Recombinant leptin administration improves early angiogenesis in full-thickness skin flaps: an experimental study.

BACKGROUND: Leptin is a potent direct angiogenic factor that stimulates endothelial cell migration and activation in vitro, and angiogenesis in vivo. In addition, leptin seems to play an important role in angiogenesis as it promotes the formation of new blood vessels. OBJECTIVE: To determine the effect of local application of exogenous leptin on the survival of full thickness skin flaps in an experimental animal model. MATERIALS AND METHODS: Ninety Sprague-Dawley rats were used in this study. A full thickness dorsal flap (10 cm x 2 cm) with the pedicle located at the level of the iliac crest was designed. Animals were divided into ten groups of nine animals each. In the distal two thirds of the flap and by means of subdermal injection at 8 different locations, rats were injected with 100 ng/ml leptin, 250 ng/ml leptin, 500 ng/ml leptin, 1000 ng/ml leptin (groups A, B, C and D), 1 microg/ml VEGF (group E), or 1 ml saline (control group), respectively. For each of the four leptin doses used, another animal group was injected with a combination of leptin/antileptin: 100 ng/ml leptin with 150 ng/ml antileptin, 250 ng/ml leptin with 375 ng/ml antileptin, 500 ng/ml leptin with 750 ng/ml antileptin or 1000 ng/ml leptin with 1500 ng/ml antileptin (groups A1, B1, C1 and D1, respectively), in order to study the inhibition of the leptin factor. Nine rats served as controls and were injected with 1 ml saline solution. Rats were sacrificed 3, 7 and 9 days postoperatively. After sacrifice of the animals, the skin was grossly arranged on its appearance, colour and texture. Full thickness skin flaps were dissected for histological examination. A qualitative analysis of angiogenesis in the flap was conducted following a standard hematoxylin and eosin stain. The wound tissue samples from each experimental group underwent immunohistochemical evaluation of microvessel density by endothelial cell staining with mouse anti-rat CD 34 monoclonal antibody. RESULTS: Immunohistochemical staining revealed that more granulation tissue and improved angiogenesis were observed in group D (1000 ng/ml leptin) flaps compared to those in the VEGF, leptin/antileptin and saline groups. In addition, skin flap survival rate in group D (1000 ng/ml leptin) and group E (1 microg/ml VEGF) were significantly better than those of the other groups. The most impressive formation of new blood vessels was noted in the groups with the higher leptin doses. Surgical wounds in the control, as well as in the leptin/antileptin groups, did not demonstrate any new vessels. CONCLUSION: Exogenous administration of recombinant leptin increases early skin flap angiogenesis in an experimental animal model. Local application of leptin could efficiently improve survival of ischemic skin flaps.

Exogenously-administered leptin increases early incisional wound angiogenesis in an experimental animal model.

BACKGROUND: Leptin is a potent direct angiogenic factor that stimulates endothelial cell migration and activation in vitro, as well as angiogenesis in vivo. In addition, leptin seems to play an important role in clinical angiogenesis by promoting the development of new blood vessels. OBJECTIVE: To determine the effect of exogenously administered leptin on incisional wound healing in an experimental animal model. MATERIALS AND METHODS: Sixty-three Sprague-Dawley male mice were used for the study. Full thickness incisional wound was considered as the wound model. The mice were divided into seven groups of nine animals each. Surgical wounds were injected with murine recombinant leptin. Three different leptin doses of 100 pg/ml, 200 pg/ml and 500 pg/ml were used in different animal groups (A, B and C). For each of the three leptin doses used, another animal group was evaluated with a combined injection of leptin and antileptin: 100 pg/ml leptin with 50 pg antileptin, 200 pg/ml leptin with 100 pg antileptin, 500 pg/ml leptin with 250 pg antileptin (A1, B1, and C1), in order to study the inhibitory effect on the leptin factor. Nine mice served as controls. These were injected with 0.3 ml water for injection solution. Mice were sacrificed 3, 7 and 9 days postoperatively. After sacrifice of the animals, the skin was grossly assessed for appearance, colour and texture. Full thickness incisional wounds were dissected for histological examination. A qualitative analysis of angiogenesis in the surgical wound was conducted following a standard hematoxylin and eosin stain. The wound tissue samples from each experimental group underwent immunohistochemical evaluation of microvessel density by endothelial cell staining with mouse anti-rat CD34 monoclonal antibody. RESULTS: The most impressive growth of new blood vessels appeared seven and nine days after treatment with the highest leptin doses. There were no significant differences in microvessel density at seven or nine postoperative days among different groups treated with leptin. None of the wounds from the control group, or those from animal groups treated with the combined injection of leptin and antileptin developed any new vessels. CONCLUSION: Exogenous administration of leptin may increase early tissue angiogenesis in the incisional wound of an experimental animal model.

