Frequency and factors associated with arterial remodeling in persons living with human immunodeficiency virus in Parakou in 2019.

BACKGROUND: The side effects of antiretroviral drugs and the chronic inflammation induced by human immunodeficiency virus (HIV) infection contribute to the development of atherosclerotic arterial remodeling in people living with HIV (PLWH). OBJECTIVES: To determine the frequency and factors associated with arterial remodeling in PLWH treated at the university hospital of Parakou. METHODS: It was a cross-sectional, descriptive, and analytic study. Data were collected from March to August 2019 at the university hospital of Parakou in Benin. PLWH aged at least 18years and consenting were included. The diagnosis of arterial remodeling was retained in the presence of at least one of the following criteria: carotid intima-media thickness≥1mm, anteroposterior diameter of the abdominal aorta≥25mm, ankle brachial index<0.9, presence of atheromatous plaque. Data were recorded and analyzed with R 3.5.1 software, and the threshold of significance was 5%. RESULTS: A total of 114 patients have undergone arterial Doppler ultrasound. The majority were women (71.9%). The patients' mean age was 43.2±10.2years with extremes of 18 and 67years. The frequency of arterial remodeling was 24.6%. The most common atherosclerotic lesion found was atheromatous overload (IMT≥1mm). Age≥50y (p=0.003; ORa=4.9[1.5-15.6]), male sex (p=0.037; ORa=4.1[1.3-13.4]), and a family history of hypertension and/or diabetes (p=0.027; ORa=3.6[1.1-12.8]) were significantly associated with atherosclerosis in PLWH. CONCLUSION: Arterial remodeling was frequent among PLWH in Parakou in 2019. The associated factors were the classic cardiovascular risk factors that should be systematically taken into account in the follow-up of these patients.

Central vascular ligation and mesentery based abdominal surgery.

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Measurement of intra-abdominal pressure in large incisional hernia repair to prevent abdominal compartmental syndrome.

INTRODUCTION: The repair of large incisional hernias may occasionally lead to a substantial increase in intra-abdominal pressure (IAP), and rarely to abdominal compartmental syndrome (ACS) with subsequent respiratory, vascular, and visceral complications. Measurement of the IAP has recently become a common practice in monitoring critical patients, even though such measurements were obtained in the early 1900s. PATIENTS AND METHODS: A prospective study involving 54 patients undergoing elective abdominal wall gap repair (mean length, 17.4 cm) with a tension-free technique after incisional hernia was conducted. The purpose of the study was to determine whether or not urinary pressure for indirect IAP measurement is a reliable method for the early identification of patients with a higher risk of developing ACS. IAP measurements were performed using a Foley catheter connected to a HOLTECH® medical manometer. IAP values were determined preoperatively, after anesthetic induction, upon patient awakening, upon patient arrival in the ward after surgery, and 24 h after surgery before removing the catheter. All patients were treated by the same surgical team using a prosthetic composite mesh (PARIETEX®). RESULTS: Incisional hernia repair caused an increase in the mean IAP score of 2.68 mmHg in 47 of 54 patients (87.04%); the IAP was decreased in two patients (3.7%) and remained equal in five patients before and 24 h after surgery (9.26%). FEV-1, measured 24 h after surgery, increased in 50 patients (92.6%), remained stable in two patients (3.7%), and decreased in two patients (3.7%). The mean increase in FEV-1 was 0.0676 L (maximum increase = 0.42 L and minimum increase = 0.01 L) in any patient who developed ACS. CONCLUSIONS: Measurement of urinary bladder pressure has been shown to be easy to perform and free of complications. Measurement of urinary bladder pressure can also be a useful tool to identify patients with a higher risk of developing ACS.

Contribution of intestinal smooth muscle to Crohn's disease fibrogenesis.

