Perirenal fat thickness as a predictor of postoperative complications after laparoscopic distal gastrectomy for gastric cancer

Background

Laparoscopic distal gastrectomy is used widely in surgery for gastric cancer. Excess visceral fat can limit the ability to dissect the suprapancreatic region, potentially increasing the risk of local complications, particularly pancreatic fistula. This study evaluated perirenal fat thickness as a surrogate for visceral fat to see whether this was related to complications after laparoscopic distal gastrectomy.

Methods

Perirenal fat thickness was measured dorsal to the left kidney as an indicator of visceral fat in patients with gastric cancer who underwent laparoscopic distal gastrectomy. Patients were divided into two groups: those with and those without complications. The relationship between perirenal fat thickness and postoperative complications was evaluated.

Results

The optimal cut‐off value for predicting morbidity using adipose tissue thickness was 10·7 mm; a distance equal to or greater than this was considered a positive perirenal fat thickness sign (PTS). A positive PTS showed a significant correlation with visceral fat area. Multivariable analysis found that a positive PTS was an independent risk factor for complications (hazard ratio 4·42, 95 per cent c.i. 2·31 to 8·86; P < 0·001).

Conclusion

Perirenal fat thickness as an indicator of visceral fat was an independent predictor of postoperative complications after laparoscopic distal gastrectomy for gastric cancer.

Laparoscopic proximal gastrectomy with double-flap technique versus laparoscopic subtotal gastrectomy for proximal early gastric cancer

Background

Laparoscopic proximal gastrectomy with double‐flap technique (LPG‐DFT) and laparoscopic subtotal gastrectomy (LSTG) may replace laparoscopic total gastrectomy (LTG) for proximal early gastric cancer. The aim of this study was to evaluate short‐ and long‐term outcomes after LPG‐DFT and LSTG.

Methods

Patients who underwent LPG‐DFT or LSTG at the Cancer Institute Hospital in Tokyo between January 2006 and April 2015 were included in this retrospective study. Operative procedures were selected based on the distance from the cardia to the proximal boundary of the tumour, tumour location and predicted remnant stomach volume. Patient characteristics, surgical data, markers of postoperative nutritional status, such as blood chemistry and bodyweight loss, and endoscopic findings were compared between procedures. The main study outcome was nutritional status.

Results

A total of 161 patients (LPG‐DFT 51, LSTG 110) were included. Types of postoperative complication occurring more than 30 days after surgery differed between the two procedures. Remnant stomach ulcers, including anastomotic ulcers, were observed only after LPG‐DFT, whereas complications involving the small intestine, such as internal hernia or small bowel obstruction, occurred more frequently after LSTG. Values for total protein, albumin, prealbumin and bodyweight loss were comparable between the two procedures at 36 months after surgery. Haemoglobin concentrations were higher after LPG‐DFT than after LSTG at 24 months (13·4 versus 12·8 g/dl respectively; P = 0·045) and 36 months (13·5 versus 12·8 g/dl; P = 0·007) after surgery. The rate of Los Angeles grade B or more severe reflux oesophagitis was comparable.

Conclusion

LPG‐DFT and LSTG for proximal early gastric cancer have similar outcomes, but different types of complication.

Randomized clinical trial comparing standard diet with perioperative oral immunonutrition in total gastrectomy for gastric cancer

BACKGROUND

Total gastrectomy for gastric cancer is associated with excessive weight loss and decreased calorie intake. Nutritional support using eicosapentaenoic acid modulates immune function and limits catabolism in patients with advanced cancer, but its impact in the perioperative period is unclear.

METHODS

This was a randomized phase III clinical trial of addition of eicosapentaenoic acid-rich nutrition to a standard diet in patients having total gastrectomy for gastric cancer. Patients were randomized to either a standard diet or standard diet with oral supplementation of an eicosapentaenoic acid (ProSure®), comprising 600 kcal with 2·2 g eicosapentaenoic acid, for 7 days before and 21 days after surgery. The primary endpoint was percentage bodyweight loss at 1 and 3 months after surgery.

