[Laparoscopic pancreatic resection]

Over a long time laparascopy for pancreatic diseases was performed only as staging laparoscopy in order to find hidden metastasis. The laparoscopic pyloric preserving duodeno-pancreatectomy showed many problems and could not establish. Laparoscopic distal resection of pancreas is much more feasible due to lack of intestinal anastomoses. Anyway there is only few literature about laparoscopic left pancreatic resection found. We demonstrate our experiences in four cases of the last months.

RESULTS

In all four cases laparoscopic distal pancreatic resection was performed for tumor. In three cases the resection of the spleen was necessary. In another case we performed a laparoscopic hemifundoplicaton (DOR) for GERD in the same session. Histologic examination showed a neuroendocrine carcinoma, a serous-microcystic adenoma, a low differentiated ductal adenocarcinoma and an intraductal papillary-mucinous tumor of borderline type. Postoperative stay was between eight and ten days. There was no patient suffering from intra- or postoperative complications.

CONCLUSION

Laparoscopic resection of distal pancreas shows the common benefit of minimal invasive surgery for the early postoperative period and is an attractive alternative for treatment of benign and semimalign pancreatic tumors.

Angiotensin II antagonism fails to ameliorate bleomycin-induced pulmonary fibrosis in mice

Based on current evidence, transforming growth factor (TGF)-beta plays a central pathogenic role in the development of pulmonary fibrosis. There is growing evidence that angiotensin II can serve as a stimulus for TGF-beta-mediated lung fibrosis. However, the role of angiotensin II in the pathobiology of pulmonary fibrosis in vivo remains unclear and the therapeutic potential for targeting angiotensin II in a bleomycin-induced pulmonary fibrosis model is not well known. Therefore, the aim of this study was to test whether the angiotensin II antagonist, losartan, attenuated the development of bleomycin-induced pulmonary fibrosis in two distinct murine strains, C57/BL6 and Sv129. This was determined by histopathology and quantification of collagen content by hydroxyproline assay. Despite demonstrable angiotensin II antagonism in vivo and a reduction in measures of acute lung injury, losartan therapy, at a dose shown to reduce renal and cardiac fibrosis in mice, failed to significantly ameliorate bleomycin-induced pulmonary fibrosis. In conclusion, these data suggest that the pulmonary fibrotic disease process in vivo is not solely dependent on angiotensin II activity and the potential for angiotensin II receptor blockers as a therapeutic strategy in patients with pulmonary fibrosis may be limited.

Analysis of mRNA in hemophilia A patients with undetectable mutations reveals normal splicing in the factor VIII gene

BACKGROUND

haemophilia A (HA) is characterized by partial or total deficiency of factor VIII (FVIII) protein activity. It is caused by a broad spectrum of mutations in the FVIII gene. Despite tremendous improvements in mutation screening methods, in about 2% of HA patients no DNA change could be found, even after sequencing the whole coding part of the FVIII gene including the flanking splice sites, as well as the promotor and the 3' UTR regions.

OBJECTIVES, PATIENTS AND METHODS

In the present study we performed a detailed RNA analysis of three groups of patients. The first included control patients with known splicing defects, the second included two patients with already identified nucleotide changes close to splicing sites, that could potentially alter the normal splicing process, and a third group of 11 unrelated patients whose genomic DNA have already been screened for mutations by DHPLC and direct sequencing with no mutation being identified.

RESULTS

Both candidate splice site mutations were shown to result in either skipping or alternative splicing of at least one exon, therefore these DNA changes must be considered as causal for the patients' HA phenotype. In contrast, no abnormalities on the RNA level were observed in any of 11 unrelated patients without mutations in the FVIII gene.

CONCLUSIONS

These findings exclude mutations that could be located deep in the introns and affecting either normal splicing or lead to mechanisms causing some unknown rearrangements of the FVIII gene. In fact, our results point to the presence of still unknown factor(s) causing HA, which might be either allelic or in the close proximity of the FVIII gene or non-allelic associated with other genetic loci that are involved in the processing of the FVIII protein.

