Effects of malnutrition on the acute phase response of plasma proteins in patients undergoing total gastrectomy.

The serum level of six acute phase proteins (APP) has been evaluated preoperatively and for a few days in the postoperative period. Thirty patients undergoing total gastrectomy for gastric cancer have been studied in two subgroups according to their nutritional status. Those with gastric cancer had significantly higher baseline serum levels of alpha 1 acid glycoprotein (alpha1AGP) and C-reactive protein (CRP) than a control group. Malnourished patients also had reduced acute phase response for alpha1AGP and alpha 1 antitrypsin (alpha1AT) a higher increase of CRP and fibrinogen, and a lower decrease for transferrin and retinol binding protein (RBP).

Effect of Intralipid on some immunological parameters and leukocyte functions in patients with esophageal and gastric cancer.

This study has been undertaken to investigate if the intravenous (i.v.) infusion of fat emulsions may be associated with impairment of some immunological functions thus increasing the risk of septic complications. Fifteen malnourished patients with advanced gastric or esophageal cancer received for 2 weeks preoperatively and 1 week after surgery an isocaloric and isonitrogenous TPN treatment with Intralipid (group A: n=8) or glucose alone (group B: n=7) as energy substrate. Cluster analysis of 11 nutritional parameters and some tests of the humoral and cellular immunity (IgG, IgM, C3c, Factor B; polymorphonuclear (PMN) cells, total lymphocytes, T and B lymphocyte counts; 'in vitro' PMN chemotaxis, adherence to nylon fibers, phagocytosis of latex particles) were sequentially determined. The incidence and severity of post-operative infections were investigated and a 'sepsis score' was calculated for each patient. Pre- and postoperative TPN were not associated with an improvement of the nutritional status. The humoral and cellular immune parameters showed the same behaviour in patients receiving Intralipid and in controls. The chemotactic activity of PMN cells was constantly normal, granulocyte adherence fluctuated below the normality range in controls, whereas phagocytosis of latex was similar in both groups. Post-operative infectious episodes were less severe in patients receiving Intralipid. Our results do not confirm that Intralipid adversely affects some aspects of the humoral and cellular immune response.

Pre-operative nutritional support and tumour cell kinetics in malnourished patients with gastric cancer.

Stimulation of tumour growth by intensive exogenous nutrient administration could be a major clinical problem when nutritional support is provided in malnourished cancer patients. Nutritional repletion has been clearly shown to stimulate tumour growth in animal models but not in humans. The purpose of this prospective study was to evaluate the effect of pre-operative nutritional support on the proliferative characteristics of gastric tumour cells evaluated by 3H-thymidine (3HT) incorporation and flow cytometry (FCM). Thirty-three malnourished patients with advanced gastric cancer were allocated randomly into two groups receiving different types of nutritional support during the interval between endoscopy and operation: parenteral and/or enteral hyperalimentation (Group 1), and oral alimentation as possible or peripheral fluids (Group 2). In 16 patients with diploid tumours the percentage of 3HT labelled cells and of cells in S+G(2)M phase did not differ between the multiple samples taken from the mucosal surface of the neoplasia. Tumour samples showed higher mean values of cycling cells than the surrounding normal tissue. Both methods (3HT - FCM) demonstrate that tumour cell proliferation is not enhanced following a prolonged period of pre-operative artificial nutrition.

Catheter seeding of hepatocellular carcinoma following placement of a total implantable access port system.

A 61-year-old cirrhotic patient underwent hepatic resection for hepatocellular carcinoma and placement of a total implantable access port system in the hepatic artery for chemotherapy infusion. A year later, he developed a parietal metastasis at the port site as a consequence of tumor seeding along the arterial catheter. The metastasis was excised but the patient died because of disseminated disease two years after the first operation. Tumor seeding along the catheter should be included in the group of potential complications after placement of total implantable access port systems for intrahepatic chemotherapy The possible causes of this rare but life-threatening complication are discussed.

