Minimally invasive management of colon cancer

Effects of CO2 pneumoperitoneum on proliferation, apoptosis, and migration of gastrointestinal stromal tumor cells

BACKGROUND

The purpose of the study was to investigate the proliferation and migration capability of human gastrointestinal stromal tumor line GIST-T1 after exposure to different pressures and times of CO₂ pneumoperitoneum.

METHODS

We established simulated CO₂ pneumoperitoneum environment in vitro and divided the human GIST cell GIST-T1 into open control group, 8 mmHg CO₂ pneumoperitoneum treatment group and 15 mmHg CO₂ pneumoperitoneum treatment group. Each group was divided into two subgroups respectively cultured for 1 h and 3 h. pH value of cell culture, cell growth curve, and cell cycle distribution of each group was measured. By application of scratch healing tests and Transwell chamber experiments, mobility ratio and number of cells through 8 µm membranes were measured to assess the migration ability of cells in each group after intervention.

RESULTS

Cell culture pH value of each subgroup in CO₂ group decreased significantly after exposed in CO₂ pneumoperitoneum (P < 0.01). The proliferation of GIST-T1 cells in 15 mmHg CO₂ group was significantly inhibited early (1-2 days) (P < 0.05) and the proliferation of GIST-T1 cells in 8 mmHg CO₂ 1 h subgroup and 15 mmHg CO₂ 1 h subgroup was increased significantly late (4-6 days) (P < 0.05) after the interventions of CO₂ pneumoperitoneum. The percentage of cells in G0-G1 phase increased, the percentage of S phase cells decreased (P < 0.01) in 1-h subgroup and 3-h subgroup of 15 mmHg CO₂ group 24 h after exposure to CO₂. The percentage of cells in S phase increased in 1-h subgroup of 8 mmHg CO₂ group and decreased in 3-h subgroup of 15 mmHg CO₂ group 72 h after exposure to CO₂. In the Transwell chamber experiment, the cell number through 8-µm membrane increased significantly (P < 0.01) in 3-h subgroup of CO₂ group compared to that in 3-h subgroup of control group.

CONCLUSIONS

The routine pressure and duration of CO₂ pneumoperitoneum used in clinic did not promote the proliferation of gastrointestinal stromal tumors, but had a potential risk of increasing postoperative recurrence and distant metastasis.

Tumor necrosis factor-α antagonist suppresses local inflammatory reaction and facilitates olfactory nerve recovery following injury

OBJECTIVE

Olfactory dysfunction is a common finding in head trauma due to injury to the olfactory nerve. We previously reported that anti-inflammatory treatment with steroids improves recovery outcome in olfactory nerve injury models. Clinically, however, steroid administration is not recommended in the acute phase of head injury cases because of concerns regarding its side effects. Tumor necrosis factor (TNF-α) is known to play a key role in inflammatory response to injury. The present study examines if the inhibition of TNF-α can facilitate functional recovery in the olfactory system following injury.

MATERIALS AND METHODS

Olfactory nerve transection (NTx) was performed in olfactory marker protein (OMP-tau-lacZ) mice to establish injury models. We measured TNF-α gene expression in the olfactory bulb using semi-quantitative and real time polymerase chain reaction (PCR) assays and found that they increase within hours after NTx injury. A TNF-α antagonist (etanercept) was intraperitoneally injected immediately after the NTx and histological assessment of recovery within the olfactory bulb was performed at 5-70 days. X-gal staining labeled OMP in the degenerating and regenerating olfactory nerve fibers, and immunohistochemical staining detected the presence of reactive astrocytes and macrophages/microglia.

RESULTS

Etanercept-injected mice showed significantly smaller areas of injury-associated tissue, fewer astrocytes and macrophages/microglia, and an increase in regenerating nerve fibers. Olfactory function assessments using both an olfactory avoidance behavioral test and evoked potential recordings showed improved functional recovery in etanercept-injected animals.

CONCLUSION

These findings suggest that inhibition of TNF-α could provide a new therapeutic strategy for the treatment of olfactory dysfunction following head injuries.