Delayed perforation of the large bowel due to thermal injury during laparoscopic cholecystectomy.

We report a case of delayed perforation of the large bowel because of thermal injury during a laparoscopic cholecystectomy. A 78-year-old male with symptomatic cholelithiasis underwent a difficult laparoscopic cholecystectomy because of multiple adhesions resulting from two previous cholecystitis episodes. The patient recovered well after surgery and was discharged on post-operative day 2. On postoperative day 10, the patient returned to the hospital with peritonitis. An exploratory laparotomy revealed perforation of the wall of the hepatic flexure of the large bowel, which was centred in a necrotic area 1 cm in diameter. The perforation was sutured and a temporary ileostomy performed, which was closed at a later date. The patient was doing well at a 10-month follow-up review. A delayed rupture of any part of the bowel after laparoscopic surgery can be potentially fatal if not treated during an emergency exploratory laparotomy, even if the clinical signs are not severe.

Penetration of clarithromycin in experimental pleural empyema model fluid.

BACKGROUND: The degree of penetration of clarithromycin into the pleural fluid has not been studied. OBJECTIVE: To determine the degree to which clarithromycin penetrates into empyemic pleural fluid using a new rabbit model of empyema. METHODS: An empyema was created via the intrapleural injection of 1 ml turpentine followed 24 h later by instillation of 5 ml (10(10)) Escherichia coli bacteria (ATCC 35218) into the pleural space of New Zealand white rabbits. After an empyema was verified by thoracentesis and pleural fluid analysis, clarithromycin 30 mg/kg was administered intravenously. Antibiotic levels were determined on samples of pleural fluid and blood samples collected serially over 12 h. Antibiotic levels were estimated using HPLC. RESULTS: The antibiotic penetrated well into the empyemic pleural fluid (AUC(PF)/AUC(serum) ratio of 1.57). The time to equilibration between the pleural fluid and blood antibiotic levels was 8 h. The peak pleural fluid level (Cmax(PF) of 2.88 microg/ml) occurred 1 h (Tmax(PF) of 1 h) after infusion and decreased thereafter. The Cmax(serum) was 3.53 microg/ml at 1 h after administration. CONCLUSION: The levels of clarithromycin in the pleural fluid after intravenous administration are inhibitory for most of the usual pathogens causing empyema. The degree of penetration of clarithromycin should be considered when macrolides are selected for the treatment of patients with empyema.

Risk factors for conversion of laparoscopic cholecystectomy to open cholecystectomy.