RESULTS

Of 127 eligible patients, 126 were randomized; 124 patients (61 standard diet, 63 supplemented diet) were analysed for safety and 123 (60 standard diet, 63 supplemented diet) for efficacy. Across both groups, all but three patients underwent total gastrectomy with Roux-en-Y reconstruction. Background factors were well balanced between the groups. Median compliance with the supplement in the immunonutrition group was 100 per cent before and 54 per cent after surgery. The surgical morbidity rate was 13 per cent in patients who received a standard diet and 14 per cent among those with a supplemented diet. Median bodyweight loss at 1 month after gastrectomy was 8·7 per cent without dietary supplementation and 8·5 per cent with eicosapentaenoic acid enrichment (P = 0·818, adjusted P = 1·000). Similarly, there was no difference between groups in percentage bodyweight loss at 3 months (P = 0·529, adjusted P = 1·000).

CONCLUSION

Immunonutrition based on an eicosapentaenoic acid-enriched oral diet did not reduce bodyweight loss after total gastrectomy for gastric cancer compared with a standard diet. Registration number: UMIN000006380 ( http://www.umin.ac.jp/).

Role of Prealbumin as a Powerful and Simple Index for Predicting Postoperative Complications After Gastric Cancer Surgery

BACKGROUND

Preoperative factors, including nutritional status, may have strong correlations with postoperative morbidities. The current study evaluated preoperative prealbumin concentrations as a predictor of postoperative complications after gastric surgery.

METHODS

A retrospective study of 1798 patients who underwent gastrectomy for gastric adenocarcinoma was performed. Information was collected on basic patient characteristics, preoperative laboratory findings, and 30 day postoperative complications. The patients were divided into three groups based on prealbumin concentrations (≥22 mg/dL, <22 to ≥15 mg/dL, and <15 mg/dL) for analysis.

RESULTS

The overall complication rate was 21.7 %, and the infection rate was 16 %. Subgroup analysis based on prealbumin concentrations showed that complication rates were markedly elevated with decreasing concentrations of prealbumin. Multivariate analysis using a logistic regression model showed that both overall and infectious complications were strongly associated with male gender, elevated C-reactive protein (CRP), and decreased prealbumin levels (p < 0.05). Even in patients with a CRP level higher than 0.1 mg/dL, male gender and low prealbumin concentrations (<15 mg/dL) were significantly correlated with overall and infectious morbidities (p < 0.05).

CONCLUSIONS

Preoperative prealbumin concentrations are useful predictors of short-term postoperative outcomes after gastrectomy.

Proximal margin length with transhiatal gastrectomy for Siewert type II and III adenocarcinomas of the oesophagogastric junction

BACKGROUND

A gross proximal oesophageal margin greater than 5 cm is considered to be necessary for curative surgery of adenocarcinoma of the oesophagogastric junction. This study investigated whether a shorter proximal margin might suffice in the context of total gastrectomy for Siewert type II and III tumours.

METHODS

The gross proximal margin was measured on stretched specimens just after resection. Relationships between gross proximal margin lengths and clinicopathological features were investigated in patients with Siewert type II and III adenocarcinoma of the oesophagogastric junction treated by R0-1 surgical resection. For survival analyses, only patients who had undergone R0 resection for pathological (p) T2-4N0-3M0 tumour via a transhiatal approach were evaluated.

RESULTS

Of the 140 patients, 120 had a total gastrectomy. Two patients (1·4 per cent) had histologically positive proximal margins and another two (1·4 per cent) developed anastomotic recurrence. Of 100 patients with pT2-4N0-3M0 tumours who underwent gastrectomy via a transhiatal approach, those with gross proximal margins larger than 20 mm appeared to have better survival than those with shorter margins (P = 0·027). Multivariable analysis demonstrated that a gross proximal margin of 20 mm or less was an independent prognostic factor (hazard ratio (HR) 3·56, 95 per cent confidence interval 1·39 to 9·14; P = 0·008), as was pathological node status (HR 1·76, 1·08 to 2·86; P = 0·024).

