Combined colon and hepatic resection for synchronous colorectal liver metastases

BACKGROUND AND OBJECTIVES

The surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer remains controversial. This study was performed to assess the outcome of combined resection of colorectal cancer and liver metastases.

METHODS

The perioperative data, morbidity, and survival of the patients who underwent combined colon and liver resections for synchronous colorectal liver metastases from 1988 to 1999 were compared to the parameters of the patients who underwent colon resection followed by resection of liver metastases in a staged setting.

RESULTS

198 hepatic resections were performed, of which 112 procedures in 103 patients were done for metastatic colorectal carcinoma. Twenty six patients (25%) had combined hepatic and colon resection and were compared to 86 patients with metachronous metastases who underwent colon and hepatic resection in the staging setting. Postoperative morbidity was 27 and 35%, respectively. There was no hospital mortality in the combined group vs. 2.3% in the staged group. Blood loss, intensive care unit (ICU) stay and length of postoperative stay (LOS) were similar in both groups. The 5 years cumulative survival of the group after combined surgery was 28% vs. 27% of the group after isolated hepatic resections (P = 0.21).

CONCLUSION

Combined colon and hepatic resection is a safe and efficient procedure for the treatment of synchronous colorectal liver metastases. It can be performed with acceptable morbidity and no perioperative mortality. The survival after combined procedure is comparable to the one achieved after staged procedure of colon resection followed by liver resection.

Immunopotentiation of a developed Salmonella enterica serotype enteritidis vaccine by thymulin and zinc in meat chicken breeders

The humoral immunity, spleen and thymus weight indices, lymphocyte count in the thymus cortex, and granuloma diameter at vaccination sites were assessed in four differently immunopotentiated groups of meat chicken breeders. Breeders in the first two groups were given a killed Salmonella enterica serotype Enteritidis (SE) vaccine subcutaneously at 15 and 19 weeks of age. Breeders in the third and fourth groups were left unvaccinated. Breeders in the first group were further immunopotentiated with zinc and thymulin. Each bird in the first group was given the immunopotentiators intraperitoneally in a volume of 0.1 ml at intervals of 3 days for a period of 3 weeks, starting at 15 weeks of age. At each time, each bird in the first group received thymulin (10 ng) and ZnCl2 (1 micromol/L), using a carboxymethyl cellulose carrier, totalling 90 ng thymulin and 9 micromol of ZnCl2 per bird. Each bird in the first three groups was challenged orally with 6.7 x 10(6) cfu/ml of highly virulent SE organisms, at an age of 22 weeks. The first group, which had received zinc and thymulin, had the earliest and highest humoral immune response to SE (p<0.05). This was observed at 2 and 4 weeks after the first vaccination. In addition, the first group had the highest mean thymus weight index, and the highest mean lymphocyte count in the thymus cortex. No significant difference was observed between the first two vaccinated groups in the mean granuloma diameter developed at the two vaccination sites 48 h after administration of the vaccine (p>0.05).

Severe thrombotic complications associated with activated protein C resistance acquired by orthotopic liver transplantation

We report a patient who developed recurrent hepatic artery thrombosis and deep venous thrombosis following orthotopic liver transplantation. Investigations revealed the presence of activated protein C (APC) resistance due to a mutation in the factor V gene in the transplanted liver. The patient's own peripheral blood cells did not carry the mutation. Although part of factor V is located in the platelets and may be endogenously synthesized by megakaryocytes, this case demonstrates the major clinical importance of hepatic-derived factor V. It may be reasonable to screen liver donors with a history of a thrombotic event for APC, and to consider anticoagulation in the recipients of livers positive for this defect.

