From the Titanic and other shipwrecks to biofilm prevention: The interesting role of polyphenol-protein complexes in biofilm inhibition.

Bacteria attach themselves either reversibly or irreversibly onto practically any surface in aqueous and other environments in order to reproduce, while generating extracellular polymeric substances (EPS) as a supportive structure for biofilm formation. Surfaces with a potential to prevent cellular attachment and aggregation (biofilm) would be extremely useful in environmental, biotechnological, medical and industrial applications. The scientific community is currently focusing on the design of micro- and nano-scale textured surfaces with antibacterial and/or antifouling properties (e.g., filtration membranes). Several serum and tissue proteins promote bacterial adhesion (for example, albumin, fibronectin and fibrinogen), whereas polyphenols form complexes with proteins which change their structural, functional and nutritional properties. For example, tannic acid, a compound composed of polygalloyl glucoses or polygalloyl quinic acid esters and several galloyl moieties, inhibits the growth of many bacterial strains. The present review is based on different nautical archaeology research data, and asks a simple but as yet unanswered question: What is the chemistry that prevents leather biodegradation by environmental bacteria and/or formation of biofilms? Future research should answer these questions, which are highly important for biofilm prevention.

Co-cultivation of microalgae and nitrifiers for higher biomass production and better carbon capture.

The aim of this work was to study co-cultivation of nitrifiers with microalgae as a non-intrusive technique for selective removal of oxygen generated by microalgae. Biomass concentration was, at least, 23% higher in mixed-cultures where nitrifiers kept the dissolved oxygen concentration below 9.0µLL(-1) than in control Chlorella vulgaris axenic-cultures where the concentration of dissolved oxygen was higher than 10.0µLL(-1). This approach to eliminating oxygen inhibition of microalgal growth could become the basis for the development of advanced microalgae reactors for removal of CO2 from the atmosphere, and concentrated CO2 streams. CO2 sequestration would become a chemically and geologically safer and environmentally more sound technology provided it uses microalgal, or other biomass, instead of CO2, for carbon storage.

Preparation of biodegradable xanthan-glycerol hydrogel, foam, film, aerogel and xerogel at room temperature.

Polymers, hence hydrogels, pollute waters and soils accelerating environmental degradation. Environmentally benign hydrogels were made in water from biodegradable xanthan (X) and glycerol (G) at 22.5±2.5°C. Molar ratio [G]/[X]<3.0 was used to maximize crosslinking by mono-glycerol instead by poly-glycerol. XG-hydrogels were transformed into: XG-foams, XG-films, and XG-aerogel. Anionic character of XG-materials changes with changing [G]/[X] ratio. XG-films made from XG-hydrogels absorb up to 40 times more water than XG-films made from XG-foams. The films made from XG-foams and HCl do not dissolve in water during 48h. Making XG-materials is a no-waste process which decreases pollution, eliminates waste disposal costs, and minimizes energy expenses. XG-materials are suitable for both industrial and environmental applications including slow release and concentration of cations. XG-materials, made of xanthan, microbial polysaccharide, could also be used in applications targeting populations that do not consume meat or meat based products.

Interventional Treatment of Abdominal Compartment Syndrome during Severe Acute Pancreatitis: Current Status and Historical Perspective.

Abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) is a marker of severe disease. It occurs as combination of inflammation of retroperitoneum, visceral edema, ascites, acute peripancreatic fluid collections, paralytic ileus, and aggressive fluid resuscitation. The frequency of ACS in SAP may be rising due to more aggressive fluid resuscitation, a trend towards conservative treatment, and attempts to use a minimally invasive approach. There remains uncertainty about the most appropriate surgical technique for the treatment of ACS in SAP. Some unresolved questions remain including medical treatment, indications, timing, and interventional techniques. This review will focus on interventional treatment of this serious condition. First line therapy is conservative treatment aiming to decrease IAP and to restore organ dysfunction. If nonoperative measures are not effective, early abdominal decompression is mandatory. Midline laparostomy seems to be method of choice. Since it carries significant morbidity we need randomized studies to establish firm advantages over other described techniques. After ACS resolves efforts should be made to achieve early primary fascia closure. Additional data are necessary to resolve uncertainties regarding ideal timing and indication for operative treatment.