Mesenchymal cells transdifferentiation and extracellular matrix deposition are involved in the fibrotic process of Crohn's disease (CD). Mesenchymal smooth muscle cells (SMCs) de-differentiation, driven by Platelet-derived growth factor (PDGF) that counteracts Transforming growth factor (TGF-ß) has been studied in vascular muscle. The role of SMCs in intestinal fibrogenesis is still not clearly elucidated. Aim of the study was to evaluate the possible myogenic contribution to CD fibrotic process through the comparative analysis of histological, morphometric and molecular alterations occurring in human smooth muscle. Full thickness specimens were obtained from CD (non-involved and stenotic tracts) and healthy (control) ileum. Tissues were processed for histological and immunohistochemical (IHC) analyses and SMCs were isolated from the muscularis propria for morphofunctional and molecular (qPCR) analyses. CD stenotic ileum showed a significant increased thickness of all layers compared to CD non-involved and control ileum. IHC revealed an overexpression of α-smooth muscle actin and collagens I-III throughout all intestinal layers only in stenotic tracts. The two growth factors, PDGF and TGF-ß, showed a progressive increase in expression in the muscle layer from CD non-involved to stenotic tracts. Freshly isolated SMCs presented alterations in CD non-involved tracts that progressively increased in the stenotic tracts consisting in a statistical increase in mRNA encoding for PDGF-ß and collagen III, paralleled to a decrease in TGF-ß and Tribbles-like protein-3 mRNA, and altered morphofunctional parameters consisting in progressive decreases in cell length and contraction to acetylcholine. These findings indicate that intrinsic myogenic alterations occur in CD ileum, that they likely precede stricture formation, and might represent suitable new targets for anti-fibrotic interventions.

Lactobacillus rhamnosus protects human colonic muscle from pathogen lipopolysaccharide-induced damage.

BACKGROUND: Lactobacillus species might positively affect gastrointestinal motility. These Gram-positive bacteria bind Toll-like receptor 2 (TLR2) that elicits anti-inflammatory activity and exerts protective effects on damage induced by lipopolysaccharide (LPS). Whether such effect occurs in gastrointestinal smooth muscle has not been established yet. Aim of this study was to characterize the effects of Lactobacillus rhamnosus GG (LGG) and of supernatants harvested from LGG cultures on human colonic smooth muscle and to explore their protective activity against LPS-induced myogenic morpho-functional alterations. METHODS: The effects of LGG (ATCC 53103 strain) and of supernatants have been tested on both human colonic smooth muscle strips and isolated cells in the absence or presence of LPS obtained from a pathogenic strain of Escherichia coli. Their effects on myogenic morpho-functional properties, on LPS-induced NFκB activation, and on cytokine production have been evaluated. Toll-like receptor 2 expression has been analyzed by qPCR and flow cytometry. KEY RESULTS: Lactobacillus rhamnosus GG exerted negligible transient effects per se whereas it was capable of activating an intrinsic myogenic response counteracting LPS-induced alterations. In particular, both LGG and supernatants significantly reduced the LPS-induced morpho-functional alterations of muscle cells, i.e. cell shortening and inhibition of contractile response. They also hindered LPS-induced pro-inflammatory effects by decreasing pro-inflammatory transcription factor NFκB activation and pro-inflammatory cytokine IL-6 secretion, and restored the secretion levels of anti-inflammatory cytokine IL10. CONCLUSIONS & INFERENCES: Taken together these data demonstrate that LGG protects human colonic smooth muscle from LPS-induced myogenic damage and might be beneficial on intestinal motor disorders due to bacterial infection.

Perioperative management in patients undergoing pancreatic surgery: the anesthesiologist's point of view.

BACKGROUND: A high rate of mortality and morbidity has been associated with pancreaticoduodenectomy; the 5-year survival rate is 15% to 25% compared with 1% to 5% among those who did not have any cancer-directed treatment. Systemic rather than surgical complications cause the majority of perioperative deaths, so the anesthesiologist has a crucial role in the management of these patients. This work sought to evaluate an improved approach to perioperative pain management, postsurgical complications as well as outcomes. PATIENTS: From 2002 to 2007, 40 patients underwent pancreaticoduodenectomy for pancreatic or periampullary cancer. The anesthesia protocol was standardized for postoperative pain control. Patients were randomly divided into two groups: 16 patients received an epidural analgesia with local anesthetics combined with opioids (T(9)-T(10); group A) and 24 had IV analgesia with morphine (group B). RESULTS: Postoperative mortality was 2.5%. With regard to complications we observed 4 biliary fistulas, 2 pancreatic fistulas with spontaneous healing in one patient and death in the other as well as wound infections. Patients treated with epidural analgesia experienced better pain relief, compared with subjects receiving IV analgesia, which demonstrated a higher incidence of opioid-related adverse effects such as sedation and respiratory depression. CONCLUSION: Adequate perioperative treatment included suitable nutritional support and pain management using loco-regional techniques, which seem to improve the surgical outcomes among pancreatic cancer patients.