Inguinal hernia: measurement of the biomechanics of the lower abdominal wall and the inguinal canal

BACKGROUND

The stability of the lower abdominal wall may play a considerable role in the development of inguinal hernia. Therefore, the strength of the individual wall layers needs to be quantified. Despite numerous advances in hernia repair, comparatively few systematic biomechanic and morphometric analyses have been performed. Our aim was to establish and apply a standardised procedure for testing the abdominal wall layers' stability.

METHODS

After dissecting the abdominal walls of 16 cadavers into separate layers, we used a spherical punch and a force transducer to investigate the forces necessary to foraminate the layer. In addition, maximum tensile-strength and suction tests and histologic morphometry were performed.

RESULTS

The transversalis fascia was torn up on an average of 10.5 N, the peritoneum including pre- and subperitoneal tissue on 46.6 N, the aponeurosis of obliquus internus abdominis muscle on 51.7 N, and the aponeurosis of obliquus externus abdominis muscle on 92.6 N. Tensile tests of tissue strips obtained from defined areas showed comparable results. In contrast, surgical mesh revealed values between 60 and 150 N in punching tests. Left-right comparisons, as well as comparisons of the individual areas, revealed considerable intra- and inter-individual differences.

CONCLUSIONS

Biological hernia repair should focus on a reinforcement of the tissue layers with the highest biomechanic stability. Reinforcement of the transversal fascia must be questioned according to our results of poor mechanical resistance.

Selektion von Patienten mit Rektumtumoren zur lokalen Exzision aufgrund der pr�operativen Diagnostik

INTRODUCTION

The aim of our study was to evaluate the accuracy of clinical staging (CS), biopsies, and endoluminal ultrasonic examination (EUS) in preoperative staging of rectal tumors treated with transanal local excision. This local excision is an adequate procedure for benign rectal polyps and low-risk T1 carcinoma.

PATIENTS AND METHODS

The study included 552 patients with rectal adenocarcinoma, villous adenoma, or tumors with other histologic characteristics who underwent a transanal excision (transanal endoscopic microsurgery n=513 or transanal excision n=39). We compared the results of CS, biopsies, and EUS with postoperative pathology findings.

RESULTS

Preoperative histological diagnosis of the rectal carcinoma depended on tumor size (52% in cancers <3 cm, 25% in cancers >3 cm; p=0.001) and was correct in 56% of cases. Transanal ultrasonography (uT0/1) had superior sensitivity (95% vs 78%) and a higher positive predictive value (93% vs 85%) than clinical staging (CS I) in detecting adenoma or T1 rectal carcinoma, whereas specificity was similar in both (62% vs 58%). In patients in whom preoperative histological analysis revealed adenomas, transanal ultrasonography was accurate (uT0/1) for the postoperatively assessed adenoma pT1 in 97%, whereas diagnosis (uT0/1) was correct in only 71% of cases in which preoperative histological analyses showed rectal carcinomas.

CONCLUSIONS

In patients with rectal tumors, preoperative staging with transanal ultrasonography and biopsy is essential for the indication and allows selection of patients for transanal local excision.

Bacterial enterotoxins are associated with resistance to colon cancer

One half million patients suffer from colorectal cancer in industrialized nations, yet this disease exhibits a low incidence in under-developed countries. This geographic imbalance suggests an environmental contribution to the resistance of endemic populations to intestinal neoplasia. A common epidemiological characteristic of these colon cancer-spared regions is the prevalence of enterotoxigenic bacteria associated with diarrheal disease. Here, a bacterial heat-stable enterotoxin was demonstrated to suppress colon cancer cell proliferation by a guanylyl cyclase C-mediated signaling cascade. The heat-stable enterotoxin suppressed proliferation by increasing intracellular cGMP, an effect mimicked by the cell-permeant analog 8-br-cGMP. The antiproliferative effects of the enterotoxin and 8-br-cGMP were reversed by L-cis-diltiazem, a cyclic nucleotide-gated channel inhibitor, as well as by removal of extracellular Ca(2+), or chelation of intracellular Ca(2+). In fact, both the enterotoxin and 8-br-cGMP induced an L-cis-diltiazem-sensitive conductance, promoting Ca(2+) influx and inhibition of DNA synthesis in colon cancer cells. Induction of this previously unrecognized antiproliferative signaling pathway by bacterial enterotoxin could contribute to the resistance of endemic populations to intestinal neoplasia, and offers a paradigm for targeted prevention and therapy of primary and metastatic colorectal cancer.

