[Immunity and surgery]

In surgical patients, the development of post operative sepsis and the high rate of mortality may be related to defects in host immune mechanisms. The presence of anergy defines patients with a high rate of sepsis and mortality. Factors know to depress cell mediated immunity are essentially malignancy and sepsis. Those two factors are often associated with protein calorie malnutrition. The presence of anergy require further explorations in order to discover disseminated malignancy and/or latent sepsis. Those two factors are the major determinant of post operative risks.

[Peroperative echotomography in the surgery of liver tumors]

Intra-operative ultrasonography was performed in 10 patients with apparently single malignant tumours of the liver without invasion of the portal or hepatic veins. Five patients had hepatocellular carcinoma associated with cirrhosis and 5 had a secondary liver cancer. At laparotomy other tumoral lesions in 3 cases, portal vein thrombosis in 2 cases and invasion of the left hepatic vein in 1 case were detected by ultrasonography. In 2 patients deep intra-hepatic tumours less than 2 cm in diameter, which were neither visible nor palpable, were also detected by this method. As a result of the examination, subsegmental resection was carried out in 3 cases and hepatic lobectomy in 2 cases. Intra-operative ultrasonography therefore is a useful method to locate invisible tumours and vascular structures, thus preventing vascular injuries during the operation, facilitating limited tumoral resections and generally improving prognosis in patients operated upon for malignant hepatic tumours.

Mechanism for isaxonine hepatitis. I. Metabolic activation by mouse and human cytochrome P-450

The metabolism of isaxonine was first investigated in mice. Incubation, under air, of [2-14C] isaxonine (1 mM) with mouse liver microsomes and an NADPH-generating system resulted in the irreversible binding of a [14C] isaxonine metabolite to microsomal proteins; binding required active microsomes, NADPH and oxygen, it was inhibited by 4 mM piperonyl butoxide or by a CO-O2 (80:20) atmosphere. In the presence of various concentrations of isaxonine (0.125-2 mM), binding followed Michaelis-Menten kinetics; the Vmax was increased by both phenobarbital and 3-methylcholanthrene pretreatments. In vivo, 2.5 hr after the administration of [2-14C] isaxonine (4 mmol X kg-1 i.p.), a [14C] isaxonine material was irreversibly bound to mouse liver proteins; this binding was decreased by piperonyl butoxide and increased by phenobarbital or 3-methylcholanthrene pretreatments. Irreversible binding also occurred in the kidney. Unlike their effects in the liver, piperonyl butoxide and phenobarbital did not modify significantly in vitro metabolic activation by kidney microsomes and in vivo covalent binding to kidney proteins; pretreatment with 3-methylcholanthrene increased both in vitro and in vivo binding in the kidney. In a second series of experiments, in vitro metabolic activation was demonstrated with human liver microsomes; as in mice, covalent binding required NADPH and was markedly inhibited by piperonyl butoxide. We conclude that isaxonine is activated by mouse and human cytochromes P-450 into a reactive metabolite. In vivo covalent binding to mouse liver and kidney proteins appears to result mainly from the in situ binding of the metabolite formed in each organ.

In vitro effect of benzodiazepines on polymorphonuclear leukocyte oxidative activity

The effect of three benzodiazepine compounds, diazepam, flunitrazepam, and clorazepate, on oxidative activity of human polymorphonuclear leukocyte (PMN) was investigated. The oxidative activity of zymosan-stimulated PMN in the presence of three concentrations (10, 20, and 40 micrograms/ml) of these compounds was measured polarographically. In addition, zymosan-stimulated nitroblue tetrazolium (NBT) reduction was measured in the presence of various concentrations of flunitrazepam. All three compounds inhibited oxygen consumption of the PMN. The extent of inhibition was linear with respect to log-concentrations; oxygen consumption was reduced 50% for concentrations of diazepam, flunitrazepam, and clorazepate of 13 micrograms/ml, 56 micrograms/ml, and 285 micrograms/ml, respectively. In addition 30% and 100% inhibition of NBT reduction by flunitrazepam were observed at respective concentrations of 10 micrograms/ml and 60 micrograms/ml. The clinical relevance of these findings remains to be determined.

Nutrition and immunity after peritoneovenous drainage of intractable ascites in cirrhotic patients

Severe malnutrition and related impaired cell-mediated immunity are commonly found in cirrhotic patients with intractable ascites and may be responsible for the poor prognosis of these patients. The effects of LeVeen peritoneovenous shunting of ascites on protein reserves and cell-mediated immunity were studied in 31 cirrhotic patients with intractable ascites over a period of 1 year following operation. Arm-muscle circumference, serum albumin, and transferrin levels markedly increased and became close to the normal values. In the same period, delayed hypersensitivity improved. Although the lymphocyte count and the absolute T cell concentration in peripheral blood remained low after peritoneovenous shunting, the in vitro lymphoblastic transformation in response to phytohemagglutinin was augmented. An increased capacity to eat normal meals and the resumption of a good appetite due to the discontinuation of a salt-restricted diet seemed to be the most important factors in the dramatic improvement in the nutritional status of these patients. Restriction from heavy alcohol use may have also contributed, although the patients had already stopped drinking for several months before operation. Improvement in cell-mediated immunity might have been secondary to the increase in protein reserves.