Abdominal hypertension in Meigs' syndrome.

AIMS: Two cases of chronic abdominal hypertension in pseudo-Meigs' syndrome, one sustained by a large ovarian bilateral carcinoma and the other by a giant genital angiomyolipoma, are reported. METHODS AND RESULTS: Both patients presented to the emergency room for abdominal distention and pain with progressive respiratory dysfunction, hypotension over several days, and early symptoms of renal failure, together suggestive of chronic, intra-abdominal hypertension. DISCUSSION: Intra-abdominal hypertension and abdominal compartment syndrome are serious conditions which may complicate large tumors and tense ascites, apart from their benign or malignant nature. The chronic development of abdominal hypertension and onset of the abdominal compartment syndrome associated with Meigs' syndrome must be recognized in a timely manner and promptly treated by performing as complete a resection of the pelvic mass as possible; alternatively, in acute abdominal hypertension the monitoring of bladder pressure can evaluate the effectiveness of medical therapy and determine the optimal timing of decompressive laparotomy in case of the abdominal compartment syndrome.

Two synchronous adenocarcinomas of the small bowel in a patient with undiagnosed Crohn's disease of the terminal ileum.

A small but significant excess of deaths for tumors of the digestive system has been described in Crohn's disease. In a study analyzing all cancers of the small intestine within a defined population, Crohn's disease was the major underlying factor for cancer of the small intestine. Areas of the small intestine containing strictures are unusually prone to malignant transformation. We report the rare case of a patient in whom surgery for intestinal occlusion disclosed Crohn's disease of the distal ileum complicated by two adenocarcinomas arising within distinct areas of the inflamed bowel.

Gastrointestinal surgical emergencies in patients treated for hemathological malignancies.

BACKGROUND: Upper and lower gastrointestinal symptoms are major and serious complications in patients who undergo chemotherapy for hematological malignancies. Their most frequent causes are acute intestinal graft-versus-host disease (GVHD) after bone marrow transplant, infections, toxicity or preexisting gastrointestinal diseases. Mortality can reach 30-60% of cases. PATIENTS AND METHODS: We report 15 cases operated on for abdominal emergencies: 3 severe gastrointestinal bleeding and 12 acute abdomen. RESULTS: We performed 10 bowel resections, one cholecystectomy, one splenectomy, two laparotomy with pancreatic debridement and peritoneal lavage, and one suture of perforated peptic ulcer. Operative mortality was 33.3% (5/15). Deaths have been reported only in the group of patients with acute abdomen. In all cases death was correlated to generalized sepsis related to immunosuppression. CONCLUSIONS: We believe that an aggressive approach, consisting of close monitoring and early laparotomy combined with vigorous supportive therapy, should be used when dealing with suspected gastrointestinal complications in patients with hematological malignancies.

Results of emergency surgery in patients with Moschowitz's disease refractory to hematological treatment: is splenectomy always advisable?

BACKGROUND: Patients with thrombotic thrombocytopenic purpura (TTP), Moschowitz's disease, run a high risk of perioperative bleeding and need intensive hematologic support. In some patients, TTP is associated with cancer but the surgical role in these patients is still unclear. To illustrate the surgical problems and outcome we present the case histories of three patients with TTP observed in our emergency department. MATERIALS AND METHODS: Two patients had TTP secondary to cancer and one patient with primary TTP (no evidence of neoplasia) had emergency operation for gastric hemorrhage, occlusion and TTP unresponsive to plasmapheresis. RESULTS: The first two patients who had not radical resection of cancer and no splenectomy, died for TTP complications. The third patient who underwent emergency splenectomy, had an uneventful postoperative course and TTP completely regressed. CONCLUSIONS: These case reports suggest that patients with TTP should be screened to rule out cancer. In patients with acute cancer-related complications emergency surgery should aim to resect the cancer. An associated splenectomy may increase the effectiveness of postoperative hematologic therapy.

[Surgical management of pancreatic endocrine tumors in patients with MEN 1 syndrome. Considerations on one case observed]. / Problematiche chirurgiche nel trattamento delle neoplasie pancreatiche nel paziente affetto da MEN 1. Considerazioni su un caso osservato.

