Hepatic carbohydrate metabolism in rats after laparotomy and laparoscopy

BACKGROUND

Portal venous and mesenteric blood flow are reduced by 40-60% in humans and animals during laparoscopic surgery compared to laparotomy. Little is known about whether these intraabdominal micro- and macrocirculatory changes are associated with alterations in the hepatic energy metabolism.

METHODS

We operated on male Sprague-Dawley rats, performing either laparoscopy (CO2, 6 mmHg; n = 27) or laparotomy (n = 28), and compared the results with two control groups: intraperitoneal (i.p.) endotoxin administration (n = 28, positive control) and anesthesia only (n = 28, negative control). We investigated the impact of the two different surgical techniques on daily food intake, body weight gain, glycogen content in the liver, levels of blood glucose, and liver function tests (LFTs) on postoperative days 1, 2, 4, and 8. Local (hepatic) and systemic inflammatory responses (interleukin-6 and tumor necrosis factor-alpha) during the postoperative time course were also determined. Data were analyzed using the Kruskal-Wallis test or univariate analysis of variance.

RESULTS

Body weight gain, food intake, liver and spleen weights, as well as LFTs [except aspartate aminotransferase (AST)] did not differ among the four groups. The significant increase in the AST level following laparoscopy compared to the anesthesia-only group was found on postoperative days 1 and 2; however, a similar difference was not detected after laparotomy or i.p. endotoxin injection. Laparoscopy showed no alterations in the hepatic glycogen stores compared to anesthesia only, whereas laparotomy and endotoxinemia significantly reduced the hepatic glycogen stores on postoperative days 2 and 4. The systemic postoperative inflammatory response did not differ between laparotomy and laparoscopy, but it was higher in both groups than in anesthesia only. In rats treated with endotoxin, the systemic inflammatory response was even higher than in the two surgical groups. The hepatic inflammatory response did not differ between the four groups.

CONCLUSION

This study shows a significant postoperative decrease in the hepatic glycogen content after laparotomy and i.p. endotoxin injection but not after laparoscopy. Food intake and inflammatory response cannot explain this difference between the two surgical groups, which suggests that alterations in the postsurgical hormonal stress response are the most likely explanation for these findings.

Interactions of the ergosterol biosynthetic pathway with other lipid pathways

Micro-organisms have recently received broad attention as sources of novel lipids. An increased understanding of the effects of fats and oils and their composition on the metabolism and on health has shifted the focus towards the use of lipids for disease treatment and prevention and for the promotion of good health. A large range of lipidic products produced by yeast is known today. Ergosterol and its metabolic precursors are major lipidic components of industrial and commercial interest. Having in mind the aim to increase the productivity of ergosterol and its precursor metabolites, both the knowledge of regulatory mechanisms of the biosynthetic pathway and its interactions with other lipid pathways like those of sphingolipids, phospholipids and fatty acids are crucial.

Glial fibrillary acidic protein and myelin basic protein as markers for the immunochemical detection of bovine central nervous tissue in heat-treated meat products

Because bovine central nervous tissue (CNT) is the main risk material in transmission of the infective agent of bovine spongiform encephalopathy, a suitable test is needed to enforce the ban on CNT in human foodstuffs in the United States and the European Union and to ensure that meat products are free of CNT To detect bovine CNT in heat-treated meat products, we used immunohistochemistry and Western blots with antibodies against glial fibrillary acidic protein (GFAP) and myelin basic protein (MBP). Both antigens were resistant to processing methods used for meat products. The anti-GFAP antibody showed a high degree of tissue specificity, whereas the anti-MBP antibody had high species specificity, clearly differentiating between porcine and bovine CNT Therefore, immunochemistry performed with both proteins provides an effective means for detecting bovine CNT in meat products.

The combination of acoustic rhinometry, rhinoresistometry and flow simulation in noses before and after turbinate surgery: a model study

BACKGROUND

Especially to young examiners, the interpretation of rhinometric findings seems to be difficult. In order to understand rhinometric assessments precisely, knowledge of airflow behavior in the nose is necessary. We therefore investigated the influence of nasal concha surgery on acoustic rhinometry and rhinoresistometry in a model.

METHOD

Six nose models were examined with acoustic rhinometry and rhinoresistometry, each of these models with its lateral wall altered to represent various conditions after nasal concha surgery. Besides, all models were rinsed with water and the flow was visualized for observation.