Surgical implications of malnutrition and immunodeficiency in patients with carcinoma of the oesophagus

A nutritional and immunological assessment was respectively performed in 75 patients with squamous cell carcinoma of the oesophagus. Abnormal nutritional and/or immunological values were present in 37 patients (50 per cent) and absent in 38. The tumour was resectable in 27 patients (71 per cent) with normal values and only in 11 among the 37 (29 per cent) with abnormal values (P less than 0.001). Complications after resection including death, pneumonia and anastomotic failure were not significantly different in the two groups of patients except for anastomotic failure. This observation suggests that reduction of surgical complications by preoperative nutritional therapy might be expected only in few patients with oesophageal carcinoma.

Impaired in vitro bactericidal power of polymorphonuclear leukocytes in patients with protein calorie malnutrition

Bactericidal power of polymorphonuclear leukocytes was determined in eight patients with protein calorie malnutrition before and after nutritional therapy. Oxygen consumption associated with the uptake of zymosan particle by polymorphonuclear leukocytes, which is an exact reflection of the bactericidal power of leukocytes, was significantly decreased in untreated patients in the presence of both autologous and AB serum when compared with two control groups of eight normal patients. After nutritional therapy, oxygen consumption was found to be in the normal range in the presence of both autologous and AB serum. It is concluded that, in patients with protein calorie malnutrition, polymorphonuclear leukocytes have an intrinsic dysfunction, and this dysfunction is corrected after nutritional repletion.

Formation of an inactive cytochrome P-450 Fe(II)-metabolite complex after administration of troleandomycin in humans

In rats, it has been shown that troleandomycin induces its own transformation into a metabolite forming an inactive complex with reduced cytochrome P-450. To determine whether similar effects occur in humans, we studied hepatic microsomes from 6 untreated patients and 6 patients treated with troleandomycin, 2 g per os daily for 7 days. In the treated patients, NADPH-cytochrome c reductase activity was increased by 48%; total cytochrome P-450 concentration was also increased, but 33% of total cytochrome P-450 was complexed by a troleandomycin metabolite. The cytochrome P-450 Fe(II)-metabolite complex exhibited properties identical to those of the inactive complex formed in rats: it exhibited a Soret peak at 456 nm, was unable to bind CO, and was destroyed by addition of 50 microM potassium ferricyanide. We also measured the clearance of antipyrine in 6 other subjects. This clearance was decreased by 45% when measured again on te seventh day of the troleandomycin treatment. We conclude that repeated administration of troleandomycin induces microsomal enzymes, produces an inactive cytochrome P-450 Fe(II)-metabolite complex, and decreases the clearance of antipyrine in humans.

Mirizzi syndrome and biliobiliary fistulas: roentgenologic appearance

Five cases of extrahepatic cholestasis caused by impaction of a voluminous gallstone in the neck of the gallbladder or the cystic duct are reported. The formation of a biliobiliary fistula is the rule. Percutaneous transhepatic cholangiography visualizes the fistulas and permits their classification into 2 groups: gallbladder to hepatic duct, and cystic to hepatic duct. Preoperative diagnosis permits the best resolutions of 2 problems encountered during surgery: (1) the tumor-like feature often produced by the cholecystitis can be ascribed to benign lithiasic etiology if the biliobiliary fistula is diagnosed in the preoperative phase; and (b) treatment by biliary plasty, which requires first opening the gallbladder and partial cholecystectomy, has to be achieved.

Long-term loss of Warren's shunt selectivity. Angiographic demonstration

Fifteen patients with a patent shunt after distal splenorenal shunt with gastrosplenic disconnection were prospectively studied by angiography three to 36 months after operation. In all patients a collateral circulation from the portomesenteric to the gastrosplenic system was developed through enlarged venous channels. In all patients the portal flow decreased, as suggested by the angiographically assessed degradation of the portal perfusion of the liver and/or the diminution of the diameter of the portal vein. In two patients the portal vein was thrombotic. We conclude that three months after operation distal splenorenal shunt with gastrosplenic disconnection is not hemodynamically different than portacaval laterolateral shunt.

[Should undernutrition be corrected prior to surgery in patients with cancer of the oesophagus or cardia? (author's transl)]

A prospective study of 40 patients with cancer of the oesophage or cardia considered for surgery showed that 27 had no evidence of protein or calorie deficiency, while 13 had undernutrition. The 18 patients who benefited from ablative surgery belonged to the group with normal nutritional status; none of the undernourished patients could have benefited from resection. Only controlled studies will show whether or not correcting undernutrition is advantageous, but the number of people with both resectable tumour and corrigible undernutrition is probably very small.

[Compartmentalized portal hypertension after spleno-renal shunt occlusion (author's transl)]

This is a report of a patient with a thrombosed distal spleno-renal shunt with gastro-splenic disconnection and post-operative recurrent variceal hemorrhage. After portocaval shunt, a high venous pressure in the gastro-splenic sector demonstrates a compartmentalized venous hypertension. Splenectomy normalized this segmental portal hypertension, this confirming the concept that this type of portosystemic shunt is selective in early post-operative period.