CONCLUSION

Gross proximal margin lengths of more than 20 mm in resected specimens seem satisfactory for patients with type II and III adenocarcinoma of the oesophagogastric junction treated by transhiatal gastrectomy.

Lymphadenectomy around the left renal vein in Siewert type II adenocarcinoma of the oesophagogastric junction

BACKGROUND

The extent of lymphadenectomy in patients with Siewert type II adenocarcinoma of the oesophagogastric junction is controversial. The aim of this study was to investigate lymph node involvement around the left renal vein.

METHODS

Lymph node involvement and prognosis in patients with Siewert type II cancers treated by R0-1 surgical resection were investigated, with regard to lymphadenectomy around the left renal vein. Based on the incidence of involvement at each node, the node stations were divided into three tiers (first tier, more than 20 per cent involvement; second tier, 10-20 per cent involvement; third tier, less than 10 per cent involvement).

RESULTS

Of 150 patients with type II oesophagogastric adenocarcinoma, 94 had left renal vein lymphadenectomy. The first lymph node tier included nodes along the lesser curvature, right cardia, left cardia and left gastric artery, with involvement of 28·0-46·0 per cent and a 5-year survival rate of 42-53 per cent in patients with positive nodes. The nodes around the lower mediastinum, left renal vein, splenic artery and coeliac axis constituted the second tier, with involvement of 12·7-18 per cent and a 5-year survival rate of 11-35 per cent. With regard to the left renal vein, the incidence of involvement was 17 per cent and the 5-year rate survival rate was 19 per cent. Multivariable analysis showed that left renal vein lymphadenectomy was an independent prognostic factor in patients with pathological tumour category pathological T3-4 disease (hazard ratio 0·51, 95 per cent confidence interval 0·26 to 0·99; P = 0·048).

CONCLUSION

Left renal vein nodal involvement is similar to that seen along the splenic artery, in the lower mediastinum and coeliac axis, with similar impact on patient survival.

Prognostic importance of the inflammation-based Glasgow prognostic score in patients with gastric cancer

Background:

The inflammation-based Glasgow prognostic score (GPS) has been shown to be a prognostic factor for a variety of tumours. This study investigates the significance of the modified GPS (mGPS) for the prognosis of patients with gastric cancer.

Methods:

The mGPS (0=C-reactive protein (CRP)⩽10 mg l⁻¹, 1=CRP>10 mg l⁻¹ and 2=CRP>10 mg l⁻¹ and albumin<35 g l⁻¹) was calculated on the basis of preoperative data for 1710 patients with gastric cancer who underwent surgery between January 2000 and December 2007. Patients were given an mGPS of 0, 1 or 2. The prognostic significance was analysed by univariate and multivariate analyses.

Results:

Increased mGPS was associated with male patient, old age, low body mass index, increased white cell count and neutrophils, elevated carcinoembryonic antigen and CA19-9 and advanced tumour stage. Kaplan–Meier analysis and log-rank test revealed that a higher mGPS predicted a higher risk of postoperative mortality in both relative early-stage (stage I; P<0.001) and advanced-stage cancer (stage II, III and IV; P<0.001). Multivariate analysis demonstrated the mGPS to be a risk factor for postoperative mortality (odds ratio 1.845; 95% confidence interval 1.184–2.875; P=0.007).

Conclusion:

The preoperative mGPS is a simple and useful prognostic factor for postoperative survival in patients with gastric cancer.

Learning curve of laparoscopy-assisted gastrectomy using a standardized surgical technique and an established educational system

BACKGROUND AND AIMS

The learning curve of a trainee for laparoscopy-assisted gastrectomy in a high volume center, in which an educational system and a standardized laparoscopic procedure are already established, remains unclear.