RESULTS AND CONCLUSIONS

The normal nose presented an even flow distribution over the entire nasal cavity. After nasal concha resection, though, an unfavorable flow course and a strong increase in turbulence were seen. Additionally, flow resistance decreased considerably. In the model with general lateral wall hyperplasia, reduction of the inferior and even of the middle nasal concha showed good functional results. The model revealed a good correlation between the result of flow observation and findings in acoustic rhinometry and rhinoresistometry. Both methods complement one another in their diagnostic outcome.

Production of lipid compounds in the yeast Saccharomyces cerevisiae

This review describes progress using the yeast Saccharomyces cerevisiae as a model organism for the fast and efficient analysis of genes and enzyme activities involved in the lipid biosynthetic pathways of several donor organisms. Furthermore, we assess the impact of baker's yeast on the production of novel, high-value lipid compounds. Yeast can be genetically modified to produce selected substances in relatively high amounts. A major advantage in choosing yeast as an object for metabolic engineering is the fact that the lipid pathways in this organism have been described in detail and are well characterized. We focus on the de novo production of three major families of lipid products. These are: (1) sterols, providing some previously known and some novel applications as examples of the lipid pathway enhancement that occurs naturally in yeast, (2) the reconstitution of the biosynthetic pathway of steroid hormones and (3) the biosynthesis of polyunsaturated fatty acids, leading to the biosynthesis of different omega-3 and omega-6 fatty acids which do not occur naturally in yeast. We utilize the current knowledge and point out perspectives and problems for future biotechnological applications in the field of lipid compounds.

[Objectivation of nasal swelling--a comparison of four methods]

BACKGROUND

The measurement of the nasal swelling is very common in rhinologic diagnostics. For that, there are different methods available. Especially the nasal provocation test is important in this relationship. The measurement of the obstruction, caused by swelling of the nasal erectile tissue, allows a quantification of the allergic reaction.

METHOD

We tested four different methods for objectivation of the mucosal swelling, which are used in the routine clinical examination: 1. acoustic rhinometry, 2. rhinoresistometry, 3. expiratory peak-flow-metry and 4. rhinomanometry. 40 volunteers were examined with the four methods before and after decongestion of the nose. We compared the results of each method (1. - 3.) with the results obtained by rhinomanometry.

RESULTS

We found only a good correlation between rhinomanometry and rhinoresistometry. Both methods seem to be suited for the objectivation of nasal swelling.

Stereotactic Aspiration and Fibrinolysis of Spontaneous Supratentorial Intracerebral Hematomas versus Conservative Treatment: A Matched-Pair Study

OBJECTIVES

Since introduction of stereotactic aspiration and fibrinolysis into the treatment of deep-seated intracerebral hematomas by Hondo and Matsumoto 1984 this method has become widely used, and satisfactory morphological results are achieved. Nevertheless, whether the outcome is improved has not yet been investigated.

MATERIAL AND METHOD

17 patients with spontaneous intracerebral hematomas have been treated surgically; after angiographic exclusion of a vascular malformation stereotactic aspiration and fibrinolysis with 3 mg rTPA was performed. Between 1992 and 1995 104 patients were treated conservatively according to best medical treatment. From this group "matched pairs" with the surgical patients were set up concurring in primary (consciousness, size and location of the hematoma) and secondary parameters (age, sex, ventricular hemorrhage). Endpoint of the study was the Glasgow outcome score (GOS) six months after treatment. Data were analyzed statistically and p < 0.05 was considered significant.

RESULTS

In respect of primary parameters complete concurrence and regarding secondary parameters far-reaching concurrence was achieved. In no parameter the surgical and conservative group were significantly different from each other. Six months after the ictus no significant difference between surgical and conservative treatment concerning GOS could be established.

CONCLUSION

These results indicate that patients do not benefit from stereotactic aspiration and fibrinolysis of putamenal hematomas. For a final treatment recommendation a prospective randomised trial is required.

[Special features of intensive care of toxic shock syndrome. Review and case report of a TSST-1 associated toxic-shock syndrome with adult respiratory distress syndrome and multiple organ failure from a staphylococcal panaritium]

