamin D system is severely compromised. In the mouse colon we found an inverse relationship between VDR levels and proliferation in colon descendens, a tissue known to be specifically affected by nutrients during carcinogenesis. Expression of 8-hydroxy-2'-deoxyguanosine (8-OHdG), a marker of oxidative DNA damage, was significantly augmented with complete loss of VDR. These data suggest that genomic 1,25-D(3) action is necessary to protect against nutrition-linked hyperproliferation and oxidative DNA damage.

Improved results after aggressive treatment of colonic involvement in necrotizing pancreatitis.

BACKGROUND/AIMS: Colonic involvement is a rare but serious event in necrotizing pancreatitis. Early detection of this complication is difficult; a delay of diagnosis may lead to perforation and peritonitis. Two strategies of therapy have been developed in the last few years: an aggressive regimen of early resection and a conservative approach with ileostomy and observation. MATERIALS AND METHODS: Fourteen of 118 patients treated for necrotizing pancreatitis from 1988 to 1995 presented with colonic necrosis. The diagnosis of necrosis was made if the color of the bowel wall demonstrated ischemia or hemorrhagic infarction or pulsations of the mesocolic vessels could not be palpated. The first two patients were treated by a conservative approach the following 12 by immediate large bowel resection. Follow-up results of all surviving patients were obtained. RESULTS: Patients with colonic lesions demonstrated an advanced septic state compared to patients who did not present this complication. Differences in the average Apache 2 scores on admission and the incidence of multiple organ failure were significant (Apache 2 score; 16.6 versus 11.9, p = 0.028, Wilcoxon; multiple organ failure; 71% versus 35%, p = 0.028, Fisher's exact test). Results after establishment of early discontinuity-resection of colonic necrosis compared favorably to those of a conservative strategy (mortality 4/12; 33% versus 2/2; 100%). The overall mortality was 43% (6 of 14 patients). Restorative surgery was performed in 6 patients without substantial morbidity and no mortality. Follow-up results were satisfactory in the majority of the patients. CONCLUSIONS: Early resection of colonic lesions improves results in this dangerous complication of necrotizing pancreatitis.

Improved results after aggressive treatment of colonic involvement in necrotizing pancreatitis.

BACKGROUND/AIMS: Colonic involvement is a rare but serious event in necrotizing pancreatitis. Early detection of this complication is difficult; a delay of diagnosis may lead to perforation and peritonitis. Two strategies of therapy have been developed in the past few years: an aggressive regimen of early resection and a conservative approach by ileostomy and observation. MATERIALS AND METHODS: Fourteen of 118 patients treated for necrotizing pancreatitis from 1988 to 1995 presented with colonic necrosis. The diagnosis of necrosis was made if the color of the bowel wall demonstrated ischemia or hemorrhagic infarction or pulsations of the mesocolic vessels could not be palpated. The first two patients were treated by a conservative approach, the following 12 patients by immediate large bowel resection. Follow-up results of all surviving patients were obtained. RESULTS: Patients with colonic lesions demonstrated an advanced septic state compared to patients who did not present this complication. Differences in the average Apache 2 scores on admission and the incidence of multiple organ failure were significant (Apache 2 score; 16.6 versus 11.9, p = 0.028, Wilcoxon; multiple organ failure; 71% versus 35%, p = 0.028, Fisher's exact test). Results after establishment of early discontinuity-resection of colonic necrosis compared favorably to those of a conservative strategy (mortality 4/12; 33% versus 2/2; 100%). The overall mortality was 43% (6 of 14 patients). Restorative surgery was performed in 6 patients without substantial morbidity and no mortality. Follow-up results were satisfactory in the majority of the patients. CONCLUSIONS: Early resection of colonic lesions improves results in this dangerous complication of necrotizing pancreatitis.

[Arthur Biedl and the beginnings of modern endocrinology. On the 125th birthday of the Austrian pathophysiologist]. / Arthur Biedl und die Anfänge der modernen Endokrinologie. Zum 125. Geburtstag des österreichischen Pathophysiologen.