Expression levels of tumor necrosis factor-α and the corresponding receptors are correlated with trauma severity

This study investigated the plasma levels of tumor necrosis factor α (TNF-α) and the expression levels of TNF receptors (TNFRs) in patients with multiple trauma, together with the association between the levels of this cytokine and these cytokine receptors with the severity of traumatic injury. Blood samples were obtained from 60 multiple trauma patients at hospital admission (within 2 h of injury), and 6–8 h and 1–5 days after admission. The plasma levels of TNF-α and TNFR1/TNFR2 were detected using enzyme immunoassay. TNFR1 and TNFR2 expression levels on leukocytes, including neutrophils, lymphocytes and monocytes, were determined by flow cytometry. Clinical parameters were determined by injury severity score (ISS). At hospital admission, the plasma TNF-α and soluble TNFR levels in the trauma patients were elevated compared with those of healthy controls. Increased expression levels of TNFR1 and TNFR2 were also detected on leukocytes, particularly on lymphocytes and monocytes. The expression levels of the cytokine and the corresponding receptors were correlated with the ISS. TNF-α and TNFR expression levels remained significantly elevated for up to the third to fifth day following the traumatic injury. In the trauma patients, increased levels of TNF-α and TNFRs were correlated with the severity of traumatic injury in the early post-injury period, supporting the hypothesis that trauma-provoked organ dysfunction may be caused by an overwhelming auto-destructive inflammatory response.

Lethal effect of a hyperthermic CO₂ pneumoperitoneum on gastric cancer cells

OBJECTIVES

We investigated the lethal effect of a hyperthermic CO₂ pneumoperitoneum on gastric cancer cells. This could form the theoretical basis for further studies of the feasibility and safety of inflating hyperthermic CO₂ in the abdominal cavity of gastric cancer patients during laparoscopy.

METHODS

An in vitro hyperthermic CO₂ pneumoperitoneum experimental model was built, where gastric cancer cell line SGC-7901 cells were grouped according to temperature. Cytotoxicity was detected using a cell counting kit; apoptosis was detected by Annexin V-FITC/PI flow cytometry and Hoechst 33342/PI fluorescent microscopy. Morphological alterations were observed by transmission electron microscopy. Invasion and migration were detected by a scratch test and by transwell migration, respectively.

RESULTS

Cytotoxicity assays showed that a hyperthermic CO₂ pneumoperitoneum significantly inhibited the proliferation of SGC-7901 cells (P<0.05); it also significantly induced apoptosis of SGC-7901 cells (P<0.05). Morphological observations showed that the cell membrane and nucleus had an apoptotic phenotype. The invasiveness and migration ability of the gastric cancer cells subjected to hyperthermic CO₂ were significantly reduced.

CONCLUSIONS

A hyperthermic CO₂ pneumoperitoneum had a lethal effect on gastric cancer SGC-7901 cells by inhibiting their invasion and migration, and by inducing apoptosis.

Early results and complications of colorectal laparoscopic surgery and analysis of risk factors in 492 operated cases

This study aimed to evaluate the early results of colorectal laparoscopic surgery with special attention to surgical and medical complications. The risk factors of such surgery are also investigated on the basis of a large series of operated cases: the preoperative knowledge of such factors could guide the operative program and the postoperative treatment with reduction of complications and improvement of the outcome. Between 1998 and 2008, 492 patients had been submitted to colorectal laparoscopic surgery by the same team: 387 for cancer and 105 for benign disease. All colorectal surgical operations are included in the series. No selection of the patients was made: laparoscopy was performed in all cases accepting the procedure. Several risk factors have been analysed in cases of fistula (age, pathology sex, type of the operation, cancer stages, preoperative radiochemotherapy, stool diversion and team experience) and in cases of medical complications (age, pathology, cancer stages and type of operation). The overall results in this series of laparoscopic colorectal operated cases are similar to other results published at present by the main surgical Department all over the world; no mortality and low number of medical (2.4%) and surgical complications (9.3%), with no differences also with the best open surgery series. Complete or partial conversion to open surgery was required in few cases (1.2%) and same others (1.4%) were operated again for bleeding or sudden anastomotic leakage. Regarding the risk factors in such surgery, a good correlation has been discovered between anastomotic leakage and the team experience, the age over 70 of the patients, the rectal tumour site in man, the advanced tumour stages, the previous radiochemotherapy, while medical complications seem to depend on advanced patients age and advanced cancer stages. Laparoscopic colorectal surgery at present is going to be considered the gold standard in the large majority of colorectal diseases including all cancer stages in the preoperative balance and in the early postoperative follow-up a special attention is required to same risk factors like the advanced patients age, the extended cancers, the low positioned rectal tumours. Complications are more frequent at the beginning of the experience of the surgical team and if more than one risk factors coexist, but it do not represent contraindication to laparoscopic surgery.