[Nutritional support in acute pancreatitis]. / La nutrizione artificiale nella pancreatite acuta.

Severe acute pancreatitis 3 or more Ranson's prognostic signs is characterized by a generalized hypermetabolic response and nutritional depletion leading to malnutrition and septic complications. Nutritional support has come to be a significant component of the treatment of acute pancreatitis. However the route of nutrient administration and composition of substrates administered remain controversial. Available data suggest that intravenous infusion of amino acids, glucose and fat emulsions alone or in combination does not stimulate exocrine pancreatic secretion. Similarly, enteral feeds should have low fat composition and be delivered distal to the ligament of Treitz. This review outlines the current body of specific literature and provides preliminary guidelines for the nutritional support of patients with acute pancreatitis.

[The effect of the administration of an amino acid solution containing acetate on the calcium balance in surgical patients]. / Effetto della somministrazione di una soluzione di aminoacidi contenente acetato sul bilancio del calcio in pazienti chirurgici.

A frequent trouble in total parenteral nutrition is the occurrence of a negative calcium balance, due to reduction of calcium tubular reabsorption in acidosis. This condition could depend on acid metabolites raise, coming from degradation of nutritional amino acid mixtures. Authors have evaluated the effect of acetates addition to amino acid solutions on calcium balance. In fact the bicarbonate excess could reduce calcium urinary excretion. Thirty surgical patients have been treated. They were randomized according to acetates presence or absence in the administered solutions. In the acetate-treated group authors noted a raise in plasma bicarbonate and pH and a reduction in urinary calcium excretion. Adding acetates to amino acidic mixtures could reduce in total parenteral nutrition the risk of hypercalciuria and its related complications.

Diagnostic approach to lymph node enlargement.

BACKGROUND AND OBJECTIVE: How to reach the correct diagnosis of a lymph node enlargement is still a problem which strongly challenges the knowledge and experience of the clinician. Organized and specifically oriented literature on the right sequential steps and the logical criteria that should guide this diagnostic approach is still lacking. METHODS: The authors have tried to exploit available knowledge and their personal experience by correlating a large body of information regarding size, physical characteristics, anatomical location of enlarged lymph nodes, and the possible epidemiological, environmental, occupational and clinical categorization of this condition. RESULTS AND CONCLUSIONS: It was intended that such material would have constituted the basis of a hypothetic decision-making tree, but this was impossible because of the lack of epidemiological investigation and registry data. Nevertheless, we present this preparatory work here in order to stimulate the interest of concerned readers and because of its possible direct usefulness in hematologic practice.

Sepsis score and complement factor B for monitoring severely septic surgical patients and for predicting their survival.

Sepsis score and complement factor B (FB) have been measured in 66 severely septic surgical patients in the intensive care unit, with the aim of monitoring their clinical course and predicting their outcome. Sepsis score correlated well with clinical course. 82% of patients with initial sepsis score less than 20 progressively improved and survived. Only 6% of patients with sepsis score greater than or equal to 20 survived. FB plasma level was significantly higher (p less than 0.01) in patients who subsequently survived. Two indices were identified which could predict patient outcome several days in advance with 100% accuracy: (1) the index of survival from sepsis defined as the combination of sepsis score less than 20 and FB greater than or equal to 45 mg/dl, and (2) the index of death from sepsis defined as sepsis score greater than or equal to 20 and FB less than 40 mg/dl.

Temporary intraluminal bypass for superior vena cava reconstruction after cancer invasion.

We report a case of right upper lobe bronchogenic cancer widely infiltrating the superior vena cava (SVC) in which right pneumonectomy was performed with partial resection of the SVC wall. The SVC was reconstructed by means of a pericardial patch; during reconstruction a temporary intraluminal bypass was set up to obtain a proper venous return to the right atrium.

Use of subcutaneous implantable infusion systems in neoplastic and AIDS patients requiring long-term venous access.