MATERIAL AND METHODS

The early surgical outcomes of the patients of two trainees were investigated. Both trainees followed a training program where they performed at least 20 cases being the camera assistant, 20 cases being the first assistant, before performing the surgery as an operator.

RESULTS

The average operation time, intraoperative bleeding, the number of retrieved lymph nodes, and morbidity rate were 240.2 min, 45.7 ml, 35.4, and 13.0%, respectively. There was no learning curve effect observed except with the operation time of one trainee.

CONCLUSIONS

In a high volume center with an established educational system, trainees could perform laparoscopy-assisted gastrectomy safely, although there might be a -learning curve effect in operation time and the surgeries took longer operation time in trainee's initial cases.

Standard of practice on laparoscopic gastric cancer surgery in Korea and Japan: experts' survey

INTRODUCTION

As the laparoscopic approach has become a popular gastric cancer treatment in Korea and Japan, the need for sharing current practices of surgeons who are experienced in laparoscopic gastric cancer surgery has increased.

METHODS

We sent a questionnaire on laparoscopic instruments, image documentation, preoperative evaluation, surgical indication, operative methods, and postoperative management to laparoscopic experts in Korea and Japan, and 24 (14 from Korea and 10 from Japan) responded.

RESULTS

Endoscopic ultrasound and preoperative endoscopy-guided clipping are routinely employed, respectively, by 14 (58%) and 20 (83%) of the surgeons. Surgeons perform laparoscopy-assisted distal gastrectomy (LADG) based on varying indications. Five surgeons (21%) performed LADG only for cases of stage T1 cancer, 15 (63%) performed LADG on patients with less than T2 lesions, and 4 (17%) performed LADG on patients with less than T3 lesions. With regard to postoperative anastomosis, 18 surgeons (75%) preferred extracorporeal anastomosis and 6 (25%) preferred intracorporeal anastomosis. The mean postoperative hospital stay was 6.5 days in Korea and 10.1 days in Japan (P < 0.001).

CONCLUSION

This survey can help to inform the current practice of laparoscopic gastric cancer surgery in Korea and Japan, where laparoscopic surgery is frequently performed.

Laparoscopy-assisted gastrectomy in patients with previous endoscopic resection for early gastric cancer

BACKGROUND

Some patients undergoing endoscopic resection for early gastric cancer need further surgical treatment to achieve cure. However, the influence of endoscopic resection on subsequent laparoscopy-assisted gastrectomy (LAG) remains unclear.

METHODS

A total of 711 patients who underwent LAG were analysed retrospectively; 111 patients had undergone endoscopic resection previously and the remaining 600 had no history of endoscopic resection. Patient characteristics, operative and postoperative outcomes were compared between the two groups. Risk factors associated with postoperative complications were analysed.

RESULTS

Duration of operation and blood loss were comparable between the two groups. Patients who had undergone endoscopic resection had fewer dissected lymph nodes and a lower rate of preservation of the coeliac branch of the vagus nerve, especially those who had LAG within 2 months after endoscopic resection. Early postoperative outcomes, including complications, gastrointestinal recovery and length of postoperative hospital stay, were not significantly different between the two groups. Previous endoscopic resection was not a risk factor for postoperative complications.

CONCLUSION

LAG can be performed safely even after endoscopic resection. Endoscopic resection might increase the difficulty of subsequent LAG, including lymph node dissection and preservation of the coeliac branch of the vagus nerve; however, it has little influence on early postoperative outcome.

Effect of individual fat areas on early surgical outcomes after open gastrectomy for gastric cancer

BACKGROUND

Obesity is generally considered a risk factor for postoperative morbidity following open gastrectomy. Body mass index (BMI) is widely accepted as an indicator of obesity, but does not necessarily reflect the distribution of fat. It is unclear how different types of fat may affect the operative procedure and outcome.

METHODS

The relationship between fat area (total, visceral and subcutaneous fat, and BMI) and early surgical outcomes (bleeding, operating time, morbidity, hospital death and hospital stay) was investigated in 135 patients who had a curative gastrectomy at the Cancer Institute Hospital, Tokyo, in 2006.