INTRODUCTION: Particular problems in MEN 1 syndrome come from the morphological identification of pancreatic tumors because of their are often small [<1 cm] and multiple [89% of the cases]. However intraoperatively it could be difficult to identify with palpation the tumors described by preoperative investigations and to decide the most suitable surgical treatment. The authors describe one case recently observed to underline and update the correct management. CASE REPORT: A 34 year old woman was admitted for the surgical treatment of an insulinoma. Polimenorrea, hypercalcemia and familiarity for MEN 1 syndrome were also present. A CT scan showed the tumors in the body and tail of the pancreas [diameter 0.5-1 cm]. MRI described only a small mass in pancreatic head. A calcium angiography was positive for insulin secretion after calcium infusion in hepatic and gastroduodenal artery, and for glucagon secretion after infusion in splenic artery. An intraoperative ultrasonography discovered three nodules that were enucleated. They were one insulinoma and two glucagonomas respectively. After enucleation glycemia became immediately normal. CONCLUSION: To avoid wide surgical resections [es. left pancreatectomy] we suggest a conservative treatment [multiple enucletion with or without a pancreatic-jejunum side-to-side anastomosis] with a meticulous preoperative and intraoperative evaluation of all pancreatic nodules.

Systematic radical gastrectomy and D2 lymphadenectomy in primary gastric B cell lymphoma: impact on diagnosis, classification and long term results. A prospective study.

The role of surgery in the treatment of primary gastric lymphoma has been recently re-evaluated. We report the results of a series of 37 operated patients for primary gastric lymphoma (PGL). All patients underwent gastrectomy with D2 lymphadenectony and bilateral liver biopsies. Postoperative histopathological classification was compared to preoperative staging data. No mortality and low morbidity were observed in this series of patients. We found a high incidence of mixed grading of tumors and a relatively high incidence of lymph node metastases in low grade lymphoma. Relying on preoperative biopsies and imaging techniques could lead to preoperative staging inaccuracy and therefore to inappropriate treatment planning. For these reasons we advocate systematic primary surgery in PGL. Surgery could be useful for staging purposes and seems to be curative in stage IE.

Acute abdomen in a 15-year-old patient with Peutz-Jeghers syndrome. Surgical approach.

The natural history of Peutz-Jeghers syndrome (PJS) is characterized by gastrointestinal complications (occlusion, invagination or bleeding), often the first clinical manifestation in young patients. Surgical treatment consists of treating the complication, exploring the bowel and cleaning out all polyps to prevent further emergency operations at brief intervals. For this purpose both the laparotomic and laparoscopic approaches have been proposed, especially in young patients. A 15-year-old girl was admitted for investigation of colicky abdominal pains. When she was 5 years old, PJS was diagnosed. On admission to our department, the patient underwent emergency esophagogastroduodenoscopy and colonoscopy, both negative. At 24 hours after admission peritonitis developed. Given her clinical history, we rejected the laparoscopic approach proposed at admission and decided for an open laparotomy. Laparotomy disclosed a long jejunoileal invagination that caused irreversible ischemic damage of the bowel. We resected about 130 cm of the ileum and did an end-to-end ileo-ileal anastomosis. Meticulous palpation and transillumination of the residual bowel identified no other polyps. In young patients with acute abdomen and with proven or suspected PJS instead of laparoscopy, open laparotomy is a unique occasion to explore the residual bowel thoroughly, manually and, if possible, endoscopically.

Functional results of a personal technique of reconstruction after pancreaticoduodenectomy.

The aim of the study is to propose a new technique of reconstruction after pancreaticoduodenectomy with more attention to the functional aspects. From 1995 and 2003, 25 patients underwent pancreaticoduodenectomy for pancreatic or periampullary cancer. The reconstruction was carried out by: end-to-end gastro-jejunal anastomosis (first jejunal loop); a Roux-en-Y T-T pancreatico-jejunal anastomosis leaving a silastic catheter in the Wirsung; hepatico-jejunostomy and jejuno-jejunostomy below the biliary anastomosis; superselective vagotomy. Mortality was 8%. Regarding the complications, we observed 3 biliary fistulas, mean duration 5 days, with spontaneous healing; 8 pleural effusions and 7 wound infections. Postoperative 3 months reevaluation showed weight gain in 14 patients with no other digestive symptoms (vomiting, fullness, dumping). With a scintigraphic meal we observed a good rythmic and regular gastric emptying. No jejunal peptic ulcers were noted in all patients after the gastric protonic pump inhibitors were discontinued. Fecal fats were evaluated in all cases for malabsorption 3 months after operation with low fat fecal levels. The preliminary results of our recent experience seem to be encouraging. This technique may have a useful application in the clinical setting as far as radicality and quality of life of the patients with pancreaticoduodenectomy.