Toxic-shock-syndrome (TSS) is an acute febrile, exanthematous illness caused by toxins such as toxic-shock-syndrome-toxine-1 (TSST-1) and other endotoxines from staphylococcus aureus with an incidence of 0,5 per 100.000 inhabitants. Patients with menstrual toxic-shock-syndrome (menstrual-TSS) usually have TSS associated with menstruation and use of a vaginal device such as tampons. Other patients with non-menstrual toxic-shock-syndrome (non-menstrual-TSS) have a focus of staphylococcal infection such as a surgical wound infection or soft tissue abscess. TSS usually presents with fever, pharyngitis, diarrhoea, vomiting, myalgia and may progress rapidly (within hours) to signs of hypovolaemic hypotension and shock. In some cases TSS is associated with multisystem failure including shock, renal failure, myocardial failure and adult respiratory distress syndrome. In its acute phase the diagnosis of TSS is often uncertain because of its initial symptoms are non-specific and numerous conditions need to be considered in the differential diagnosis. But obviously less incidence, the signs and symptoms of toxic-shock-syndrome should be recognised early to permit successful therapy. The site of infection should be adequately drained and treated with antimicrobial therapy. Possible complications including ARDS and myocardial failure require a thorough understanding of its underlying pathophysiology to ensure appropriate intensive-care treatment. Only if appropriate therapy is instituted as early as possible, most of patients will be able to survive their toxic-shock-syndrome. In other cases TSS can be a rapidly progressive and perhaps lethal ending disease because of possible multiple organe failure such as ARDS.

An�sthesie in der Stillperiode

Whenever an anesthetic is needed during the breast feeding period, potential pharmacological side-effects imposed on the infant by any kind of anesthetic agent used during both general and regional anesthesia are in contrast to the potential beneficial effects of breast feeding for the infant and the mother. Despite an increasing knowledge and understanding of the mechanisms of excretion of drugs and their metabolites through breast milk, information about most anesthetic drugs are still either inconclusive or contradictory. Often it is impossible to decide whether a certain substance that is potentially excreted through breast milk might be harmless or harmful for the breast-fed infant. In addition to that only few anesthetic agents and drugs used in conjunction with an anesthetic are officially approved for use during pregnancy and the period of breast feeding and for medico-legal reasons pharmaceutical companies generally advise against the use of any of those drugs during this period. However, based on the knowledge of pharmacological properties of commonly used anesthetic agents it is reasonable to assume that continuing breast feeding in the immediate postoperative period after a single anesthetic can be considered safe for the infant since no adverse effects caused by or secondary to the single use of those drugs can be expected. Provided there is a careful choice of anesthetic drugs, there is no need to consider that a single general or regional anesthetic is an indication to stop breast feeding. Even planned elective surgical procedures do not need to be postponed. No scientifically based interval between surgery under general or regional anesthesia and resumption of breast feeding can be recommended. Instead current opinion is that breast feeding can be resumed as soon as the mother feels physically and mentally capable to do so.

[The time-course of action of rapacuronium and mivacurium after early reversal following equally lasting relaxation]

This study was designed to compare the time course of action and the safety profile of Rapacuronium and Mivacurium in day case dental surgery. After Ethics Committee approval 61 healthy adult patients, scheduled for dental day case surgery, were randomised in an assessor-blinded manner to receive either 1.5 mg/kg Rapacuronium with and without 0.05 neostigmine 5 min later (19 patients each) or a total of 0.25 mg/kg Mivacurium (n = 16). Anaesthesia was induced using Propofol 2 - 5.1 mg/kg and Remifentanil 24 - 73 mcg/kg/h and maintained with Desflurane in N2O/O2 (2/1). Endotracheal intubation was performed when maximum blockade was achieved and scored by a blinded intubator. Neuromuscular block was monitored using the train-of-four response to supramaximal stimuli at the ulnar nerve every 15 seconds using acceleromyography (TOF Watch SX). Onset time, clinical duration (reappearance of the third twitch of a TOF-stimulation) and recovery to T4/T1 > 0.9 were recorded. Speed of recovery was evaluated by the time difference between reappearance of the third twitch and T4/T1 > 0.9. The intubating conditions at the time of maximum block revealed no statistically significant differences between the three groups. Changes in blood pressure, heart rate and airway pressure were not significant. Onset time in subjects who received Rapacuronium (99 +/- 29 s) was faster compared to the onset time in those who received Mivacurium (157 +/- 36 s). Also clinical duration was significantly shorter following Rapacuronium without reversal (12 +/- 4 min) as well as with reversal (9 +/- 1 min) compared with Mivacurium (21 +/- 5 min)). Patients treated with Rapacuronium and reversal recovered faster (14 +/- 8 min)) compared to the other two groups (Mivacurium: 20 +/- 6 min, Rapacuronium without reversal: 31 +/- 9 min). The fraction of clinical duration of the total duration was highest following Mivacurium (51 %) when compared with Rapacuronium/Neostigmine (43 %) and Rapacuronium (28 %).