RESULTS

Postoperative intra-abdominal infection, which occurred in 13 patients (9.6 per cent), correlated strongly with visceral (P = 0.023) and total (P = 0.037) fat area. Visceral fat area also correlated with hospital death (P = 0.041) and a longer hospital stay (P = 0.001). Subcutaneous fat area and BMI did not correlate with these early surgical outcomes.

CONCLUSION

Patients with a high visceral fat area are more likely to develop an intra-abdominal infection after gastrectomy. Assessment of fat area, in particular visceral fat area, should alert surgeons to increased postoperative risks.

Can immune-enhancing nutrients reduce postoperative complications in patients undergoing esophageal surgery?

Postoperative infection of esophageal neoplasm surgery is the major cause of prolonged postoperative hospitalization, as well as morbidity. The clinical benefits of administering immune-enhancing nutrients (IEN) to critically ill patients and those undergoing elective surgery were clarified. However, the benefits of preoperative administration of IEN for patients with esophageal cancer remain unclear. The present study was designed to clarify the clinical efficacy of administration of IEN prior to esophageal surgery. A total of 123 patients undergoing esophagectomy in single institute were retrospectively investigated. All patients received postoperative enteral nutrition by use of ordinal nutrients. Preoperative IEN were also given to 84 patients (IEN group), while the other 39 received an ordinary diet (control). Postoperative courses and laboratory data were compared between the two groups. The incidences of infectious complications in the IEN and control groups were 18% and 38%, respectively (P < 0.05). Pneumonia developed in 5 (6%) IEN and 7 (18%) control patients (P < 0.05). Postoperative hospitalization was shorter in the IEN group (P < 0.01). Prealbumin levels, retinal binding protein levels and the lymphocyte count were significantly higher in the IEN group on postoperative day 3. These results suggest that preoperative administration of IEN in patients undergoing esophagectomy reduces infectious complications, mainly pneumonia, and shortens postoperative hospitalization.

Celiac lymph nodes: distant or regional for thoracic esophageal carcinoma?

Involvement of celiac nodes is defined as distant metastasis in the TNM classification for thoracic esophageal carcinoma. Some textbooks, however, describe dissection of these nodes as a standard technique. The present study was, therefore, undertaken to clarify which celiac nodes are regional for thoracic esophageal carcinoma and whether or not celiac node dissection would provide a survival benefit. Eight hundred and five patients who underwent R0 resection (no residual tumor) with systematic lymphadenectomy including the celiac axis area for thoracic esophageal carcinoma were retrospectively investigated. The frequency of metastasis and the therapeutic value of dissecting celiac nodes were compared to those associated with the left gastric artery area. The frequencies of left gastric and celiac nodal involvement were 15.4% and 9.6%, respectively, for thoracic esophageal carcinoma. As for tumor location, the incidences of metastasis around left gastric artery and celiac axis from the upper, middle and lower portion were 6.7% and 1.0%; 12.3% and 7.7%; and 25.7% and 17.4%, respectively. The 5-year survivals of patients with celiac but not left gastric metastasis were 36.3% and 41.8% for the middle and lower portions, respectively, while the corresponding values with left gastric involvement but no celiac metastasis were 24.1% and 27.9%. These differences were not significant. The frequency of celiac node involvement was not low. And, their dissection has equivalent therapeutic value to that of left gastric nodes. Revision of the TNM classification to account for celiac node involvement in thoracic esophageal carcinoma, especially of the middle and lower portions, is needed.

Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection

BACKGROUND

Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. This study aimed to introduce a laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection that is applicable for submucosal tumor resection independent of tumor location and size.

METHODS

Seven patients underwent LECS for the resection of gastric submucosal tumors. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device.

RESULTS

In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In four of seven cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The remaining three tumors were in the posterior gastric wall. In two cases, the tumors were more than 5 cm in diameter, and one was a GIST of the remnant stomach. The mean operation time was 169 +/- 17 min, and the estimated blood loss was 7 +/- 2 ml. The postoperative course was uneventful in all cases.