The use of a modified hypo-osmotic swelling test for the selection of viable ejaculated and testicular immotile spermatozoa in ICSI

A modified hypo-osmotic solution was used to select viable ejaculated and testicular spermatozoa to perform intracytoplasmic sperm injection (ICSI) in 27 treatment cycles from patients with total absence of sperm motility. The treatment cycles consisted of 15 cycles in which ejaculated spermatozoa were used and 12 cycles in which testicular spermatozoa were used. The hypo-osmotic solution consisted of 50% culture medium and 50% deionized water and was shown in previous in-vitro studies to be superior to the original solution used in the classical hypo-osmotic swelling test. Fertilization was achieved in 37.3% of the oocytes injected. Embryos were replaced in 70.4% of the cycles with a mean of 2.0 embryos per cycle. There were no statistically significant differences between the ejaculated sperm group and the testicular sperm group in the fertilization rate (42.7 versus 30.1%) or in the cleavage rate (92.7 versus 77.3%). Four pregnancies resulted, two in the ejaculated sperm group and two in the testicular sperm group, a pregnancy rate of 14.8%. All pregnancies were singletons but one pregnancy in each group had an early miscarriage. There were no statistically significant differences between both groups in the pregnancy rates (13.3 versus 16.7%), in the implantation rates (5.3 versus 11.8%) or in the delivery/ongoing pregnancy rates (6.7 versus 8.3%). It is concluded that the use of this solution to select viable but immotile spermatozoa for ICSI is a simple and practical method and is associated with acceptable fertilization and pregnancy rates.

Preclinical evaluation of two human anti-hepatitis B virus (HBV) monoclonal antibodies in the HBV-trimera mouse model and in HBV chronic carrier chimpanzees

Two human monoclonal antibodies (mAbs) against hepatitis B surface antigen (HBsAg) generated in the Trimera mouse system are described. Both mAbs 17.1.41 and 19.79.5 are of the IgG1 isotype and have high affinity constants for HBsAg binding in the range of 10(-10) mol/L. Monoclonal antibody 17.1.41 recognizes a conformational epitope on the a determinant of HBsAg whereas mAb 19.79.5 recognizes a linear one. The 2 mAbs bind to a panel of hepatitis B virus (HBV) subtypes with distinct patterns. The neutralizing activity of these antibodies was tested in 2 different animal model systems. Administration of each mAb to HBV-Trimera mice, a system that provides a mouse model for human hepatitis B infection, reduced the viral load and the percentage of HBV-DNA-positive mice in a dose-dependent manner. These 2 mAbs were more effective than a polyclonal antibody preparation (Hepatect; Biotest Pharma, Dreieich, Germany) in both inhibition of HBV liver infection and reduction of viral load. A single administration of a mixture of these mAbs into HBV chronic carrier chimpanzees resulted in immediate reduction in HBsAg levels followed by recurrence to initial levels within few days. Thus, these mAbs may be potential candidates for preventive therapy or in combination with other antiviral agents against HBV. Further studies in humans are needed to assess these mAbs in various clinical indications.

Laparoscopic cholecystectomy: what does affect the outcome? A retrospective multifactorial regression analysis

BACKGROUND

The association between various factors and the postoperative outcome has not been thoroughly studied in laparoscopic cholecystectomy (LC). The aim of this retrospective study was to determine which factors significantly affect patients outcome after LC.

METHODS

The medical and operative records of all consecutive patients who underwent LC at our institution from 1991 to 1996 were reviewed. The effect of age, medical and surgical history, duration of procedure, and setup (urgent or elective) on the postoperative complication rate and on the length of postoperative hospital stay (LOS) were analyzed using multiple linear regression and logistic regression analysis. Overall, 601 patients were included in the study.

RESULTS

The factors that significantly prolonged LOS were age (p = 0.0145), acute cholecystitis (p = 0.0006), history of ischemic heart disease (p = 0.0332), and duration of procedure (p < 0.0001). A significantly higher postoperative morbidity rate was noted in patients who had a procedure longer then 2 h than in patients whose surgery required less the 2 h (13.6% vs 3.6%, respectively; p < 0.0001). Similarly, higher morbidity was noted in elderly patients than in younger patients (16% vs 6.1%; p = 0.0005). Other factors that significantly increased postoperative morbidity included acute cholecystitis (p = 0.023), a history of cholangitis (p = 0.018), and diabetes (p = 0.05).

CONCLUSIONS

According to this study, advanced age, longer duration of procedure, and acute cholecystitis significantly increase both the postoperative morbidity and the LOS. History of ischemic heart disease significantly increases LOS, but does not increase morbidity after LC.