OBJECTIVE: To evaluate the life span and complication rates of totally implantable infusion devices in patients with short bowel syndrome and in immunocompromised patients with AIDS, lymphoma, and myeloma who required long-term central venous access. DESIGN: Prospective open study. SETTING: University hospital, Italy. SUBJECTS: Group I - 5 patients with short bowel syndrome; group II - 11 patients with AIDS; and group III - 15 patients with lymphoma or multiple myeloma (1 of whom had 2 devices implanted). MAIN OUTCOME MEASURES: Duration of implantation and incidence of catheter-related complications. RESULTS: The mean duration/patient of the catheter was 422 days (range 20-1257) in group I; 104 days (range 43-262) in group II; and 415 days (range 62-1280) in group III. There were no catheter related complications in the patients in group I (short bowel syndrome). Of the 11 patients with AIDS (group II) 4 developed catheter related infections (0.32/100 catheter days), and 1 developed a thrombotic occlusion. All 5 catheters were removed (3 for infection). Of the 15 patients with lymphoma or myeloma who had 16 catheters implanted (group III), 1 patient developed 3 infective episodes (0.05/100 catheter days), 1 catheter migrated and 1 occluded. All 3 catheters were removed. CONCLUSION: Totally implantable infusion systems can safely be used for prolonged periods in immunocompromised patients, including those with AIDS if their life expectancy is reasonable.

Diagnosing malnutrition.

The measurement of selected anthropometric, biochemical and immunological variables, and clinical judgment can be used to assess nutritional state. Nutritional assessment has three main aims: to define the type and severity of malnutrition; to identify high risk patients; to monitor the efficacy of nutritional support. The problems associated with the various methods to assess the nutritional state and the applications of nutritional assessment in clinical practice are presented and discussed.

Mechanisms of platelet activation by cultured human cancer cells and cells freshly isolated from tumor tissues.

We studied the effects on platelet function of cells isolated from freshly dissociated human tumor tissues (11 breast carcinomas, 9 colon carcinomas and 1 lymph node metastasis from melanoma) obtained at surgery as compared with cultured human tumor cells: namely, human melanoma 1402 cell line derived from a primary tumor and two lines derived from lymph node metastases (ME 7110/2 and Me 665/1) as well as a human hepatoma cell line (Hep G2). The three melanoma cell lines activated platelets by producing ADP, as evidenced by the inhibitory effect of apyrase and by the direct measurement of the agonist in the supernatants of tumor cell suspensions; this production was much greater by the cells derived from metastases than by the cells derived from the primary tumor. On the other hand, aggregation induced by Hep G2 hepatoma cells was unaffected by apyrase and was inhibited by hirudin or concanavalin A, suggesting that the cells aggregate platelets by producing thrombin, probably through tissue factor activity of the cells themselves. Cells isolated from 16 of the 21 human tumor tissues possessed a potent platelet-aggregating effect, which was not inhibited by apyrase, hirudin or concanavalin A, but was virtually abolished by the cysteine protease inhibitors iodoacetic acid or p-hydroxymercuri-phenylsulfonate. Collectively, our data demonstrate that cells isolated from freshly dissociated tumor tissues activate platelets through tumor-associated cysteine proteinases rather than by the ADP- or thrombin-dependent mechanisms characteristic of cultured human tumor cell lines.

Impact of a programme of autologous blood donation on the incidence of infection in patients with colorectal cancer.

OBJECTIVE: To assess the effects of both autologous and homologous blood transfusion on the incidence of infective complications after elective operations for colorectal cancer. DESIGN: Prospective open study. SETTING: University hospital, Italy. INTERVENTIONS: Recording of variables known to influence the development of infection. MAIN OUTCOME MEASURES: Infective morbidity and mortality. RESULTS: Fifty-three patients (33%) deposited their own blood. Eighty-six of the 161 (53%) patients were transfused, 36 were given autologous blood, 48 homologous blood and 2 both autologous and homologous blood. These two were excluded from the analysis. Infective complications developed in 28 patients (17%), of which 7/75 (9%) were in patients who had not been transfused, 5/56 (14%) in patients given autologous transfusion, and 16/48 (33%) in patients given homologous transfusions (p < 0.001). Multivariate analysis identified homologous blood transfusion as the only variable significantly associated with the development of postoperative infective complications. No patient died. CONCLUSION: Transfusion of autologous blood was associated with significantly fewer postoperative infective complications than transfusion of homologous blood or no blood transfusion.