Potassium channel openers: therapeutic potential in cardiology and medicine

Potassium (K(+)) channel openers (KCOs) define a class of chemically diverse agents that share a common molecular target, the metabolism-regulated ATP-sensitive K(+) (K(ATP)) channel. In view of the unique function that K(ATP) channels play in the maintenance of cellular homeostasis, this novel class of ion channel modulators adds to existent pharmacotherapy with potential in promoting cellular protection under conditions of metabolic stress. Indeed, experimental studies have demonstrated broad therapeutic potential for KCOs, including roles as cardioprotective agents, vasodilators, bronchodilators, bladder relaxants, anti-epileptics, insulin secretagogues and promoters of hair growth. However, clinical experience with these drugs is limited and their place in patient management needs to be fully established.

Cellular energetics in the preconditioned state: protective role for phosphotransfer reactions captured by 18O-assisted 31P NMR

Cell survival is critically dependent on the preservation of cellular bioenergetics. However, the metabolic mechanisms that confer resistance to injury are poorly understood. Phosphotransfer reactions integrate ATP-consuming with ATP-producing processes and could thereby contribute to the generation of a protective phenotype. Here, we used ischemic preconditioning to induce a stress-tolerant state and (18)O-assisted (31)P nuclear magnetic resonance spectroscopy to capture intracellular phosphotransfer dynamics. Preconditioning of isolated perfused hearts triggered a redistribution in phosphotransfer flux with significant increase in creatine kinase and glycolytic rates. High energy phosphoryl fluxes through creatine kinase, adenylate kinase, and glycolysis in preconditioned hearts correlated tightly with post-ischemic functional recovery. This was associated with enhanced metabolite exchange between subcellular compartments, manifested by augmented transfer of inorganic phosphate from cellular ATPases to mitochondrial ATP synthase. Preconditioning-induced energetic remodeling protected cellular ATP synthesis and ATP consumption, improving contractile performance following ischemia-reperfusion insult. Thus, the plasticity of phosphotransfer networks contributes to the effective functioning of the cellular energetic system, providing a mechanism for increased tolerance toward injury.

Pneumatosis cystoides intestinalis as a complication of celiac disease

Pneumatosis cystoides intestinalis (PCI) is an uncommon but important condition characterized by the presence of gas-filled cysts in the submucosa and subserosa of the gastrointestinal tract. PCI has been associated with several clinical settings. We report a case where PCI developed in a patient with known celiac disease. To our knowledge, this type of coincidence has been described in seven prior cases. Since PCI often results in pneumoperitoneum through rupture of the cysts, it is important to differentiate the benign form of pneumoperitoneum, in which no intervention is indicated, from the life-threatening form with intestinal infarction and/or perforation, in which immediate surgery is mandatory. Differentiating between them can be difficult; this explains the high rate of negative laparotomy, which, in the past, occurred in 27% of cases. By performing diagnostic laparoscopy, we were able to establish the diagnosis of PCI and exclude intestinal perforation or infarction, thus permitting the patient to avoid an unnecessary laparotomy. Although diagnostic laparoscopy is not routinely indicated as a diagnostic tool for the detection of PCI, it proved to be a safe and accurate method to differentiate between the benign form of PCI and the life-threatening form. Whenever this differentiation has to be made, we recommend that diagnostic laparoscopy be performed first rather than primary laparotomy. Herein, the laparoscopic features of PCI are described and the coincidence of PCI with celiac disease is reviewed.