[D2 lymph node dissection in gastric cancer surgery: long term results--analysis of an experience with 227 patients]

AIM

The main objective of the study was to evaluate the postoperative mortality and 5 year survival in gastric cancer patients undergoing a minimum of D2 lymphadenectomy.

MATERIALS AND METHODS

A retrospective study was conducted on 1170 patients operated for gastric adenocarcinoma in the Department of General Surgery and Liver Transplantation of Fundeni Clinical Institute, between 1997 and April 2005. Only 443 patients underwent a curative resection, from which 216 patients had D1 resection and in 227 cases a D2 or D3/D4 lymphadenectomy was performed. Information about survival was available for 189 patients of those who had a D1 resection and for 210 of those who underwent a D2 or D3/D4 lymphadenectomy.

RESULTS

Postoperative mortality was 6.5% in the group of curative resection, with 9.2% for D1 and 3.9% for D2/D3 D4. Five year survival according to Kaplan Meier curves was 32 % in the D1 group vs. 51,8% in D2/D3-D4 (p <0.0001). Significant differences were noted in the median survival-- D2/D3-D4 group 63 months vs. 28 months in D1 group.

CONCLUSIONS

Our data support the gastric resection with a minimum of D2 lymphadenectomy in the radical surgery of gastric cancer. However, an accurate interpretation of the statistical interpretation between the different groups of patients is difficult, mainly because of the retrospective character of the study.

[Resection of the celiac axis increase resectability rate in locally advanced pancreatic body and gastric tumor]

Celiac axis involvement in locally advanced neoplasia was considered in the past a criteria of non resectability. Carcinoma of the body and tail of the pancreas is often diagnosed at an advanced stage or metastatic stage. Gastric carcinoma (particularly antral localization) can also be locally invasive. Celiac axis can be invaded in both neoplasias. In order to increase resectability rate in those two types of neoplasia celiac trunk resection was proposed (en bloc with distal pancreatectomy, loco-regional lymph node excision with or without total gastrectomy). We report our experience on 3 patients and some considerations about this surgical technique from medical literature.

Radiographic joint damage in rheumatoid arthritis is associated with differences in cartilage turnover and can be predicted by serum biomarkers: an evaluation from 1 to 4 years after diagnosis

INTRODUCTION

The objective of this study was to determine whether serum biomarkers for degradation and synthesis of the extracellular matrix of cartilage are associated with, and can predict, radiographic damage in patients with rheumatoid arthritis (RA).

METHODS

Clinical and radiographic data of 87 RA patients were recorded 1 year after disease onset and then annually up to four years. Serum concentrations of four cartilage biomarkers were determined at these time points: a neoepitope formed by collagenase cleavage of type II collagen (C2C), a neoepitope formed by collagenase cleavage of type II collagen as well as type I collagen (C1,2C), a carboxy propeptide of type II procollagen formed during synthesis (CPII), and a cartilage proteoglycan aggrecan turnover epitope (CS846-epitope). Biomarker concentrations between patients with rapid radiographic progression (>7.3 Sharp/van der Heijde units per year) and those with slow radiographic progression (<2.3 units per year) were compared. In addition, we evaluated the long-term and short-term predictive value of each biomarker for progression of radiographic damage.

RESULTS

Patients with rapid radiographic progression had higher C2C, higher C1,2C, and higher CS846-epitope levels than slow progressors. CPII levels showed no differences. Most importantly, the long-term radiographic progression for C2C, for C1,2C, and for CS846-epitope can be predicted by the biomarker value at year 1 after disease onset. C2C was also a predictor for joint space narrowing and annual radiographic damage during the subsequent year.

CONCLUSION

This study shows that the concentration of serum biomarkers of cartilage collagen breakdown and proteoglycan turnover, but not of collagen synthesis, are related to joint destruction in RA. The use of these biomarkers may be of value when studying progression of joint damage in patients with RA.

[Surgical treatment of liver metastases from colorectal cancer]

We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.