Flow cytometric analysis of paraffin-embedded material in human gastric cancer.

Flow cytometric DNa analysis was performed on formalin-fixed, paraffin-embedded samples obtained by gastroscopic biopsy from 9 patients with histologically normal gastric mucosa (36 specimens) and by radical gastrectomy from 42 cases of human gastric cancer (120 specimens). Ploidy patterns and the distribution of cells in the different cell cycle phases were estimated, and the results were correlated with the histologic and clinical features. All samples of normal mucosa showed a diploid modal DNA content whereas DNA aneuploidy was encountered in 71.4% of the gastric tumors. The correlation between aneuploidy and histologic malignancy grading was statistically significant: aneuploidy was found in 36.4% of highly differentiated (grade 1 and grade 2) tumors and in 75.0% of poorly differentiated (grade 3) tumors (P less than .05). The percentage of cells in S-phase in normal gastric mucosa (median: 5.0%) was lower than that in the tumors (median: 11.3%) (P less than .05). There was a trend for grade 3 tumors to have higher median values (median: 13.4%) than grade 1 and 2 tumors (median: 9.3%); however, this was not statistically significant. An aneuploid DNA pattern was associated with a poorer prognosis, both in early and in advanced stages of gastric tumors, while proliferative activity did not correlate with postoperative survival.

The role of surgery in the multimodal treatment of primary gastric non-Hodgkin's lymphomas. A report of 76 cases and review of the literature.

Seventy-six patients with primary gastric non-Hodgkin's lymphomas (PGL) were diagnosed, and 75 were treated between 1975 and 1985. According to the Working Formulation 22 patients had low-grade malignant histologic subtypes, 27 intermediate-grade, and 27 high-grade. Twenty-four cases were diagnosed by endoscopic biopsies, 52 through laparotomy biopsies. Forty-five underwent subtotal or total gastric resection; seven were considered unresectable at laparotomy; 23 did not undergo surgery because of the high operative risk, mainly due to advanced age and coexisting diseases; and one died of myocardial infarction a few days after admission, before starting therapy. All patients who did not undergo laparotomy were staged with bipedal lymphangiography or abdominal ultrasonography and/or computed tomography. Stage, evaluated according to the criteria of Musshoff, was I or II1 in 16 cases, II2 in five, and IV in the remaining 55. Treatment modalities included surgery (S), chemotherapy (CT), radiotherapy (RT), and combinations thereof in the following proportions: only S in ten cases, S + CT in 32 cases, S + RT in one case, S + CT + RT in two cases, CT only in 25 cases, CT + RT in five cases. No substantial differences in response to therapy and in survival were found in relation to the different treatments. Ten-year survival was 43% in Stage I or II and 20% in Stage IV. Of the 45 resected patients, five postoperative deaths were recorded (11%). No bleeding or perforations were observed in the 30 unresected patients, and survival of such cases compared with that of the resected ones. These findings, together with data from the literature, suggest that some of the advantages claimed for surgery in PGL (debulking and abatement of the risk of perforation or hemorrhage during CT or RT) have been overestimated in relation to the intrinsic surgical risk and to the possibility of anticancer therapy. Gastric resection may still be unavoidable as a diagnostic procedure in a minority of cases and may represent the primary therapeutic procedure in clinically assessed early-stage and low-risk patients, but it cannot be considered mandatory whenever possible merely for debulking purposes or to obviate possible perforation or hemorrhage. The CT and/or RT can be effective in unresected and even bulky cases, providing minimal risk of severe hemorrhage or perforation.