Modern endocrinology began to develop at the end of the nineteenth century in four stages: the recognition and localization of endocrine glands, the experimental proof of internal secretion by means of destruction and substitution in animals, their isolation and lastly the synthesis of pure hormones. Arthur Biedl (1869-1933), an assistant of Salomon Stricker (1834-1898), was essentially involved in the first two stages of this research process. This paper presents his work from 1895 to 1914.

[Gastric bypass in the management of morbid obesity]. / Der Magenbypass in der Therapie der morbiden Fettsucht.

A report is presented on 82 gastric bypass operations performed from 1979 to 1988. The average preoperative body weight was 132 kg, the body mass index (BMI) 45.0 +/- 7.0. 1 patient died (mortality 1%). 88 per cent of all patients were followed up 2 months to 9 years (2.5 years on average) postoperatively. The mean weight loss was 40.8 kg (reduction of BMI 15.1). Obesity-related diseases decreased remarkably, 3 stomal ulcers and 5 cases of anemia occurred as late complications. On the basis of these results gastric bypass is shown to be an effective and safe treatment of morbid obesity.

Gender-specific differences in the natural history, clinical features, and socioeconomic status of HIV-infected patients: experience of a treatment centre in Vienna.

BACKGROUND: In order to evaluate natural history, clinical features, and socioeconomic aspects in HIV-infected women, a prospective study comprising 695 HIV-infected patients was performed at our department. METHODS: Demographic data, CD4+ T-lymphocyte counts, human immunodeficiency virus-1 (HIV-1) plasma loads, AIDS indicator diseases and socioeconomic variables were recorded. Prognostic factors for survival were evaluated by univariate and multivariate analysis. Data of men and women were compared. RESULTS: The mean age of the 150 women (29.4 +/- 9.4 years) was significantly lower than that of men (32.6 +/- 9.7 years, p = 0.0002). CD4+ T-lymphocyte counts, HIV1-plasma loads, and AIDS indicator diseases did not significantly differ between men and women; the same was true for all socioeconomic variables (family status, education, professional training, employment status) except family status. No significant difference in median overall and AIDS-free survival was observed between females (2033 and 1593 days) and males (1554.5 and 1235 days, respectively, p = 0.36 and p = 0.098). Overall survival compared by age groups (< 30, 31-50, > 50 years), by risk categories (homosexuals, i.v. drug users, heterosexual contacts) and by CD4+ T-lymphocyte count (< 200, 200-500, > 500 cells/mm3), differed significantly (p < 0.001) as did AIDS-free survival. Lower age and a high CD4+ T-lymphocyte count were independently associated with the outcome in the multivariate analysis. (Overall survival/relative risk: 0.49 for age < 30 years and 2.3 for CD4+ T-lymphocyte count < 200 cells/mm3, AIDS-free survival/relative risk: 0.65 for age < 30 years and 3.3 for CD4+ T-lymphocyte count < 200 cells/mm3). HIV-1 plasma loads as a prognostic factor could not be evaluated due to the small number of patients who died or developed AIDS (2/375 and 10/375 patients, respectively). CONCLUSION: Our results showed no difference in the natural history and clinical features of HIV infection between men and women. However, pulmonary tuberculosis was associated with a significantly longer survival compared to other AIDS-defining diseases. Lower age and high CD4+ T-lymphocyte count are independent predictors for survival. With the exception of family status, socioeconomic variables showed no differences between male and female patients.

[Diagnosis of pneumocystis carinii pneumonia in AIDS patients]. / Zur Diagnostik der Pneumocystis carinii-Pneumonie bei AIDS-Patienten.