Diagnostic Value of Matrix Metalloproteinase-9 and Tissue Inhibitor of Matrix Metalloproteinase-1 in Sepsis-Associated Acute Kidney Injury.

Sepsis-associated acute kidney injury (SA-AKI) severely impacts morbidity and mortality in surgical patients with sepsis. Matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) have an important role in pathophysiology of sepsis but they have been unexplored in SA-AKI. We aimed to investigate the role of MMP-9 and TIMP-1 in septic surgical patients with SA-AKI and to evaluate them as diagnostic biomarkers of SA-AKI. This prospective observational study compared 53 major abdominal surgery patients with sepsis divided into SA-AKI (n = 37) and non-SA-AKI (n =16) group to 50 controls without sepsis matched by age, gender, comorbidities and type of surgery. Blood and urine samples from septic patients were collected on admission to ICU and 24, 48, 72 and 96 h later and once from the controls. The levels of MMP-9, TIMP-1, neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1, urea and creatinine were measured. MMP-9/TIMP-1 ratio and disease severity scores, such as Sequential Organ Failure Assessment (SOFA), were calculated. Septic patients with SA-AKI had higher serum TIMP-1 levels and lower serum MMP-9 levels and lower MMP-9/TIMP ratio, compared to septic patients without SA-AKI and controls. The levels of these biomarkers did not change significantly over time. MMP-9, TIMP-1 and MMP-9/TIMP-1 ratio correlated with urea, creatinine, NGAL, and SOFA scores. Moreover, using the area under ROC curve, we showed that TIMP-1 and MMP-9/TIMP-1 ratio, but not MMP-9, were good diagnostic biomarkers of SA-AKI. We report for the first time the potential diagnostic value of TIMP-1 and MMP-9/TIMP-1 ratio in SA-AKI.

Nutritional insight into preduodenal pouch reconstruction one year after total gastrectomy.

BACKGROUND: Various types of reconstructions have been developed to improve the quality of life of patients following total gastrectomy. In addition, to ensure larger food-intake reservoirs and extend meal transit times, different types of pouch reconstructions have been developed and described. Our opinion is that the most important factor in providing better physiologic regulation of ingested food is restoration of the duodenal passage and enlargement of the gastric substituent. MATERIALS AND METHODS: In the present study, we compared standard a Roux-en-Y reconstruction and a preduodenal pouch (PDP) reconstruction. We evaluated the quality of life (QoL) for 60 patients during the first postoperative year, comparing serum albumin, protein, hemoglobin, iron, body weight, body mass index, and QoL. QoL was defined according to Korenaga's score scale, which has 14 questions, for better understanding of subjective patient perceptions of digestive function. RESULTS: Our study population did not differ in iron and hemoglobin levels at a 1-y follow-up. The difference between total serum albumin level was significant in all observed patients in the follow-up period in favor of the PDP reconstruction group (P = 0.001). The PDP reconstruction group also had a significantly higher serum protein level after 12 mo. The higher score difference between the two groups generally confirm the improved QoL in the PDP group (P = 0.001). CONCLUSION: The most important aspects of improved QoL after gastrectomy due to gastric carcinoma are maintenance of the duodenal transit and the addition of a pouch. Jejunal preduodenal pouches provide a better QoL than Roux-en-Y reconstruction. Our study results suggest preduodenal pouch reconstruction should be used as the method of choice.

Early dumping syndrome and reflux esophagitis prevention with pouch reconstruction.