[Severe upper gastrointestinal hemorrhage of a rare cause: aorto-esophageal fistula successfully treated]

Aorto-esophageal fistula is a rare entity, determining huge digestive bleeding with a very poor prognostic most often. We present the case of a patient with aorto-esophageal fistula of unknown origin, treated successfully in the Center of Surgery and Liver Transplantation from Fundeni Clinical Institute. A young man, 21 years old, was admitted in our clinic from another hospital for repetitive severe upper gastrointestinal bleeding, with hematemesis and melena, pale, asthenia, without any pain; the bleeding stopped when he was admitted. The upper digestive endoscopy and esophago-gastro-duodenal radioscopy with barium did not show any lesion. During the 7th day the patient presents sudden massive hematemesis with hemodynamic instability; during the surgery we found two subcardial ulcers (stress ulcers?) for which we have done excision and suture which temporary stopped the bleeding. After 14 days, the patient had another massive bleeding; the upper endoscopy shows 28 cm far from the dental arch a protrusive formation of 6-7 mm with a telangiectasis aspect and with a white spot (possibly a central ulceration); 1 ml pure alcohol was injected inside it with temporary bleeding ceasing. After 3 days the patient is bleeding again, with marked decrease in blood pressure; a Blakemore tube stopped the bleeding until surgery was performed. During the intervention an aorto-oesophageal fistula is detected; we made the excision of the fistula with simple suture of the aorta, subtotal esophagectomy, cervico-stoma and gastrostomy, with good postoperative evolution. After 4 months the digestive transit is restored by esophagoplasty with tubulized stomach placed behind the sternum. The diagnostic and treatment difficulties encountered in these kind of cases need to consider also an aorto-esophageal fistula diagnosis, especially for the cases with Chiari triad (mild thoracic pain, sentinel digestive bleeding and exsanguination). The Blakemore tube can save patient's life by ensuring temporary hemostasis and allowing the time for a definitive surgical intervention. The subtotal esophagectomy with cervicostoma and feeding gastrostomy, followed after few months by a esophageal reconstruction , is a solution for this extreme severe cases.

[Thoracoscopic splanchnicectomy--a method of pain palliation in non-resectable pancreatic cancer and chronic pancreatitis]

Severe upper abdominal pain is a dominant and distressing feature in advanced pancreatic cancer and in chronic pancreatitis. A way of palliation needs to be practiced in the non-resectable pancreatic cancer in order to control the pain. Between the many methods of palliation the thoracoscopic splanchnicectomy seems to be the best due its simplicity, no risk to the patient and the good results. In the Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute we have practiced 50 thoracoscopic splanchnicectomies in a number of 49 patients during a period of 3 years. The morbidity was 2% and the mortality 0. We noticed a significant improvement in the pain score, the quality of sleep and the overall quality of life and consecutively a quick social reintegration of these patients. The quality of life is greatly improved (with a significant reduction of the pain score in 92% of the cases) after this minimally invasive procedure, a fact the qualifies this procedure as the technique of choice in these patients.

[Central pancreatectomy--indications, technique, outcomes]

Central pancreatectomy is a conservative resectional procedure indicated for benign and low malignant tumors located in the neck and/or body of the pancreas. We report our experience on 5 patients and some considerations about this surgical technique from medical literature.

Orientation behavior of retinal photoreceptors in alternating electric fields

In alternating electric (AC) fields, particles experience polarizing effects that induce dipoles that orient elongated specimens either parallel or perpendicular to the field lines. In this work we studied the behavior of photoreceptor cells' rod outer segments (ROS) in AC fields of different frequencies. We showed that at low frequencies, ROS orient parallel to the field, whereas at higher frequencies they orient perpendicular to the field lines (in the frequency range from 100 Hz to 10 MHz). We found this behavior to be dependent on the physiological state of cells (due to modifications in their electrical properties). To simulate cell damage, the membrane conductivity was changed by treating the cell with gramicidin A, which resulted in a decrease of cytosol conductivity and, consequently, in a change of the orientation behavior of the treated cells. The change of cell orientation with cytosol conductivity is rather sharp, suggesting the potential of the method for accurate evaluation of the cell physiological status. We modeled the interaction between ROS and AC fields approximating the rod cell by a prolate spheroid with a very long axis. The internal compartment of the ellipsoid was considered to be filled with an inhomogeneous medium consisting of alternating layers of membrane and cytoplasm as media modeling the disks. This theoretical model proved to be in good agreement with the experimental results and enabled the derivation (by fitting with the experimental results) of the membrane and cytosol parameters for normal and damaged cells.