Determination of ethyl-p-hydroxybenzoate in sow pancreatic juice by reversed-phase high-performance liquid chromatography.

We have developed a high-performance liquid chromatographic-UV-Vis-diode-array detection (HPLC-DAD) method for the determination of ethyl-p-hydroxybenzoate, a hydrolytic degradation product of the synthetic protease inhibitor, gabexate-mesilate ethyl-p-(6-guanidinohexanoyloxy) benzoate methanesulfonate (GM) (FOY) in sow pancreatic juice. Methyl-p-hydroxybenzoate (I) was used as the internal standard. The pancreatic juice was deproteinised by acetonitrile and the analytes were chromatographed on a reversed-phase C18 LC column using the gradient elution method. The mobile phase consisted of a solution of 0.017 M orthophosphoric acid and another solution of acetonitrile-water (80:20, v/v). The wavelength of detection was 237 nm. The limit of quantification of the method was 0.20 microM at a 9:1 signal-to-noise ratio. The overall intra- and inter-day accuracy (relative error, RE) ranged from 14.2 to 8.3% and from 13.3 to 9.8, respectively. The overall intra- and inter-day precision (relative standard deviation, RSD) ranged from 7.6 to 2.62% and from 6.7 to 3.1%, respectively. The method proved to be sensitive, specific, accurate and precise and was successfully used to determine the ethyl-p-hydroxybenzoate (II) in sow pancreatic juice.

Localized stage I-IE aggressive non-Hodgkin's lymphoma (NHL): results of prospective study with multimodality therapeutic approach.

BACKGROUND: A brief course of chemotherapy followed by radiation therapy was considered the best treatment for localized high-grade Non-Hodgkin's Lymphoma (NHL). The purpose of this study was to determine the efficacy and feasibility of a brief-course of anthracycline-based chemotherapy (CHOP) and consolidation radiation therapy (CRT) in a series of 57 consecutive patients with stage I-IE intermediate-high grade NHL. PATIENTS AND METHODS: Between January 1990 and December 1998, 57 consecutive patients, stage I=31 (55%) and stage IE=26 (45%), were treated with 3 cycles of CHOP regimen. Forty-four (77%) received a CRT and thirteen (23%) with primitive gastric and splenic NHL underwent radical surgery. Multivariate analysis was performed to evaluate age, lactate dehydrogenase (LDH), bulky, nodal versus extranodal localization, as prognostic factors of locoregional control and survival. RESULTS: After a median follow-up of 84 months (range 4-128 months) the 5-year overall survival (OS), disease-free survival (DFS) and event-free survival (EFS) rates were 88%, 87.5% and 84%, respectively. Risk factor analysis revealed that the LDH value was the most important adverse prognostic factor for OS and EFS. No differences were found regarding the age and or extranodal localization. The 5-year OS, DFS and EFS was 100% in thirteen patients with primitive gastric or splenic NHL treated with a radical surgical approach followed by chemotherapy without CRT. CONCLUSION: We confirm the efficacy and feasibility of a brief course of CHOP chemotherapy followed by CRT in localized I-IE intermediate-high grade NHL without adverse prognostic factors. Randomized studies are warranted in order to define the dose and the target volume of CRT (involved field or extended field) in this setting of patients.

Topographic diagnosis and surgical treatment of insulinoma.