[Fibrolipoma of the larynx]

Benign mesenchymal tumors of the upper aerodigestive tract are very rare. In this localisation some tumors cause life-threatening upper airway obstruction. We report on a 42-year old man who complained dysphagia and globus sensation. The physical examination revealed a smooth tumor of the left aryepiglottic fold. A magnet resonance imaging (MRI) leaded to the suspicion of a laryngocele with extension in the left aryepiglottic fold. The therapeutical procedure included the microlaryngoscopical extirpation of the tumor with laser surgery. The histology showed a fibrolipoma of the larynx. Because of frequent recurrences even after an extended period of time long term follow-up is necessary.

[Placental passage of anesthetics and adjuvants]

In obstetric anaesthesia almost all anaesthetic agents are capable of traversing the fetomaternal blood barrier. They all carry potential side-effects putting the unborn or newborn child at risk. Of major relevance is their potential for embryotoxicity, teratogenicity, postpartal cardiorespiratory or neuromuscular depression and the disturbance of thermoregulation. This can possibly lead to fetal malformation, asphyxia or floppy infant syndrome. Furthermore compromisation of uterine blood flow or contractility of the mature uterus plays an important role for the incidence of intrauterine asphyxia and premature labour or birth. Considering the physiological and pathophysiological alterations during pregnancy regarding all organ systems, the overall goal is to find an ideal choice of anaesthetic drugs and techniques in order to minimise an increased anaesthetic risk during pregnancy.

[First findings about the nasal airflow in noses with septal perforation]

BACKGROUND

A nasal septum perforation often leads to considerable complaints like nasal obstruction, crusting, epistaxis or whistling. Up to now there is no certain knowledge about the airflow pattern in noses with septal perforations.

METHOD

We performed fluid dynamic experiments on functional nasal models (so-called modified Mink boxes). We investigated the flow pattern in models with septal perforations, different in size and location and in combination with and without septal deviations.

RESULTS AND CONCLUSIONS

We have found no essential influence of the location of perforation on the airflow pattern. With increasing size of perforation the streamlines bump toward the posterior border of the perforation, causing turbulence. The whistling during inspiration is based on the principle of a lip whistle. The required flow velocity for vibration of the air depends on the dimension of the perforation. For large perforations it is impossible to get the required high flow velocity to cause a whistle.

Clear cell chondrosarcoma of the larynx: a case report of a rare histologic variant in an uncommon localization

The authors describe a clear cell chondrosarcoma of the larynx. The clear cell type is a rare variant of chondrosarcoma that only twice has been reported in this localization. The light-microscopic diagnosis of the actual case was confirmed by immunohistochemical results, in particular by positive staining for S-100 protein and collagen type II, and ultrastructural findings. Loss of heterozygosity analysis demonstrated allelic loss at 9p22 and 18q21, but neither in the region of the Rb gene on chromosome 13q nor at the p53 locus on chromosome 17p where allelic loss has already been reported in chondrosarcomas. Furthermore, our molecular genetic investigations revealed a methylation of the cell cycle control gene p16, which is localized on chromosome 9p. This characteristic has been recorded previously only in high-grade chondrosarcomas. Mutations in the exons of p16, alterations of the putative tumor suppressor gene MMAC1/PTEN on chromosome 10q, or an amplification of the cyclin D1 gene (CCND1) on 11q13, which were found to be changed in other studies of chondrosarcomas, could not be demonstrated here.

[Plasma cholinesterase variations as a result of prolonged neuromuscular blockade. Review and problems encountered in two cases of prolonged neuromuscular blockade after muscle relaxation with succinylcholine as compared to mivacurium]

Succinylcholine and mivacurium are degraded more slowly in patients with a qualitatively or quantitatively reduced plasma cholinesterase and are therefore known for inducing a prolonged postoperative apnea. Perioperative laboratory screening even including plasma cholinesterase activity testing will not prevent this due to a possible aberration only in the qualitative cholinesterase activity. This is illustrated by introducing two cases reports of prolonged apnea after administration of mivacurium or succinylcholine. The pathophysiology of plasma cholinesterase is reviewed including genetically determined variants and the degradation pathways of mivacurium and succinylcholine. Only extensive laboratory chemical tests are sufficient to prevent this possible complication. Due to the rare incidence there is no evidence for recommending these laboratory investigations in all patients. Once prolonged apnea occurs following the administration of mivacurium or succinylcholine the best choice is ongoing ventilation combined with a sufficient sedation.