Bacteremic and nonbacteremic pneumococcal pneumonia. A prospective study

We prospectively identified cases of pneumococcal pneumonia and used stringent criteria to stratify them into bacteremic and nonbacteremic cases. Although patients were distributed among racial groups in proportion to all patients seen at this medical center, the proportion of African-Americans with bacteremic disease was significantly increased. All patients had at least 1 underlying condition predisposing to pneumococcal infection, and most had several. Although the mean number of predisposing factors was greater among bacteremic patients than nonbacteremic patients, only alcohol ingestion was significantly more common. Nearly one-third of patients had substantial anemia (hemoglobin < or = 10 g/dL) on admission, which may have predisposed to infection. In the case of other laboratory abnormalities, such as albumin, creatinine, and bilirubin, it was difficult to determine which abnormality might have predisposed to pneumococcal infection and which might have resulted from it. The radiologic appearance was varied. Airspace consolidation and air bronchogram on chest X-ray were highly associated with bacteremic disease, as was the presence of pleural effusion. Although the Pneumonia Patient Outcomes Research Team (PORT) risk score was a predictor of mortality, it did not help to predict the presence of bacteremia in an individual case. Most patients who died in the first week in hospital were bacteremic, and a high PORT risk score with bacteremia reliably predicted a high likelihood of a fatal outcome. Eleven patients had extrapulmonary disease with meningitis, empyema, and septic arthritis predominating; all of these patients were bacteremic. The antibiotic susceptibility of our strains correlated well with those that have been reported in the United States during the years of this study. The use of numerous antibiotics of different classes in many patients, especially those who were the most ill, precluded analysis of outcome based on antibiotic therapy. Only 17 patients had been vaccinated. Since nearly all patients had conditions for which pneumococcal vaccine is recommended and more than one-third had been hospitalized in the preceding 6 months, the low rate of vaccination can be regarded as a missed opportunity to administer a potentially beneficial vaccine.

Human interleukin-6 facilitates hepatitis B virus infection in vitro and in vivo

BACKGROUND AND AIM

Research on hepatitis B virus (HBV) infection in vivo has been limited due to the absence of a suitable animal model. We have developed a human-mouse radiation chimera in which normal mice, preconditioned by lethal total body irradiation and radioprotected with SCID mouse bone marrow cells, are permissive for engraftment of human hematopoietic cells and solid tissues. This resulting human-mouse model, which comprises three genetically disparate sources of tissue, is therefore termed Trimera. This study was aimed at assessing the effect of human IL-6 on HBV infection in vivo in Trimera mice.

METHODS

Trimera mice were transplanted with human liver tissue fragments or with HepG2-derived cell lines, which had been previously infected ex vivo with HBV in the presence or absence of human interleukin-6 (hIL-6) and in the presence of anti-IL-6-neutralizing antibodies.

RESULTS

HBV sequences appeared in the sera of animals in which the liver tissue was incubated with both HBV and hIL-6 prior to transplantation. A similar result was obtained when a human hepatoblastoma cell line (HepG2), expressing the hIL-6 receptor, was infected ex vivo with HBV in the presence of hIL-6 prior to their injection into spleens of Trimera mice. However, when liver fragments were infected ex vivo and simultaneously treated with neutralizing antibodies against hIL-6 or were incubated with HBV prior to transplantation without hIL-6, the rate of mice positive for HBV DNA in their sera was lower. Human mononuclear cells are also permissive for HBV infection in vitro: in the presence of hIL-6 the infection of these cells is enhanced; and this infection is suppressed by the chimeric protein named Hyper-IL-6, generated by the fusion of hIL-6 to the soluble hIL-6 receptor (sIL-6Ralpha, gp80).

CONCLUSION

hIL-6 facilitates HBV infection in vitro and in vivo.

Extension of the organ pool in kidney transplantation: first year experience of the Israel Transplant Center

BACKGROUND

Over a 12 month period, the Israel Transplant Center doubled the number of donors by assigning a nurse coordinator to each of 22 hospitals around the country and by using kidneys from elderly donors.