BACKGROUND: Based on the changing disease pattern of human immunodeficiency virus (HIV) associated pulmonary complications we conducted a prospective study in order to compare the value of laboratory tests in patients with Pneumocystis (P.) carinii pneumonia (PCP) and other pulmonary complications and of different identification methods of P. carinii in bronchoalveolar lavage fluid (BALF) in PCP patients. PATIENTS AND METHODS: In 217 HIV-1-infected patients we evaluated the following parameters: platelets, serum lactat dehydrogenase (LDH), total serum protein (TP), hemoglobin (Hb), and CD4+ and CD8+ T-lymphocyte count. P. carinii was identified in BALF by May Grünwald Giemsa stain (MGG), direct immunofluorescence test (DIFT), and polymerase chain reaction (PCR). We correlated these parameters in patients with a presumptive diagnosis of PCP and compared them with those of patients suffering from other pulmonary complications. RESULTS: All patients underwent bronchoscopy. 55 patients (25.3%) had a presumptive diagnosis of PCP. The sensitivity values of MGG stain, DIFT, and PCR differed considerably (79.1%, 56.1%, and 65.9%, respectively), but specificity values did not (99.2%, 97.3%, and 98.2%, respectively) as well as accuracy values (93.8%, 86.2%, and 89.7%, respectively). The mean values of platelets, of LDH, and of total serum protein of PCP patients and those of patients with other pulmonary diseases differed statistically significant as well as the mean values of these parameters of PCP patients and those of patients with bacterial pneumonia. Logistic-regression analysis revealed the number of platelets and the amount of total serum protein as independent, significant prognostic factors. Moreover, each PCP patient had a CD4+ T-lymphocyte count of less than 200 cells/mm3 blood. The CD4/CD8 ratio of PCP patients was statistically significant lower than that of patients with bacterial pneumonia. CONCLUSIONS: A detection of P. carinii in BALF is inevitable for a definitive diagnosis of a PCP. The most efficient identification method in this case is the MGG stain. Platelets, total serum protein, and CD4+ T-lymphocyte count should be included into the criteria for the presumptive diagnosis of PCP.

[The place of selective proximal vagotomy in complicated duodenal ulcers]. / Der Stellenwert der selektiv proximalen Vagotomie beim komplizierten Ulcus duodeni.

From 1980 to 1988 417 patients underwent surgery for peptic duodenal ulcer. Complications were present in 217 patients: perforation (40%), bleeding (32%), stenosis (20%) or penetration (8%). Highly selective vagotomy was performed in 67% of all patients. The number of operations for duodenal ulcer decreased (1984 n = 61, 1988 n = 28) due to fewer operations for uncomplicated ulcers, whereas the number of operations for complicated cases remained equal. Mortality after highly selective vagotomy for complicated duodenal ulcer was 5.2%. All fatalities occurred after bleeding. Whereas highly selective vagotomy was performed frequently for stenosing (72%) and bleeding (68%) ulcers it was the exception in perforate duodenal ulcers (13%). A tendency to increased performance of highly selective vagotomy in complicated cases is evident (1981 40%, 1988 70%). A further increase seems possible by using more liberal indications for selective vagotomy in perforated ulcers and by more frequently carrying out preoperative endoscopic hemostasis in bleeding duodenal ulcers.

[Spontaneous perforation of the large intestine. Resection with primary anastomosis or staged (Hartmann) procedure?]. / Spontane Dickdarmperforation. Resektion mit primärer Anastomose oder Diskontinuitätsresektion (Hartmann)?

Whereas primary resection to remove the septic focus stands undisputed in the therapy of spontaneous perforation of the colon, there is still no consensus as to whether to perform a primary anastomosis or a staged procedure (Hartmann). Prospective randomized studies comparing both concepts are lacking. Obviously these two competing therapies fit different groups of patients whose diseases differ concerning etiology, localisation and severity. Analysis of the literature of the past few years defined some criteria that help to decide when to omit primary anastomosis: MPI > 20, APACHE II score > 15, preoperative organ insufficiency, Hinchey grade III or IV and ASA score IV. In these cases a discontinuity resection is recommended. Primary resection with anastomosis and Hartmann procedure are not competing operations but situation-dependent therapeutic concepts in spontaneous colonic perforation.