BACKGROUND: Conversion to open cholecystectomy is still required in some patients. The aim of this study was to evaluate preoperative factors associated with conversion to open cholecystectomy in elective cholecystectomy and acute cholecystitis. METHODS: The records of 1,804 patients who underwent cholecystectomy from May 1992 to January 2004 were reviewed retrospectively. The demographics and preoperative data of patients who required conversion to laparotomy were compared to those with successful laparoscopic cholecystectomy. RESULTS: Conversion to open cholecystectomy was needed in 94 patients (5.2%),of which 44 (2.8%) had no inflammation and 50 (18.4%) had acute inflammation of the gallbladder. Male gender, age older than 60 years, previous upper abdominal surgery, diabetes, and severity of inflammation were all significantly correlated with an increased conversion rate to laparotomy. Also, the conversion from laparoscopic to open cholecystectomy in acute cholecystitis patients was associated with greater white blood cell count, fever, elevated total bilirubin, aspartate transaminase, and alanine transaminase levels, and the various types of inflammation. CONCLUSIONS: None of these risk factors were contraindications to laparoscopic cholecystectomy. This may help predict the difficulty of the procedure and permit the surgeon to better inform patients about the risk of conversion from laparoscopic to open cholecystectomy.

Extramedullary plasmacytoma: report of two cases with uncommon presentation.

Lymph node infiltration by monoclonal plasma cells can occur either in aggressive forms of myeloma or may represent regional extension of extramedullary plasmacytomas, whereas lymph node plasmacytoma presenting as a solitary extramedullary plasmacytoma is very unusual. We report two cases of lymph node plasmacytomas without systemic disease diagnosed after surgical excision. Clinical remission was achieved after local radiotherapy although one patient relapsed with multifocal extramedullary plasmacytomas 20 months after radiotherapy.

Circulating soluble E-cadherin levels are of prognostic significance in patients with multiple myeloma.

BACKGROUND: The epithelial transmembrane molecule E-cadherin (E-Cad) is the prime mediator of epithelial cell-cell adhesion, through homotypic interactions. It also participates in the maintenance of cytoskeletal structure and cell-cell signalling, while there are no published reports of expression of E-Cad in non-epithelial tissues. We examined whether the circulating levels of soluble E-Cad in newly diagnosed patients with multiple myeloma (MM) are of prognostic significance. PATIENTS AND METHODS: We used an ELISA method to determine the levels of circulating soluble E-cadherin (sE-Cad) in 21 newly diagnosed patients with MM and in 29 healthy volunteers, as a control group. RESULTS: MM patients demonstrated increased circulating levels of sE-Cad, compared with controls (p<0.0001). Increased circulating sE-Cad levels correlated with LDH levels at diagnosis (p<0.001) and poor prognosis. Multivariate analysis demonstrated that sE-Cad levels are an independent prognostic factor of survival (p<0.0207). CONCLUSION: Our data suggest that adhesion molecules play a role in the pathogenesis of MM, establish sE-Cad as an independent marker of survival and, finally, provide evidence of non-epithelial production of E-Cad in MM patients.

Prognostic significance of soluble adhesion molecules in Hodgkin's disease.

BACKGROUND: Cell adhesion may play a pivotal role in the development, progression and metastasis of solid malignancies. We evaluated the serum concentration of four adhesion molecules and their prognostic significance in patients with Hodgkin's Disease (HD). PATIENTS AND METHODS: Serum samples from 20 HD patients were collected at diagnosis, after 3 cycles of chemotherapy and at completion of treatment and compared with a control group of 29 apparently healthy subjects. Soluble forms of E-Selectin (sE-Selectin), ICAM-1 (sICAM-1), VCAM-1 (sVCAM-1) and E-Cadherin (sE-Cad) were measured by standard ELISA assays. RESULTS: Significantly increased serum levels of sICAM-1 and sE-Selectin were determined in HD patients at diagnosis compared to controls (p<0.0001), while sVCAM-1 at diagnosis correlated significantly with both sICAM-1 and sE-Selectin levels (r=0.5, p=0.03). Chemotherapy resulted in a significant decrease of sICAM-1 and sE-Selectin levels (p=0.02 and p=0.002, respectively). CONCLUSION: Serum levels of ICAM-1 and E-Selectin in newly diagnosed HD patients were found significantly increased, suggesting a possible involvement of these two molecules in the pathogenesis of the disease. Their rapid decrease following chemotherapy was found to be an independent predictor of response to treatment.

Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery.