[Current treatment of hepatocellular carcinoma. Analysis of a series of 123 cases over a 5-year period]

We analyze a 123-cases experience over a 5-year period in the treatment of hepatocellular carcinoma (HCC). Liver resection, transplantation and hyperthermic ablation of the tumor were used according to the indication and patient selection. Systemic chemotherapy followed resection in 18 cases and hyperthermic ablation in 5 cases. Chemo-embolisation was performed in patients to be transplanted and in other two patients with tumor destruction. A number of 86 liver resections were performed in 84 patients (2 re- resections in 1 patient, subsequently transplanted) - 43 on normal liver and 41 on cirrhotic liver. Postoperative mortality was 4.7% in non-cirrhotic and 4.9% in cirrhotic patients. Survival in non-cirrhotic patients was 77% at 1 year, 65% at 2 years, and constant - 45% at 3 and 4 years, whereas in cirrhotic patients it was 60%, 56%, 56% and 36% (Kaplan-Meyer actuarial survival rates). Nine patients underwent liver transplantation (4 OLTs, 3 living donor LT, 1 split LT and 1 "domino" LT); postoperative mortality was 11% (1 patient). At present five patients are alive and well. One patient died by peritoneal carcinomatosis at 10 months; another patient died at 6 months by severe cholestatic recurrent C virus hepatitis and one patient was discharged with permanent severe neurologic disturbances. In 31 patients hyperthermic ablation of the tumor was used with zero mortality. Actuarial survival rates were 75% at one year and 67% at 2 years. In conclusion, in non-cirrhotic patients with HCC resection is the treatment of choice. In cirrhotic patients limited resections should be preferred and liver transplantation is the best solution in selected cases; local ablative methods may be used for some unresectable tumors. The role of adjuvant chemotherapy has to be determined in future comparative studies.

[Pancreatic carcinoma with osteoclast-like giant cell tumor and portal vein fistula]

Osteoclast-like giant cell tumor of the pancreas (OGTP) is a rare neoplasm. We report a case of OGTP involving the head of the pancreas in a 64 year old woman with an uncommon complication--portal vein fistula. We present the diagnostic strategy and therapy. Postoperative outcome after Whipple's pancreatoduodenectomy was uneventful. The patient is still alive at 16 month after operation, without disease recurrence.

[Orthotopic liver transplantation in adult patients with cadaveric grafts. Experience of the Fundeni Center of General Surgery and Liver Transplantation]

We analyze the experience of the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest, Romania) regarding orthotopic liver transplantation (OLT) in adult recipients, with whole liver grafts from cadaveric donors, between April 2000 (when the first successful LT was performed in Romania) and December 2004. This series includes 37 OLTs in adult recipients (16 women and 21 men, aged between 29-57 years--average 46 years). Other two LT with whole liver cadaveric grafts and two reduced-size LT were performed in children; also, in the same period, due to the acute organ shortage, other methods of LT were performed in 28 patients (21 living donor LT, 6 split LT and one "do mino" LT), that were not included in the present series. The indications for OLT were HBV cirrhosis--10, HBV+HDV cirrhosis--4, HCV cirrhosis--11, HBV+HCV cirrhosis--2, biliary cirrhosis--5, Wilson disease--2, alcoholic cirrhosis--1, non-alcoholic liver disease--1, autoimmune cirrhosis--1. With three exceptions, in which the classical transplantation technique was used, the liver was grafted following the technique described by Belghiti. Local postoperative complications occurred in 15 patients (41%) and general complications in 17 (46%); late complications were registered in 18 patients (49%) and recurrence of the initial disease in 6 patients (16%). Intrao- and postoperative mortality was 8% (3/37). There were two patients (5%) who died because of immunosuppressive drug neurotoxicity at more than 30 days following LT. Four patients (11%) died lately because of PTLD, liver venoocclusive disease, recurrent autoimmune hepatitis and liver venoocclusive disease, myocardial infarction, respectively. Thirty-four patients survived the postoperative period (92%); according to Kaplan-Meier analysis, actuarial patient-survival rate at month 31 was 75%.