Correlation of nasal morphology and respiratory function

In order to investigate the fluid dynamic preconditions that guarantee a sufficient contact of air with nasal mucosa, we studied flow patterns in modified "Mink's boxes" and in nasal models. As a result, the nose can be divided into 1) a functional area, i.e. area of turbinates, 2) an inflow area, i.e. vestibulum, isthmus and anterior cavum and 3) an outflow area, i.e. posterior cavum, choanae and epipharynx. The vestibulum is shaped like and acts as a bend, redirecting air to the cavum, and as a nozzle, reducing turbulence. With its concavely curved shape, the isthmus facilitates equal distribution of air throughout the entire area of the turbinates. The anterior cavum acts as a diffuser, where turbulence increases and velocity decreases. In the slit-like space of the area of turbinates, the flow behavior is determined by flow dynamics in the inflow area. The structure elements of the outflow area are similar to those of the inflow area but lined up in an inverse order.

Visualization of neuropeptide expression, transport, and exocytosis in Drosophila melanogaster

Neuropeptides affect an extremely diverse set of physiological processes. Neuropeptides are often coreleased with neurotransmitters but, unlike neurotransmitters, the neuropeptide target cells may be distant from the site(s) of secretion. Thus, it is often difficult to measure the amount of neuropeptide release in vivo by electrophysiological methods. Here we establish an in vivo system for studying the developmental expression, processing, transport, and release of neuropeptides. A GFP-tagged atrial natriuretic factor fusion (preproANF-EMD) was expressed in the Drosophila nervous system with the panneural promoter, elav. During embryonic development, proANF-EMD was first seen to accumulate in synaptic regions of the CNS in stage 17 embryos. By the third instar larval stage, highly fluorescent neurons were evident throughout the CNS. In the adult, fluorescence was pronounced in the mushroom bodies, antennal lobe, and the central complex. At the larval neuromuscular junction, proANF-EMD was concentrated in nerve terminals. We compared the release of proANF-EMD from synaptic boutons of NMJ 6/7, which contain almost exclusively glutamate-containing clear vesicles, to those of NMJ 12, which include the peptidergic type III boutons. Upon depolarization, approximately 60% of the tagged neuropeptide was released from NMJs of both muscles in 15 min, as assayed by decreased fluorescence. Although the elav promoter was equally active in the motor neurons that innervate both NMJs 6/7 and 12, NMJ 12 contained 46-fold more neuropeptide and released much more proANF-EMD during stimulation than did NMJ 6/7. Our results suggest that peptidergic neurons have an enhanced ability to accumulate and/or release neuropeptides as compared to neurons that primarily release classical neurotransmitters.

Neuroleptic malignant syndrome in pregnancy

BACKGROUND

Neuroleptic malignant syndrome can be a serious neurologic complication of drug therapy during pregnancy.

CASE

A young woman was admitted to the intensive care unit with worsening varicella pneumonia. After being given haldol for agitation, she developed fever, increasing agitation, rigidity, tachycardia, and tremors; she was diagnosed as having neuroleptic malignant syndrome. She was treated successfully with bromocriptine and dantrolene.

CONCLUSION

Despite the common use of antipsychotic medications, neuroleptic malignant syndrome is seen infrequently during pregnancy. The diagnosis can be difficult to make, but if suspected, it can be treated successfully.

Radiologic and endoscopic evaluation for laparoscopic adjustable gastric banding: preoperative and follow-up

BACKGROUND

Laparoscopic adjustable silicone gastric banding (LASGB) has replaced vertical banded gastroplasty (VBG) as the most widespread restrictive bariatric operation in Europe. Although these two procedures are similar in principle, the experience concerning the preoperative examinations and follow-up cannot be arbitrarily transferred from VBG to LASGB. The reasons for and consequences drawn from radiologic and endoscopic examinations are described.

METHODS

From December 1996 to January 2000, 148 patients (84% women, average age 39 years, body weight 127 kg, BMI 45 kg/m2) underwent LASGB. The mean follow-up was 17 months. Upper GI series, abdominal ultrasound, and gastroscopy were done before operation. The postoperative stoma adjustments were performed under radiological observation. All adjustments were analyzed.

RESULTS

Preoperative: Of 147 upper GI series, 74 showed hiatal hernia, 2 motility disorders, and 1 an incomplete malrotation. In 104 gastroscopies, 35 reflux and 53 gastritis with 24 Helicobacter pylori infections were found. Postoperative: On average, 2.7 radiological adjustments were done per patient. Until satisfactory satiety and weight reduction, 78% of the patients needed 0-3 adjustments. Besides routine adjustments, an additional 57 upper GI series were done in 35 patients, 44 times with opening of the stoma-diameter. A total of 14 slippages and 4 pouch enlargements were found. A gastroscopy was required in 12 patients.

CONCLUSION

Radiologic and endoscopic examinations before LASGB revealed pathology needing therapy in 42% of the patients and provided important additional information influencing the operative procedure. At an average follow-up of 17 months, 24% of the 148 patients needed unplanned additional upper GI series.