BACKGROUND: Total gastrectomy causes numerous disorders, such as reflux esophagitis, dumping syndrome, malabsorption, and malnutrition. To minimize the consequences, different variants of reconstruction are performed. The aim of our study is the comparison of two reconstructive methods: the standard Roux-en-Y and a new modality of pouch interposition, preduodenal-pouch interposition. This study aims to investigate the advantage of bile reflux prevention and to reduce symptoms of dumping syndrome after 3- and 6-mo follow-up. MATERIALS AND METHODS: A total of 60 patients were divided in two groups: (A) 30 patients with Roux-en-Y reconstruction, and (B) 30 patients with the preduodenal-pouch (PDP) type of reconstruction. Endoscopic examination and endoluminal jejunal limb pressure measurements were performed. Scintigraphic measurements of half-emptying time were performed to evaluate meal elimination in the context of reflux esophagitis and early dumping syndrome. The Japan Society of Gastrointestinal Surgery has provided guidelines with which to classify the symptoms of early dumping syndrome. Patients were followed up for periods of 3 and 6 mo after the surgery. RESULTS: Our study groups did not differ with regard to the level of reflux esophagitis (P = 0.688). Average values of pressure at 10 and 15 cm below the esophago-jejunal junction were significantly lower in the PDP group (P < 0.001). Elimination of the test meal between two groups was not significant (P = 0.222). Evaluation of early dumping syndrome symptoms revealed a significant reduction among PDP patients after 3 and 6 mo. CONCLUSION: Our study showed significant superiority of the new pouch reconstruction over the standard Roux-en-Y approach in the treatment of early dumping syndrome.

Obstructive jaundice and cholangitis caused by an arterial ring of the proper hepatic artery around the common bile duct.

BACKGROUND: Many different benign and malignant diseases can cause obstruction of the extrahepatic biliary duct. One of the more serious complications of biliary obstruction is cholangitis leading to emergency decompression. Anatomic variations are frequent in this region; however, it has rarely been reported that the extrahepatic bile duct is compressed by the arterial vessels. CASE REPORT: We present the case of a 68-year-old woman who was admitted through the emergency department of our hospital with jaundice, abdominal pain and fever. Biochemical analyses of liver function showed increased value of AST (113 IU/L) and AST (128 IU/L). Total bilirubin was 5.88 mg/dl, conjugated bilirubin was 3.00 mg/dl, and alkaline phosphatase was 393 IU/L. We performed abdominal ultrasound (US), magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) imaging. Multislice CT angiography showed that the arterial ring of the common hepatic artery around the common bile duct (CBD) originated from the superior mesenteric artery. Cholecystectomy and intraoperative cholangiography were performed, as well as decompression and lavage of the biliary tree. Escherichia coli was identified from bile. Dissection of the hepatoduodenal ligament confirmed that the proper hepatic artery made a vascular ring around the CBD. Finally, a T tube was placed into the CBD. During 5 years of follow-up the patient has been without recurrent episodes of jaundice. In such cases dissection of the proper hepatic artery from the common hepatic duct is the treatment of choice. CONCLUSIONS: If there are signs of cholangitis decompression and lavage of the biliary tree with "T", drainage should be performed. Vascular malformations should be considered as a possible cause of extrahepatic biliary obstruction. CT angiography may be helpful in identifying these malformations.

Allogeneic blood transfusion in patients in Dukes B stage of colorectal cancer.

The aim of this study is to evaluate influence of allogeneic blood transfusion on prognosis in patients in Dukes B stage of colorectal cancer. All patients with colorectal cancer who were admitted at our Department of Surgery between January 2000 and December 2004 were analyzed. One hundred fifty-one patients who fulfilled inclusion criteria were enrolled in further evaluation. B stage according to Dukes classification and curative resection were inclusion criteria. Exclusion criteria were polyposis syndromes, nonpolyposis syndromes, inflammatory bowel disease, autoimmune disease and previous blood transfusion. Patients were divided into two groups: Group 1 received ≤ 3 units of allogeneic blood transfusion and group 2 received >3 units of allogeneic blood transfusion. "Cutoff" value of 3 units of blood was defined according to our results and literature data. Follow-up was 5 year. There was no statistical difference between these groups in local recurrence (χ(2) = 0.009, P > 0.05) and distant metastasis (χ(2) = 0.44, P > 0.05). Also, the Kaplan-Meier survival curves were calculated, and long-rank test did not show a survival difference between these two groups (log rank = 0.075, P > 0.05). Postoperative complications are significantly more frequent in Group 2 (χ(2) = 4.67, P < 0.05). Multivariate logistic regression analysis confirmed that intraoperative blood transfusion more than three units had independent influence on local recurrence. Postoperative transfusion more than 3 units was statistically independent prognostic factor for metastasis and mortality. Overall transfusion less than 3 units of allogeneic blood does not influence the outcome of patients in Dukes B stage of colorectal cancer.