[Rare case of retroperitoneal malignant Schwannoma]

Malignant Schwannoma, recently renamed malignant peripheral nerve sheat tumor retroperitoneally localized, represents 0.01 of retroperitoneal tumours. A 41-year old woman, without pathological record--and without cutaneous neurofibromatosis--hospitalized for increased volume of the abdomen, without symptomatology, is diagnosed after the imaging and biological tests--without CT and RMN--with retroperitoneal tumour. The unusual size of tumour--6000 gr.--the macroscopic aspect suggesting malignancy (histopathologically and immunohistochemically confirmed), the relatively easy extirpation which, nevertheless, required caudal spleen- and pancreatectomy as well as transvers colectomy, the absence of proximity adenopathy and remote secondary determinations, the simple postoperative evolution represent overwhelming elements in this case. Two years after the operation, during which the patient was under chemotherapy, on a routine control we found a relapse at a distance from the initial tumour (primitive tumour ?), totally operable. For the time being, after almost five years from the first operation, there are no clinical, biological and imaging changes.

CONCLUSIONS

the retroperitoneal space is quite enough for the development of large tumour masses, without symptomatology. The present case combines most characteristics of retroperitoneal neoplasms: large or very large size, quasi-absent symptomatology, difficulty in preoperative diagnosis, surgical tactics and techniques--quite often, the total extirpation of tumour mass led to the sacrifice of other organs within the limits of a justified risk--and unforeseeable evolution with relapses having the same characteristics.

[The value of resection in pancreatic cancer: the analysis of an experience of 180 patients in 10 years]

Pancreatic cancer (PC) represents one of the most severe malignant diseases, with an extremely high mortality rate (80% in the first year following diagnosis). The only potentially curative treatment is resection. This report evaluates the last 10-year experience in surgical resection for pancreatic cancer in the Center of General Surgery and Liver Transplantation from the Fundeni Clinical Institute (Bucharest--Romania), between 01.01.1995-01.05.2004. From a total of 832 patients with pancreatic cancer who were surgically treated, 180 underwent various resections (a resecability rate of 21.6%). There were 120 resections for cancer of the pancreatic head: 61 Whipple procedures, 10 pilorus preserving pancreaticoduodenectomies, 10 pancreaticoduodenectomies associated with complex resection, 17 pancreaticoduodenectomies with resection of the portal vein, 15 pancreaticoduodenectomies with extensive lymphodissection, 2 subtotal pancreatectomies and 5 total pancreatectomies; 60 standard splenopancreatectomies were performed for cancer of the pancreatic tail. The overall morbidity was 34%--61 patients (38 with cancer of the pancreatic head and 23 with pancreatic cancer of the tail), with the prevalent complication represented by pancreatic fistula. The mortality rate was 6.6%--12 patients (9 with cancer of the pancreatic head and 3 with cancer of the tail); there was a continuous decreasing trend from 9.1% between 1994-1999 to 1.6% between 2002-2004. In our Center an increasing preoccupation for pancreatic surgery, along with an improved surgical experience, resulted in a constant raise in the number of patients resected for pancreatic cancer, with a low morbidity and mortality rate.

[Surgical treatment in ulcerative rectocolitis . Analysis of a 24 years experience of 50 patients]

Ulcerative colitis (UC) is an inflammatory bowel disease that may be cured by surgery being indicated for emergency situations resulting from complications of fulminant disease and for elective indications. We analyzed the last 24 years experience regarding 50 patients surgically treated for ulcerative colitis in the Center of General Surgery and Liver Transplantation of Fundeni Clinical Institute. The indications for surgery were: failure of medical treatment in 22 patients, acute disease with complications in 20, chronic complications in 8 cases. We used the following surgical procedures: total proctocolectomy in all 2 cases with associated rectal cancer, total colectomy with ileo-rectal anastomosis (one staged or two staged procedures) in 31, and restorative proctocolectomy in 17 cases (in all cases as a 2 or 3 staged procedure). In acute disease with complications we have performed total colectomy with terminal ileostomy, closure of the rectal stump, or exteriorization of the sigmoid stump in a mucous fistula. The gravity of acute complications does not justify the use of palliative procedures such as ileostomy, colostomy or Hartmann procedure because the mortality rate of these operations is higher than the postoperative mortality rate of total colectomy performed in emergency. Even in the elective surgery, when the patients are in a poor condition, nutritionally depleted, taking large doses of steroids or immunosuppressive drugs, we prefer the staged procedure. Total proctocolectomy is performed only in the cases of ulcerative colitis associated with rectal cancer, severe perianal disease, sphincter incontinence. Total colectomy with ileo-rectal anastomosis is indicated when the rectal stump has minimal inflammatory lesions. Restorative proctocolectomy is the surgery of choice for UC, the functional results being comparable with those of total colectomy with ileo-rectal anastomosis, but having the advantage of curing the disease. The global mortality rate was 12% (6 patients).