OBJECTIVE

To evaluate the impact of our "marginal donors" policy on the results immediately following transplantation.

METHODS

Between October 1997 and September 1998, 140 cadaveric kidney transplantations from 72 donors were performed in Israel. We defined two groups of recipients: patients with immediate graft function and patients with either delayed graft function requiring > 1 week of dialysis post-transplant or with primary graft non-function. We compared the following parameters between groups: donor and recipient age and gender, cause of donor's death, length of stay in the intensive care unit, vasopressor dosage and creatinine levels before harvesting, cold ischemic time, and the number of recipient grafts.

RESULTS

There were 102 recipients (72.8%) with immediate graft function and 38 with either PNF (n = 13, 9.3%) or DGF (n = 25, 17.9%). On regression analysis, donor age > 50 year and retransplantation were significant risk factors for PNF or DGF (odds ratio 4.4 and 2.8, respectively). Of the 56 kidneys from donors > 50 years old, 21 (37.5%) developed either PNF (n = 9) or DGF (n = 12).

CONCLUSIONS

We conclude that kidneys from donors over age 50 are at increased risk for graft non-function or delayed function. Better assessment of functional capacity of kidneys from "aged" donors may help to choose appropriate donors from that pool.

Emergence of Salmonella enteritidis outbreaks in broiler chickens in the Lebanon: epidemiological markers and competitive exclusion control

This study investigates the first emergence of Salmonella Enteritidis outbreaks among chickens in the Lebanon and identifies the epidemiological markers of selected recovered Enteritidis strains. In addition, the authors evaluate a competitive exclusion approach to control infection in broiler chickens by Enteritidis organisms which possess the prevalent identified markers. The basic procedure in this investigation involved recording signs and lesions in eleven broiler chicken flocks on eleven farms, and culturing livers, spleens, and caeca of ten randomly selected birds per flock for Salmonella isolation and serotyping. Furthermore, culturing for Salmonella and serotyping was attempted from the livers, spleens, caeca and oviduct swabs of ten hens in four broiler breeder flocks which provided hatching eggs for the broilers under study. The identification of epidemiological markers in recovered S. Enteritidis included the determination of drug-resistance patterns and plasmid profiling. The competitive exclusion was evaluated by spraying the microflora on day-old broilers in the hatchery, followed by a controlled oral challenge at three days of age, with 2.85 x 10(5) colony-forming units of S. Enteritidis organisms per bird. Exclusion was evaluated by culturing for S. Enteritidis in anal swabs, spleens, livers, and caeca of individual challenged birds treated with the microflora and in untreated challenged birds. A total of 112 invasive S. Enteritidis strains were recovered on eleven farms from individual organs of broiler chickens with typical signs and lesions of salmonellosis. The prevalent resistance to drugs in such strains was to furaltadone and gentamycin, a marker identified in 93 strains (83%), recovered from nine out of eleven farms. The same resistance pattern was present in S. Enteritidis strains recovered from breeders on one out of four farms. The prevalent plasmid profile in nine S. Enteritidis organisms selected randomly from a pool of 93 strains (one per each of the nine broiler farms) was 14.1 kilobases (kb) and approximately 50.0 kb, a typical pattern to that identified in S. Enteritidis organisms recovered from oviducts of breeders on one out of four breeder farms. The exclusion significantly reduced cumulative mortality in birds of up to 45 days of age by 3.93%, in comparison to that observed in untreated challenged birds (P < 0.05). At 45 days of age, exclusion resulted in a 15.6% reduction in the percentage infection rate by S. Enteritidis in spleens or livers and a 34.4% reduction in the percentage infection rate of the caeca (P < 0.05).

Combination of intra-articular tenoxicam, lidocaine, and pethidine for outpatient knee arthroscopy

BACKGROUND

Studies of intra-articular non-steroidal anti-inflammatory drugs have revealed an analgesic effect equivalent to that of intra-articular local anaesthetic agents and morphine. The aim of this study was to evaluate the analgesic effect of intra-articular lidocaine, pethidine and tenoxicam compared with that of lidocaine and pethidine on postoperative pain after arthroscopy.