Lesion of the femoral nerve caused by a hydatid cyst of the right psoas muscle.

INTRODUCTION: Hydatidosis is a human disease caused by the larval form of Echinococcus granulosus. All organs in the human body may be affected by hydatid disease, but excluding liver and lungs, all other organs are considered as uncommon locations. Hydatid disease located in the psoas muscle is uncommon. CASE OUTLINE: The authors present a 36-year-old male living in endemic areas of Serbia, admitted due to pain and weakness of the right thigh and weight loss. Duration of symptoms was one year. CT and MRI revealed a big cystic mass (20 cm long) in the right psoas muscle. Neurological investigation showed a loss of function of the right femoral nerve. Serology for Echinococcosis was negative. Surgery was indicated and performed by median laparotomy. Total excision of the cyst was done. Pathohystology confirmed the nature of the cyst. Three years after operation the patient was without any signs of disease relapse. CONCLUSION: Echinococcal disease of the psoas has been very rarely reported, sometimes associated with paraspinal disease and often with vertebral involvement. Cystic or complex retroperitoneal tumour, pyogenic abscess of the psoas and even tuberculosis should be considered in the differential diagnosis. Treatment of choice is surgery. The greatest danger for the patient is dissemination and anaphylactic reaction. Also, compression of adjacent organs may produce significant morbidity.

Decompressive laparotomy with temporary abdominal closure versus percutaneous puncture with placement of abdominal catheter in patients with abdominal compartment syndrome during acute pancreatitis: background and design of multicenter, randomised, controlled study.

BACKGROUND: Development of abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) has a strong impact on the course of disease. Number of patients with this complication increases during the years due more aggressive fluid resuscitation, much bigger proportion of patients who is treated conservatively or by minimal invasive approach, and efforts to delay open surgery. There have not been standard recommendations for a surgical or some other interventional treatment of patients who develop ACS during the SAP. The aim of DECOMPRESS study was to compare decompresive laparotomy with temporary abdominal closure and percutaneus puncture with placement of abdominal catheter in these patients. METHODS: One hundred patients with ACS will be randomly allocated to two groups: I) decompresive laparotomy with temporary abdominal closure or II) percutaneus puncture with placement of abdominal catheter. Patients will be recruited from five hospitals in Belgrade during two years period. The primary endpoint is the mortality rate within hospitalization. Secondary endpoints are time interval between intervention and resolving of organ failure and multi organ dysfunction syndrome, incidence of infectious complications and duration of hospital and ICU stay. A total sample size of 100 patients was calculated to demonstrate that decompresive laparotomy with temporary abdominal closure can reduce mortality rate from 60% to 40% with 80% power at 5% alfa. CONCLUSION: DECOMPRESS study is designed to reveal a reduction in mortality and major morbidity by using decompresive laparotomy with temporary abdominal closure in comparison with percutaneus puncture with placement of abdominal catheter in patients with ACS during SAP. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NTC00793715.

[Biliobronchial fistula due to hydatidosis of the liver and choledocholithiasis].