[Ovarian cancer--diagnostic dilemmas and unusual therapeutic response]

The aims of this paper are both to highlight some dilemmas concerning the diagnosis of primary epithelial ovarian carcinoma mainly in its early stages and to underline the capricious responses of this type of malignancy to an otherwise well coded modern management. This study is based on the analysis of the records of 78 patients with ovarian carcinoma admitted for diagnosis and surgical treatment to the Department of General Surgery of Craiova C.F.R. Clinic from 1993 through 2003. The results of this analysis are difficult to interpret due to loss to follow up (in terms of response rates) of some of our 78 operated on ovarian carcinoma patients who went on with their platinum-based chemotherapy (following surgical cytoreduction) under the supervision of different Oncology Departments nationwide. Nevertheless, it is worth mentioning that most of this study patients (71.9%) presented with advanced-stage (III and IV) ovarian carcinoma which sometimes seemed quite confusing by its clinical polymorphism but its prognosis was very much related to both the degree of surgical cytoreduction accomplished and tumor sensitivity to chemotherapy. Finally, although this study does not allow us to draw firm conclusions it is an attempt to share out our current perception on the primary epithelial ovarian cancer management.

[Clinical course of an ileal carcinoid with mesenteric metastasis]

This paper aim is to present the case of a male patient, age 63 admitted in hospital for non-specific gastroenterologic symptoms easily attributed to colecyst calculosis; the anamnesis and careful clinical examination have avoided a useless cholecystectomy and permitted to establish indication for laparotomy; during that was found an ileal tumor with massive metastasis in the base of mesentery. The surgical attitude was dictated by histological diagnostic difficulties (prostate adenocarcinoma metastasis), so it has given up the idea of tumor excision (unjustified intraoperative risk for a metastasis), performing a bypass of the ileal tumor by an enteroenterostomy, then the patient was sent to the Oncological Department. Postoperative evaluation of the patient finally permitted to establish the neuroendocrine origin of the tumor; after oncological treatment (chemotherapy), about 10 months after operation the patient didn't present any sign of tumor (tumor markers and CT scan within normal). The paper emphasizes the problem of practicing an aggressive surgical treatment for carcinoid intestinal tumors with mesenteric metastasis but also brings attention to nonsymptomatic forms of cholecyst calculosis that may hide associated malignant tumors undetected by laparoscopic cholecystectomy.

[Locoregionally advanced rectosigmoid cancer: diagnosis, surgical approach, late results]

The colorectal cancer continues to be diagnosed in advanced stages in our country, mainly due to unapplying of a programmer of active diagnosis through screening on the population with risk for colorectal cancer, and inefficiency of primary care system. In the department of General Surgery CFR Craiova Hospital between 1991-2001 were operated a number of 231 patients with colon cancer and 104 patients with rectal cancer. The results, showing an increased number of recurrences in cases of resection performed for advanced loco-regional tumors of rectosigmoid, made us to reconsider the attitude of avoiding the abdominoperineal resection even when the distance between the inferior limits of the tumors and the anal edge exceeded the distance considered being standard for a low anastomosis performing. The follow-up of the patients with paraclinic technique that didn't prove efficient led in the most cases to a delaying in diagnosis of local recurrences until the moment of resectability was exceeded. The applying of efficient methods in early diagnosis of colorectal cancer and follow-up could provide in the future better results for anterior resections with low anastomosis.