METHODS

After day-case knee arthroscopy, 60 patients were randomly allocated to one of three groups to receive 20 ml of a solution containing 0.9% saline (group S), 2% lidocaine and 10 mg preservative-free pethidine (group LP) and 2% lidocaine, 10 mg preservative-free pethidine and 20 mg tenoxicam (group LPT). Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements.

RESULTS

Pain scores were significantly lower in the LP group than in the S group at 1 and 2 h after surgery. From 4 h until the end of the first postoperative day, pain scores were significantly lower in the LPT group of patients at rest and on knee flexion than in the other two groups; these patients also used less oral analgesics (P<0.05).

CONCLUSION

The combination of 20 ml lidocaine 2%, 10 mg pethidine and 20 mg tenoxicam given intra-articularly provided superior analgesia and reduced oral analgesic requirement during the first day after arthroscopy compared with lidocaine and pethidine alone.

Dynamics of protein 27 of avian leukosis virus and transforming growth factor beta2 in lymphoid leukosis susceptible and resistant broiler chicken breeding stock

The dynamics of the serum concentration of protein 27 (P27) of avian leukosis virus and transforming growth factor beta2 (TGF-beta2) were compared during the period between 29 and 59 weeks of age in two flocks of broiler chicken breeding stock undergoing outbreaks of severe lymphoid leukosis (LL) associated with persistent high mortality (susceptible) and in another two flocks of breeding stock with the presence of avian leukosis virus in association with low mortality due to LL (resistant). The average mean concentration of serum P27 in the LL-susceptible flocks was significantly higher (p<0.05) than that in the LL-resistant flocks in six out of seven samplings performed at 5-week intervals, between 29 and 59 weeks of age. The peak in the average rise of serum P27 in the LL-resistant flocks (309 pg/ml) was associated with the highest level of TGF-beta2 (1282 pg/ml) among all flocks and at all sampling times. The significance of TGF-beta2 in inhibition of lymphoid tumour development is discussed.

Complications from supervised mask use in post-operative surgical patients during the Gulf War

This is a report of three patients in a surgical ward of a hospital who developed complications seemingly related to the use of full-face-fitting masks associated with the first Scud Missile attack on Israel during the Gulf War. Patient 1 developed atrial fibrillation with an uncontrolled ventricular rate; Patient 2 redeveloped a gastrointestinal hemorrhage; and Patient 3 developed a severe anxiety attack. Each of the three was severely ill prior to the event. Special attention should be given to severely ill patients during such events.

The hepatitis B virus-trimera mouse: a model for human HBV infection and evaluation of anti-HBV therapeutic agents

Previous studies have demonstrated the feasibility of implantation of human blood cells or tissues in lethally irradiated mice or rats, radioprotected with SCID mouse bone marrow cells: The Trimera system. In the present study, we describe the development of a mouse Trimera model for human hepatitis B virus (HBV) infection. In this model, viremia is induced by transplantation of ex vivo HBV-infected human liver fragments. Engraftment of the human liver fragments, evaluated by hematoxylin-eosin staining and human serum albumin mRNA expression, was observed in 85% of the transplanted animals 1 month postimplantation. Viremia levels were determined in these mice by measuring serum HBV DNA using polymerase chain reaction (PCR), followed by dot-blot hybridization. HBV DNA is first detected 8 days after liver transplantation. Viremia attains a peak between days 18 and 25 when HBV infection is observed in 85% of the transplanted animals. The HBV-Trimera model was used to evaluate the therapeutic effects of human polyclonal anti-HBs antibodies (Hepatect) and of two reverse-transcriptase inhibitors, lamivudine (3TC) and beta-L-5-fluoro-2',3'-dideoxycytidine (beta-L-5FddC). Treatment of HBV-Trimera mice with these drugs effectively reduced both the percentage of infected animals and the viral load in their sera. Treatment cessation resulted in rebound of viral load, indicating HBV replication upon drug withdrawal. These results show that the HBV-Trimera model represents a novel experimental tool for simulating human HBV infection and evaluating potential anti-HBV therapeutic agents.