INTRODUCTION: Biliobronchial fistula (BBF) is an abnormal communication between the biliary system and bronchial tree due to trauma, hemiheptectomy benign biliary stricture with cholangitis and necrotic hepatic infections such as hydatid disease. Intratoracic rupture of a hydatis cyst of the liver is a rare but severe complication with an incidence about 1% and mortality rate about 10%. CASE REPORT: A 50-year-old male patient presented with cough, episodes of biliary expectoration and haemoptysis followed with fever, fatigue and dyspnea. The diagnosis was set by echosonography, Chest x-ray finding, CT scan, bronchoscope aspirates while bronchography did not show results. The surgery was done through right subcostal laparotomy. A hydatid cyst was found in the right liver lobe its diameter being 10 cm, fixed with diaphragm. Intraoperative cholangiography revealed choledocholithiasis (two calculi), dilatation of bile ducts and communication of right hepatic duct with the irregular liver cavity as well as with the bronchi of the right lower pulmonary lobe. Cholecystectomy, choledocholitotomy with drainage lavage of bile ducts pericystectomy and cyst evacuation was performed, followed by diaphragm necrosectomy. The postoperative period and control cholangiography through T drain were normal. DISCUSSION: The surgical treatment has five goals: to treat the liver cyst, secure free biliary drainage, perform hepatodiaphragmatic disconection, solve intratoracic lesion and restore the diaphragm. We believe these goals could be achieved through abdominal approach except for irreversible bronchiectasis, intratoracal collection and chronic pulmonary sepsis. CONCLUSION: In any case, a surgery still remains the treatment of choice in cases of echinococcosis. Most cases can be solved by laparotomy.

[Implication of late diagnosis for survival of patients with colorectal carcinoma].

BACKGROUND/AIM: Colorectal cancer (CRC) is one of the most frequent diseases and early diagnosis has a potential role to improve survival. The aim of this study was to analyze influence of delay in diagnosis on survival in patiens with colorectal cancer. METHODS: A total of 119 patients with pathohystological diagnosis of CRC were included in the study. They were operated at our Department for Surgery from 2000 to 2002. They were divided into two groups according to the duration of symptoms: early operated patients - EOP (symptoms were presented for 3 months) and late operated patients - LOP (duration of symptoms was more than 3 months). Follow-up period was 5 year. RESULTS: Weight loss, intermittent abdominal pain and anorexia were more frequent in LOP (p < 0.01). Young age, blood in stool, and tumor localized in rectum were dominant characteristics in EOP (p < 0.05). Overall delay in diagnosis was 2.19 +/- 0.79 months in EOP and 11.37 +/- 5.68 months in LOP. There was highly statistically significant difference between these two groups (p < 0.01). Overall survival was 44.75%. Five years survival was 65.9% in the group of EOP and 26.5% in the group of LOP (chi2 = 28.16, p < 0.01) Weight loss was dominant characteristics in the patients who did not survive five years (chi2 = 14.26, p < 0.01). A period of 2 months in delay in diagnosis is "cut-off' value in prediction of death (sensitivity of 75.5% and specificity of 90.3%). CONCLUSION: A delay in diagnosis and stage of the disease are highly significant factors of patients with CRC survival. In everyday medical practice higher importance should be put on weight loss, intermittent abdominal pain, change in bowel habits, as well as on syderopenic anaemia.

[Efficient way in early detection of malignant skin tumors by applying epiluminescence microscopy in skin screening].

Screening is the identification of a preclinical disease by a relatively simple test. It is usually regarded as public health policy that is applied to population. The aim is to identify disease not recognized by the health services and the term preclinical refers rather to such an unrecognized disease than to clinical detectability or recognition. The majority of pigmented lesions of the skin can be diagnosed on the basis of clinical criteria, although there is an astonishing number of discrete pigmented lesions where the difference between melanocytic and non-melanocytic, benign and malignant lesions, melanoma and non-melanoma, is very hard or almost impossible to detect by a simple examination with the naked eye. With the use of the computer system for melanomoscopy and melanomography, Mole Max II, with digital epiluminescence microscopy, it is possible to see and record the changes on the skin that are located in the surface layer of the skin, as well as the changes that appear more deeply under the surface, on the border between the epidermis and the dermis, the place where melanocytes are placed. With such examination it is possible to differentiate benign from malignant lesions in the very early stage of the development. An early recognition of malignant alterations on the skin increases the chances of cure and total recovery to over 90%.

[William Stewart Halsted--110 years of the use of surgical gloves].