CONCLUSIONS

The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.

Manipulation of the small intestine as a cause of the increased inflammatory response after open compared with laparoscopic surgery

BACKGROUND

Laparoscopic surgery of the gastrointestinal tract involves a reduced immune response compared with open surgery. The aim of this study was to assess manual handling of the gut in open procedures as the principal cause of the enhanced immune response.

METHODS

Eighteen Landrace pigs underwent gastrectomy by three different methods: conventional open wound with bowel manipulation, laparoscopically assisted gastrectomy, and gastrectomy without manipulation using a combination of open wound and laparoscopic surgical devices. Local inflammatory changes were assessed by ascites formation, intestinal adhesion development and intestinal inflammatory gene expression. Associated systemic inflammatory changes were determined by measuring portal and systemic plasma endotoxin levels, plasma inflammatory cytokine levels, liver inflammatory gene expression and transaminase levels.

RESULTS

Significantly more postoperative intra-abdominal fluid and adhesions were seen in the open group. The expression of inflammatory cytokines was significantly greater in the intestine and liver in the open group. Portal and systemic levels of endotoxin, inflammatory cytokines and transaminases were also higher.

CONCLUSION

Manual handling of organs during gastrectomy is an important contributor to the molecular and humoral inflammatory response to surgery, supporting the use of minimally invasive techniques in gastrointestinal surgery.

A seasonal variation in the onset of postoperative adhesive small bowel obstruction is related to changes in the climate

BACKGROUND

Postoperative small bowel obstruction following abdominal procedures is more common in patients who have undergone laparotomy. However, little is known about the influence of climate on the incidence of postoperative small bowel obstruction.

METHODS

To evaluate whether seasonal climatic variations are a risk factor for postoperative small bowel obstruction, hospital-based, retrospective case series was designed from medical records of 230 patients suffering from postoperative small bowel obstruction admitted to the Tokyo University Branch Hospital. Detailed analysis of weather charts from the Japanese Meteorological Agency and review of medical records for selected patients who were diagnosed with postoperative small bowel obstruction. The obstruction was diagnosed by abdominal X-ray imaging, clinical examination, and patient interviews.

RESULTS

A total of 233 patients diagnosed with postoperative small bowel obstruction were identified. Analysis of the medical records of these 233 patients revealed that the variables associated with an increased risk of postoperative small bowel obstruction included low ambient temperatures of 5-10 degrees C, an increase in air humidity by 40-50% and air pressure of 1010-1015 hPa.

CONCLUSION

The typical winter weather in Tokyo is characterised by low temperatures, low humidity and moderate air pressure. These winter climate conditions could be correlated with an increased incidence of postoperative small bowel obstruction in Tokyo during our period.

Gender differences in cytokine secretion by human peripheral blood mononuclear cells: role of estrogen in modulating LPS-induced cytokine secretion in an ex vivo septic model

Clinical studies demonstrate a better outcome of sepsis in females. Elevated estrogen levels and plasma cytokine imbalance occur in septic patients. We propose that gender-different cytokine secretion by the peripheral blood mononuclear cells (PBMCs) in sepsis determines the clinical outcome. A 2 x 10(6) PBMC sample from healthy volunteers (10 males and 10 females) was incubated with 1 ng/mL of lipopolysaccharide (LPS), estradiol (E2; 0, 0.03, 0.3, 3.0, 30 ng/mL), or 1 ng/mL of LPS + E2 (0, 0.03, 0.3, 3.0, 30 ng/ml), and supernatant cytokine levels were measured. Tumor necrosis factor alpha (TNF alpha) and interleukin (IL)-6 production by PBMCs from both sexes was time-dependently stimulated by LPS. At 6 h after LPS challenge, the TNF alpha level of male PBMCs was significantly higher but IL-6 secretion by female PBMCs was higher (two-way ANOVA: P < 0.05). E2 alone stimulated cytokine secretion by male PBMCs. Addition of the same E2 concentration as in sepsis patients' plasma modulated LPS-induced cytokine production. No significant sex differences in LPS-stimulated TNF alpha or IL-6 secretion by PBMCs were found, but IL-10 secretion by male PBMCs was significantly suppressed. This study demonstrated a gender difference in PBMCs responsiveness to LPS and E2 stimulation and E2-modulated cytokine secretion. In this PBMCs model of sepsis, only the supernatant IL-10 level was significantly lower in males. These ex vivo findings may partially explain the mechanism underlying the poorer outcome of male sepsis patients.