BACKGROUND: Previous abdominal surgery has been reported as a relative contraindication to laparoscopic cholecystectomy. This study specifically examined the effect of previous intraabdominal surgery on the feasibility and safety of laparoscopic cholecystectomy. METHODS: Data from 1,638 consecutive patients who underwent laparoscopic cholecystectomy were reviewed and analyzed for open conversion rates, operative times, intra- and postoperative complications, and hospital stay. RESULTS: Of the 1,638 study patients 473 (28.9%) had undergone previous abdominal surgery: 58 upper and 415 lower abdominal operations. The 262 patients who had undergone only a previous appendectomy were excluded from further analysis. Adhesions were found in 70.7%, 58.8% and 2.1% of patients respectively, who had previous upper, lower or no previous abdominal surgery with adhesiolysis required, respectively, in 78%, 30% and 0% of these cases. There were no complications directly attributable to adhesiolysis. Patients with previous upper abdominal surgery had a longer operating time (66.4 +/- 34.2 min), a higher open conversion rate (19%), a higher incidence of postoperative wound infection (5.2%), and a longer postoperative stay (3.4 +/- 2.1 days) than those who had undergone previous lower abdominal surgery (50.8 +/- 24 min, 3.3%, 0.7%, and 2.6 +/- 1.4 days, respectively) and those without prior abdominal surgery (47.4 +/- 25.6 min, 5.4%, 1.2%, and 2.8 +/- 1.9 days, respectively). CONCLUSIONS: Previous abdominal operations, even in the upper abdomen, are not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with an increased need for adhesiolysis, a higher open conversion rate, a prolonged operating time, an increased incidence of postoperative wound infection, and a longer postoperative stay.

Serum and drainage fluid vascular endothelial growth factor levels in early surgical wounds.

BACKGROUND: Wound healing relies on a coordinated expression and release of growth factors controlling angiogenesis. We measured vascular endothelial growth factor (VEGF) levels in serum and early wound fluid following primary sutured and mesh repair of abdominal hernias. MATERIALS AND METHODS: Thirty-seven patients were studied measuring serum and wound drainage fluid VEGF by enzyme-linked immunosorbent assay preoperatively and on the 1st, 3rd, 5th and 7th postoperative days. RESULTS: Serum and wound fluid VEGF levels increased significantly by the 3rd postoperative day and continued to rise during the conduct of the study with wound fluid concentrations always exceeding serum levels. The kinetics of VEGF increases were similar in both types of hernia repair; however, serum and wound levels rose slightly earlier in the mesh repair group. CONCLUSIONS: Steadily increasing levels of VEGF are detected during the early proliferative phase of wound healing in both serum and wound fluid. It is unknown whether either is predictive for delayed hernia recurrence.

Laparoscopic cholecystectomy in a patient with previous open cholecystostomy.

We report the case of a successful elective interval laparoscopic cholecystectomy in a patient with a previous tube cholecystostomy that had been performed surgically 8 weeks earlier for an attack of acute calculous cholecystitis. At surgery, the major omentum was adherent to the right lateral abdominal wall, completely covering the liver edge, the gallbladder, and the inserted tube. The gallbladder and the tube within it were dissected free from the abdominal wall and the greater omentum, the cholecystostomy tube was removed, and the operation was completed successfully without any further difficulties.

An unusual cause of delayed presentation of laparoscopic common bile duct injury.

We describe an unusual case of a laparoscopic common bile duct (CBD) injury that presented with cholangitis 2 years after an apparently uneventful laparoscopic cholecystectomy. Preoperative ultrasound and endoscopic retrograde cholangiography suggested choledocholithiasis, showing proximal and intrahepatic duct dilatation with an inability to relieve the obstruction. At surgery, a lateral injury of the CBD wall with partial wall loss was found, adherent to an amorphous pigmented mass with the appearance of a knitted fabric causing CBD obstruction. The CBD was successfully reconstructed with a Roux-en-Y end-to-side hepaticojejunostomy, where the end of the Roux loop was anastomosed to the lateral CBD defect.