[Neoadjuvant radiochemotherapy in the treatment of esophageal squamous carcinoma:Preliminary results in a series of 15 patients]

The purpose of this study is to analyze the experience of the Center of General Surgery and Liver Transplantation from Fundeni Clinical Institute (Bucharest) regarding the results of neoadjuvant radiochemotherapy in the squamous carcinoma of the esophagus. During 01.01.2001-09.07.2003, 15 patients with squamous carcinoma of the esophagus were treated using neoadjuvant radiochemotherapy (RCT); 13 patients (86%) underwent esophageal resection (in 2 patients resection was not possible due to the mediastinal invasion). Complete histological response (the lack of malignant tissue on the esophagectomy specimens) was noted in 5 cases. The morbidity and mortality rates were 48%, respectively 6%. RCT increases the resectability in esophageal cancer and decreases the postoperative morbidity and mortality.

[Breast conserving surgery --7 years of experience]

The breast cancer treatment is based nowadays on a new surgical option: breast-conserving surgery, which is reliable at least for the first and second stage of cancer, with radical intention, obviously. We have started to practice the breast-conserving surgery in our surgical clinic (at CFR Hospital, from Craiova) for 7 years; until now we have performed 159 breast-conserving operation and, as results, we have recorded 3 local recurrences (2.12%) and 1 death due to cancer evolution. Our protocol includes removal of the primary tumor with enough surrounding tissue to ensure negative margins of resectable specimen, associated with total axillary lymph-node dissection and postoperative breast irradiation. Our oncologist on different postoperative conditions indicated the chemotherapy: tumor size, axillary lymph node involvement, patient age, etc. The purpose of this paper is to emphasize our unassuming experience but especially to draw attention on important results, obtained by long-term monitoring the patient who underwent breast-conserving surgery, in a two prospective protocols, which demonstrate the importance and applicability of breast-conserving therapy. The conclusion of this study is that breast-conserving surgery followed by breast irradiation is reliable, as the results are similar with the radical mastectomies; the main objective is to obtain a good cosmetic result, which depends on tumor size/size of the breast ratio.

[Pancreaticoduodenectomy--the rutin surgery?]

Pancreaticoduodenectomy with or without pylorus preserving remains the only possibility for cure for the patients with malignant tumors of duodenum, periampullary and cefalopancreatic region, and distal biliary tumors; Pancreaticoduodenectomy is proceeded also for benign tumors of the head of the pancreas (chronic pancreatitis, cysts) but today the standard became preserving duodenum pancreatectomy with good functional results comparing with standard Whipple resection. The last decade had shown a dramatically decrease of the postoperative death for this kind of operations, centers with high volume have been reported a postoperative mortality rate between 1-3%. Our study is a retrospective analysis witch compare the postoperative mortality between 1 January 1990-1 October 2002. The results have shown a decrease of the postoperative mortality from 30.4% (1990-1995) to 9.8% (1995-1999) and 3.6% in the last three years (2000-2002). Also the surgeon volume of operation is closely linked with the postoperative mortality, at the first operations the postoperative mortality rate is 20-33% and after 20 pancreaticoduodenectomy the rate decrease dramatically to 2.6-5.5%. We conclude that pancreatodudenectomy today is routine operation which mortality have decreased at 5% and should be performed in high volume hospitals by surgeons with sufficient experience to minimize the postoperative death.

Excessive degradation of type II collagen in articular cartilage in equine osteochondrosis

Articular osteochondrosis (OCD) occurs in both man and animals. The etiology remains to be determined. Studies of OCD lesions in animals may provide clues as to its pathogenesis. The aim of our study was to determine whether there was evidence for increased degradation namely proteoglycan (PG) release and type II collagen cleavage in articular cartilage harvested from OCD lesions. We examined ex vivo explants at post-mortem from equine OCD lesions and macroscopically normal site and age matched cartilage. These were cultured over a 10 day period in serum-free medium. Type II collagen cleavage was measured in articular cartilage and media using an Elisa assay to detect the COL2-3/4C(short) epitope, which is generated on cleavage of the triple helix of type II collagen by collagenases. PG release was measured by a dye-binding assay. Cumulative release of PG and COL2-3/4C(short) and their contents in cartilage at the end of the culture period were determined. In OCD lesions there was a significant increase in type II collagen cleavage by collagenase but no evidence for increase of PG degradation. These findings point to a selective increase in type II collagen cleavage by collagenases, in OCD lesions of the kind observed in osteoarthritis. Further work is needed to determine whether changes represent primary or secondary events in the pathogenesis of OCD.