Anti-TNF therapy in the injured spinal cord

Spinal cord injury (SCI) has a significant impact on the quality and expectancy of life. It also carries a heavy economic burden, with considerable costs associated with primary care and loss of income. The normal architecture of the spinal cord is radically disrupted by injury. After the initial insult, structure and function are lost through active secondary processes that involve reactive astrocytes, glial progenitors, microglia, macrophages, fibroblasts and Schwann cells. These cells produce chemokines and cytokines such as tumor necrosis factor (TNF)-α and interleukin (IL)-1β, which mediate the recruitment of inflammatory cells to the injury site. Targeting of these cytokines represents a potential strategy to reduce the secondary damage in SCI. In this review, we focus on several emerging strategies to neutralize TNF-α, including antibodies, soluble receptors, recombinant TNF-binding proteins, TNF receptor fusion proteins, and non-specific agents (e.g. thalidomide) and discuss their potential as therapy for SCI.

Laparoscopic management of sigmoidorectal intussusception

This case of sigmoidorectal intussusception was caused by a large tubovillous adenoma and managed with laparoscopic sigmoidectomy.

Adult intussusception is an uncommon entity. Surgical resection is required because of the high incidence of pathological lead point. We report a case of sigmoidorectal intussusception caused by a large tubulovillous adenoma. The patient underwent laparoscopic sigmoidectomy.

Laparoscopic liver resection for cancer

The field of laparoscopic liver resection surgery has rapidly evolved, with more than 1000 cases now reported. Laparoscopic hepatic resection was initially described for small, peripheral, benign lesions. Experienced teams are now performing laparoscopic anatomic resections for cancer. Operative times improved with experience. When compared with open cases, blood loss was less in most laparoscopic series, but was the main indication for conversion to an open procedure. Patients undergoing laparoscopic resection had shorter length of hospital stay and quicker recovery. Perioperative complications were comparable between the two approaches. Importantly, basic oncologic principles were maintained in the laparoscopic liver resections. The purpose of this review is to summarize the data available on outcomes for laparoscopic hepatic resection for cancer. This includes primary hepatocellular carcinoma, as well as metastatic colorectal cancer to the liver. The evidence to date suggests that laparoscopic results are comparable with the open approach in cancer patients.

Development of a Functional, Internet-Accessible Department of Surgery Outcomes Database

The need for surgical outcomes data is increasing due to pressure from insurance companies, patients, and the need for surgeons to keep their own “report card”. Current data management systems are limited by inability to stratify outcomes based on patients, surgeons, and differences in surgical technique. Surgeons along with research and informatics personnel from an academic, hospital-based Department of Surgery and a state university's Department of Information Technology formed a partnership to develop a dynamic, internet-based, clinical data warehouse. A five-component model was used: data dictionary development, web application creation, participating center education and management, statistics applications, and data interpretation. A data dictionary was developed from a list of data elements to address needs of research, quality assurance, industry, and centers of excellence. A user-friendly web interface was developed with menu-driven check boxes, multiple electronic data entry points, direct downloads from hospital billing information, and web-based patient portals. Data were collected on a Health Insurance Portability and Accountability Act-compliant server with a secure firewall. Protected health information was de-identified. Data management strategies included automated auditing, on-site training, a trouble-shooting hotline, and Institutional Review Board oversight. Real-time, daily, monthly, and quarterly data reports were generated. Fifty-eight publications and 109 abstracts have been generated from the database during its development and implementation. Seven national academic departments now use the database to track patient outcomes. The development of a robust surgical outcomes database requires a combination of clinical, informatics, and research expertise. Benefits of surgeon involvement in outcomes research include: tracking individual performance, patient safety, surgical research, legal defense, and the ability to provide accurate information to patient and payers.

Cecal lipoma with pseudomalignant features: A case report and review of the literature

Colonic lipoma is a well-documented benign neoplasia, endoscopically appearing as a smooth round yellowish polyp with a thick stalk or broad-based attachment. We describe a 63-year old woman with persistent abdominal pain, in whom colonoscopy revealed a cecal mass with malignant features. Based on the colonoscopy findings, right hemicolectomy was laparoscopically performed for a presumptive diagnosis of a cecal adenocarcinoma, but histological examination revealed a colonic lipoma with overlying mucosal ulceration.