AIM: Controversy continues to reign with regard to the need for preoperative localization of insulinomas and to which are the most sensitive and accurate diagnostic imaging modalities. Our aim was to determine the role of diagnostic procedures and suggest which of them are really useful. METHODS: Over a 12-year period 34 patients underwent several preoperative diagnostic procedures to localize the insulinoma: ultrasonography (US) in 20 cases, computed tomography (CT) in 26, magnetic resonance imaging (MRI) in 28, selective angiography in 8, arterial stimulation venous sampling (ASVS) in 23 and Octreoscan in 26. All patients underwent surgical palpation and in 32 cases intraoperative ultrasonography (IOUS) was performed. Twenty-six cases underwent enucleation, six had distal pancreatic resections and two patients had only exploratory laparotomy with liver biopsies. We compared the findings of the diagnostic procedures and analyzed the surgical treatment chosen according to the pancreatic site of the tumor. RESULTS: In 32 (94.1%) of the 34 patients with clinically suspected pancreatic insulinoma the tumor was found at surgery. Preoperative US achieved 5.2% sensitivity, CT 29.1%, selective angiography 28.5% and MRI 76.9%. ASVS achieved 91.3% sensitivity and diagnostic accuracy whereas Octreoscan achieved only 65.3% diagnostic accuracy. Surgical palpation performed before IOUS identified the tumors in 30/34 patients: in the other four cases, one was a false-positive result (a cyst in the pancreatic head), two were true negatives and one was a false negative. Surgical palpation therefore yielded 88.2% diagnostic accuracy. IOUS was performed in 32 cases and localized the tumors in 29/32 cases (sensitivity: 96.6%) with one false-negative result (diagnostic accuracy: 96.8%). The operative mortality was 2.9% and the morbidity 24.6% (30.7% in patients treated by tumor enucleation). CONCLUSIONS: No single diagnostic imaging modality is reliable for localizing insulinoma. We therefore suggest combined MRI, ASVS and IOUS. ASVS provides particularly useful information for planning manual palpation and intraoperative ultrasonography.

Impaired human gallbladder lipid absorption in cholesterol gallstone disease and its effect on cholesterol solubility in bile.

BACKGROUND & AIMS: The role of the gallbladder in gallstone pathogenesis is still unclear. We examined the effects of gallbladder mucosal lipid absorption on lipid composition and cholesterol crystallization in bile. METHODS: The in vitro-isolated, intra-arterially perfused gallbladder model was used (1) to compare the absorption rates of lipids from standard bile by gallbladders obtained from 7 patients with cholesterol gallstones and 6 controls; and (2) to measure the microscopic cholesterol crystal detection time in cholesterol-enriched pig bile before and after lipid absorption by the pig gallbladder. RESULTS: Control gallbladders, but not cholesterol gallstone gallbladders, significantly reduced cholesterol (P < 0.02) and phospholipid (P < 0.01) and increased bile salt (P < 0.01) molar percentages in bile over a 5-hour period by efficient and selective cholesterol and phospholipid absorption. A histomorphometric study of the epithelial cells showed significantly higher values for nuclear density (P < 0.01) and nuclear (P < 0.05) and cytoplasmic (P < 0.05) areas in the cholesterol gallstone than the control group. Sequential microscopy of cholesterol-enriched pig bile showed significantly shorter cholesterol filament (P < 0.01) and typical cholesterol plate (P < 0. 02) detection times before than after exposure of bile to the gallbladder lipid absorption. CONCLUSIONS: In cholesterol gallstone disease, the human gallbladder epithelium loses its capacity to selectively and efficiently absorb cholesterol and phospholipids from bile, even if it is hyperplastic and hypertrophic. This epithelial dysfunction eliminates the positive effect that the normal gallbladder exerts on cholesterol solubility in bile and might be a pathogenetic cofactor for cholesterol gallstone formation.

Gastrointestinal emergencies in patients with acute intestinal graft-versus-host disease.

Acute intestinal graft-versus-host disease (GVHD) develops in about 30-50% of allogeneic bone-marrow transplant recipients: 10-20% have gastrointestinal emergencies (hemorrhage or perforation). Mortality reaches 30-60% in patients with acute, grade 2-4 GVHD. We studied 36 bone marrow recipients in whom acute intestinal GVHD developed. Seven had gastrointestinal emergencies: 4 severe gastrointestinal bleeding and 3 acute peritonitis. Three patients with gastrointestinal bleeding and one patient with peritonitis responded to medical therapy. Three needed surgery: one with bleeding and two with peritonitis, while 1 patient had embolization. Of the 7, two patients died, one after embolization and one after surgery. Two of the three surgically-treated cases are still alive several years after operation. From this experience we feel that surgery for gastrointestinal bleeding in acute GVHD is indicated only when medical treatment fails. Severe neutropenia, thrombocytopenia (<10.000 x mm3) and blood cultures positive for CMV have an unfavorable prognostic value.