Abnormal alpha-catenin expression in invasive breast cancer correlates with poor patient survival.

AIMS: alpha-Catenin is a member of the E-cadherin-catenin family of adhesion molecules whose role is essential for the function of the E-cadherin complex. In this study, we have evaluated the expression of alpha-catenin but also of the other catenins (beta-, gamma- and p120-catenin) and E-cadherin in invasive breast cancer and statistically analysed these expressions with known clinicopathological parameters, c-erbB-2 oncoprotein expression and patient survival. METHODS AND RESULTS: Abnormal E-cadherin and beta-catenin expression, especially loss of expression, was associated with lobular histological type of breast carcinomas (P=0.03 and P=0.01, respectively). Abnormal E-cadherin and alpha-catenin expression was associated with high histological grade ductal carcinomas (P=0.01 and P=0.03, respectively). Abnormal E-cadherin and beta-catenin expression was correlated with lymph node metastases (P=0.02 and P=0.05, respectively), while abnormal alpha- and beta-catenin were correlated with the advanced stage of the disease (P=0.04 and P=0.05, respectively). Abnormal p120-catenin expression was associated with loss of PR (P=0.008). Survival analysis demonstrated a statistically significant association between abnormal alpha-catenin expression and poor patient survival (P=0.02). When survival analysis was performed according to the different patterns of abnormal expression, statistically significant associations were seen between cytoplasmic alpha- and beta-catenin expression and poor survival (P=0.006 and P=0.04, respectively). CONCLUSIONS: alpha-Catenin, especially its cytoplasmic expression, seems to be a more sensitive prognostic marker than the other members of the E-cadherin complex in invasive breast cancer.

Serum E-cadherin concentrations and their response during laparoscopic and open cholecystectomy.

BACKGROUND: Elevated serum levels of the cell adhesion molecule E-cadherin have been associated with the presence of tissue injury and inflammation. We compared soluble E-cadherin response during laparoscopic and open cholecystectomy. METHODS: The E-cadherin response to surgery was studied in 16 patients undergoing laparoscopic cholecystectomy and 12 patients undergoing open cholecystectomy. Serum E-cadherin levels were measured by an enzyme immunoassay (ELISA) preoperatively, 10 and 30 min after the commencement of surgery, and at 6 and 24 h following the operation. RESULTS: Serum E-cadherin levels decreased progressively during laparoscopic cholecystectomy; their concentrations at 24 h after surgery were significantly lower when compared with preoperative values. In the open cholecystectomy group, serum E-cadherin levels did not differ from preoperative values at any time point. Serum E-cadherin concentrations at 24 h after surgery and the cumulative E-cadherin response were significantly higher in the open cholecystectomy group than in the laparoscopic group. CONCLUSION: Compared with open cholecystectomy, the cumulative E-cadherin response is significantly reduced following laparoscopic cholecystectomy.

Serum levels of E-selectin, ICAM-1 and VCAM-1 in colorectal cancer patients: correlations with clinicopathological features, patient survival and tumour surgery.

The serum concentrations of the cell adhesion molecules E-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) were investigated in 63 patients with colorectal cancer and in 51 controls by an enzyme-linked immunosorbent assay (ELISA). Their relationship to clinicopathological variables and patient survival and changes in their levels after surgery were examined. Colorectal cancer patients showed significantly higher serum levels of E-selectin, ICAM-1 and VCAM-1 compared with healthy controls. There was a significant association between the serum levels of these molecules, disease stage and the presence of both lymph node and distant metastases. Both ICAM-1 and VCAM-1 levels correlated with serum E-selectin and carcinoembryonic antigen (CEA) levels. Serum levels of all three molecules decreased significantly after radical resection of the tumour. Elevated pre-operative E-selectin, ICAM-1 and VCAM-1 levels were significant prognostic factors, although not independent of stage, for patient survival. These findings suggest that serum concentrations of E-selectin, ICAM-1 and VCAM-1 may reflect tumour progression and metastasis. Since these markers are linked to CEA levels, it is uncertain whether their measurement will prove cost-effective in colorectal cancer management.