INTRODUCTION: William Stewart Halsted was born in New York in 1852 and is generally regarded as the most innovative and influential surgeon the United States has produced. CONTRIBUTIONS TO SURGERY: The number and magnitude of Halsted's contributions to surgery are staggering. They range from the development of a surgical procedure for breast cancer, to the introduction of rubber gloves in the operating room. They include some of the earliest operations on the biliary tract, introduction of the plate and buried screw technique in the management of long bone fractures, and some of the earliest and most innovative approaches to the treatment of aneurysms of the great vessels. Halsted also developed the submucosal intestinal suture, which allowed the development of the broad field of alimentary tract surgery. He made important contributions in the area of parathyroid and thyroid surgery, and his monograph on thyroid goiter became a classic. Halsted developed an operation for inguinal hernia repair in an era in which they virtually were incurable. One of his most notable contributions was the introduction of local and regional anesthesia. He was the first surgeon in the U.S. who promulgated the philosophy of "safe" surgery. He advocated the gentle handling of tissues during surgery, careful hemostasis, avoidance of dead space, and a meticulous surgical technique at a time when speed, lack of attention to hemostasis and rough handling of tissues were the rule. Perhaps his most important contribution to surgery, however, was the introduction of a new system of training young surgeons. He died in 1922.

[Acute appendicitis in a femoral hernia].

INTRODUCTION: Acute appendicitis in a femoral hernia is an uncommon condition that can be serious. Complications are more frequent if the diagnosis is delayed and surgery is not performed on time. CASE REPORT: We present a 71-year-old man with a painful swollen mass. The patient presented with fatigue and loss of appetite, while body temperature was normal. The abdomen was not painful, and peristaltic was normal. All laboratory findings were normal. After anamnesis and physical examination, the presumed diagnosis was incarcerated femoral hernia and the patient was sent to the operating room. Intraoperative findings revealed an incarcerated femoral hernia within a phlegmonous inflammated appendix. Appendectomy and McVay hernioplastics were done. The postoperative course was without complications. CONCLUSION: It is very important to bear in mind that right femoral hernia with signs of incarceration and inflammation may contain an acutely inflamed appendix. Delayed diagnosis and misdiagnosis cause greater morbidity and mortality.

[Functional effects of preserving the intercostobrachial nerve and the lateral thoracic vein during axillary dissection in breast cancer conservative surgery].

BACKGROUND/AIM: Conventional axillary dissection in breast cancer surgery implicates the section of the neurovascular elements passing through the dissected tissue: the intercostobrachial nerve (ICBN) and lateral thoracic vein (LTV). Preservation of the ICBN during axillary dissection is well documented in the literature, with slightly contradictory results of its influence to postoperative pain. There is no published data, as far as we know, on the functional effects of preserving the LTV. We supposed that ligation of the LTV contributes to the emergence of postoperative breast edema, which is common in breast cancer conservative surgery. The preservation of venous drainage could diminish the frequency of this undesired occurrence. METHODS: In a prospective study, 126 patients undergoing axillary node clearance for breast cancer of stages I and II were randomly selected for preservation of ICBN and LTV (n=65), or for conventional dissection (n=61). Sensory deficit, pain and breast edema as a dichotomized characteristics were examined in the first two weeks after the surgery. RESULTS: No difference in the number of dissected nodes was seen between the two groups (p = 0.7). The loss of sensitivity was significantly less common in the group randomized for ICBN preservation (16/65 vs. 30/61,p < 0.005), while there was no difference in the pain intensity and duration (49/65 vs 44/61, p > 0.05). LTV was preserved in 22 patients in the group for preservation, and in none of the control group. Breast edema was registered in 33 patients from the group for preservation (51%) and in 37 patients from the control group (61%). The difference in distribution was not significant, and the same results were obtained when the frequency of breast edema in the group with preserved LTV (22 patients, 10 of them without breast edema) was compared with the all others (p > 0.05). CONCLUSION: The preservation of the ICBN significantly improved the functional effect of the axillary dissection for breast cancer by reducing sensory loss, while there was no difference in pain intensity and duration. Although we did not prove that the preservation of LTV prevents breast edema after conservative surgery for breast cancer, we think that more complex analysis, including parameters such as the extent of resection of breast tissue, the dimension and constitutional characteristics of the breast, tumor location, obesity, and further developments in surgical technique, would reveal at least discrete improvements in the functional results of this surgical approach.