[Hepatic serial resection. Portal vein resection followed by hepatic resection in second time]

Hepatic resection still remains the only potential curative treatment for either primary or secondary malignant liver tumors. In order to increase the resectability of initially considered non-resectable tumors and to decrease the posthepatectomy morbidity and mortality, ligature of a portal branch with consecutive hepatic resection is recommended. The ligature of a portal venous branch was performed in 12 patients with gross hepatic tumor: hepatocellular carcinoma (2), peripheral cholangiocarcinoma (5), hepatic metastases from colorectal cancer (5). Two-stage hepatectomy was performed in 5 patients. The interval between the two operations ranged between 4 weeks and 6 months. Hepatic resection could not be performed in 7 cases due to the loco-regional progression of the disease (4 cases) or to the absence of the hypertrophy-atrophy process (3 cases). Hepatic failure occurred posthepatectomy in 2 patients, resulting in the death of one of the patients. Two patients died at 5 and 10 months respectively while two other patients are still alive, free of recurrence at 6 and 12 months respectively. In conclusion, portal vein ligature can be considered in selected cases of unresectable gross hepatic tumors that can be eventually, resected in a second operation. The two-staged hepatectomy is not always feasible. Moreover, the hypertrophy of the controlateral lobe does not always prevent the postoperative hepatic failure..

Elevation of a collagenase generated type II collagen neoepitope and proteoglycan epitopes in synovial fluid following induction of joint instability in the dog

CLINICAL RELEVANCE

Measurement of markers of cartilage pathology in synovial fluid may provide clinical rheumatologists and osteoarthritis (OA) researchers important information for early diagnosis of OA as well as a method for monitoring disease progression and response to treatment. This study demonstrates the value of this approach in an established model of OA (cranial cruciate ligament rupture) at a point distant enough from the original surgical manipulation so as to have little to no effect on the marker concentrations.

OBJECTIVE

The objective of this study was to determine whether measurement of markers of cartilage collagen cleavage and proteoglycan turnover in synovial fluid from a canine model could be used to detect cartilage changes following the onset of joint instability during the development of OA.

DESIGN

A model of joint instability that develops OA was created in 18 mature dogs using monopolar radiofrequency energy (MRFE). MRFE was arthroscopically applied to one cranial cruciate ligament (CCL) while the contralateral CCL was sham treated. The treated CCLs ruptured approximately 8 weeks (55 +/- 1.6 days) after MRFE treatment. Synovial fluid was collected at time zero prior to MRFE treatment, 4 weeks after MRFE treatment, and at 4, 8, and 16 weeks after CCL rupture. Synovial fluid concentrations of the neoepitope COL2-3/4C long (type II collagen cleavage by collagenase) and epitopes 3B3(-) (proteoglycan aggrecan sulfation) and 846 (associated with aggrecan synthesis) were analyzed.

RESULTS

Compared to sham treated joints, the synovial fluid concentrations of COL2-3/4C long and 3B3(-) were significantly increased 2.2 fold and 2.9 fold, respectively, in joints with MRFE treated CCLs following CCL rupture. Concentrations of the 846 epitope in synovial fluid showed a trend toward an increase, which was not significant, after CCL rupture.

CONCLUSIONS

Concentrations of the collagenase-cleaved type II collagen neoepitope and 3B3(-) epitope in synovial fluid were significantly increased by 4 weeks and remained elevated for at least 16 weeks after CCL rupture. This suggests that in dogs the COL2-3/4C long neoepitope and 3B3(-) epitope are sensitive markers for changes in joint cartilage turnover in joints that are developing OA.

Land application of phosphorus-laden sludge: a feasibility analysis

An investigation was conducted to examine aerobic digestion of the phosphorus-laden sludge produced at the Regina Wastewater Treatment Plant and feasibility of land use of this sludge combined with the dewatered anaerobically digested primary sludge from this plant. Experimental studies showed that aerobic digestion can be employed for the stabilization of the chemical sludge. Results of the feasibility analysis showed that mixing the two digested sludges met the heavy metal criteria set by various guidelines for agricultural use, presented the advantage of an increased concentration of nutrients and a decreased concentration of heavy metals, and a longer useful life of the agricultural site compared to using dewatered anaerobically digested primary sludge alone. Land application of the mixed digested sludges would be a more appropriate method of sludge disposal compared to the present practice of landfilling the dewatered sludge and lagooning the chemical sludge.