Serum levels of tumor necrosis factor-alpha and nutritional status in pancreatic cancer patients.

BACKGROUND: Tumour necrosis factor-alpha (TNF-alpha) is a multifunctional cytokine associated with cancer-related cachexia. In this study we evaluated serum levels of TNF-alpha in pancreatic cancer patients and investigated their relationships to cachexia. PATIENTS AND METHODS: Serum TNF-alpha levels were determined in 63 patients with pancreatic cancer using an enzyme immunoassay specific for human TNF-alpha. RESULTS: Serum TNF-alpha levels were detected in 36.5% of patients. Patients with metastatic disease showed significantly higher positive serum TNF-alpha rate compared to those with non-metastatic disease. Patients with detectable serum TNF-alpha levels had significantly lower body weight and body mass index, lower haematocrit and haemoglobin values, and lower serum total protein and albumin levels compared to those with undetectable TNF-alpha levels. Serum TNF-alpha levels were inversely correlated with body weight, body mass index, haematocrit, haemoglobin, and serum protein and albumin levels. CONCLUSIONS: TNF-alpha levels are detectable in the serum of pancreatic cancer patients, particularly in those with advanced disease, and these levels correlate with poor nutritional status.

Expression patterns of beta-catenin in in situ and invasive breast cancer.

BACKGROUND: beta-Catenin plays a central role in the E-cadherin/catenin cell-cell adhesion complex and is possibly involved in cellular signalling pathways. In this study, we evaluated the expression patterns of this molecule in in situ and invasive breast cancer. METHODS: The expression of beta-catenin was evaluated in 121 breast cancer specimens by immunohistochemistry. Its relationship to clinicopathological features was also investigated. RESULTS: Altered beta-catenin expression was found in 68% of tumours. Lobular carcinomas showed abnormal beta-catenin expression more frequently (77%) than ductal carcinomas (64%) with 46% of lobular cases showing complete absence of beta-catenin immunoreactivity. Cytoplasmic beta-catenin localization was seen only in ductal carcinomas. Aberrant beta-catenin expression was observed in 54% of ductal carcinomas in situ with highly concordant beta-catenin expression patterns in the nearby in situ and invasive components. CONCLUSIONS: Quantitative and qualitative changes in beta-catenin expression occur in a considerable proportion of in situ and invasive ductal carcinomas and are more prominent in invasive lobular carcinomas.

Expression patterns of alpha-, beta- and gamma-catenin in pancreatic cancer: correlation with E-cadherin expression, pathological features and prognosis.

BACKGROUND: The E-cadherin-catenin cell adhesion complex has been implicated in tumour invasion and metastasis. In this study, we evaluated the clinical significance of E-cadherin and catenin expression in pancreatic cancer. MATERIALS AND METHODS: The immunohistochemical expression and cellular co-localization of alpha-, beta- and gamma-catenin were investigated in 43 paraffin-embedded specimens of pancreatic cancer. The relationship between their expression and E-cadherin expression, clinicopathological features and prognosis was evaluated. RESULTS: Abnormal alpha-, beta- and gamma-catenin expression was found in 37%, 44% and 40% of cases, respectively. Both alpha-catenin and gamma-catenin expression correlated with disease stage and with lymph node and distant metastases, whereas aberrant beta-catenin expression only correlated with the presence of lymph node metastases. There was a significant and progressive concordance between E-cadherin and alpha-, beta- and gamma-catenin expression patterns, respectively. The expressions of alpha-, beta- and gamma-catenin also significantly correlated with one another. All three catenins, like E-cadherin, were associated with a poor prognosis, but only E-cadherin and alpha-catenin were independent prognostic factors for cancer-specific survival. CONCLUSION: Changes in catenin expression and pancreatic cancer progression are possibly related events. The expression of E-cadherin and alpha-catenin may add useful new prognostic information.