CD31 expression on leukocytes is downregulated in vivo during hemodialysis

BACKGROUND/AIM

CD31 on leukocytes is the adhesion molecule involved in the leukocyte extravasation in inflammatory conditions. During hemodialysis with cellulosic membranes, it is considered that activated leukocytes adhere to endothelium, but do not show extravasation. However, it is not elucidated why activated leukocytes do not show endothelial transmigration during hemodialysis with cellulosic membranes.

METHODS

In the present study, changes in the expressions of Mac-1 and CD31 on granulocytes and monocytes were analyzed by flow cytometry during hemodialysis in 7 patients treated with regenerated-cellulose (RC) membranes and next with polysulfone (PS) membranes.

RESULTS

During dialysis with RC, Mac-1 expressions on granulocytes and monocytes both significantly increased as compared with predialysis values and across the dialyzer. During dialysis with RC, the CD31 expression on granulocytes and monocytes significantly decreased as compared with predialysis values. During dialysis with PS, changes in Mac-1 and CD31 expressions on granulocytes and monocytes were smaller than those during dialysis with RC.

CONCLUSIONS

Decreased CD31 expression on leukocytes may affect leukocyte function more in patients chronically hemodialyzed with RC than in those hemodialyzed with PS, since CD31 is important in leukocyte transendothelial migration in inflammatory conditions.

Pathophysiological relevance of the CD14 receptor in surgical patients: biological activity of endotoxin is regulated by the CD14 receptor

Endotoxins (lipopolysaccharides, LPSs) are potent bacterial poisons, and they are always present in the intestine in considerable numbers. Stress, such that as a resulting from multiple injuries, burns, hypovolemia, hypoxia, intestinal ischemia, and surgery can lead to a breakdown of the gut barrier, allowing endotoxins to enter the systemic circulation via translocation. However, estimating the biological activity of translocated circulating endotoxins and identification of the mechanisms regulating their biological activities remain complex problems. CD14 has been found to exist as a soluble protein in the serum and as a glycosylphosphatidylinositol (GPI)-anchored protein of myeloid lineage cells. It plays key roles in both LPS-induced activation and in LPS internalization by cells. In this article, we outline: (i) the biological activity of circulating endotoxin; and (ii) the role of membrane and/or soluble CD14 regulating the bioactivity of circulating endotoxin in a human model of postoperative endotoxemia.

Ischaemic preconditioning ameliorates functional disturbance and impaired renal perfusion in rat ischaemia-reperfused kidneys

1. The effects of ischaemic preconditioning (IP) on renal function, haemodynamics and lipid peroxidation in the rat ischaemia-reperfused kidney model were examined. 2. In Wistar male rats, application of a single or three periods of 5 min bilateral renal ischaemia was performed prior to 30 min bilateral ischaemia and 90 min reperfusion (IR). The glomerular filtration rate (GFR) was estimated in terms of inulin clearance. Fractional excretion of sodium (FE(Na)) and lithium (FE(Li)), indicating total and proximal tubular sodium handling, respectively, was also measured and renal blood flow was monitored throughout the experiment. In addition, renal lipid peroxidation (LPO) levels in reperfused kidneys were evaluated. 3. A 2.8-fold increase in recovery of GFR (P < 0.005), a 50% reduction in FE(Na) (P < 0.005) and a 40% decrease in FE(Li) (P < 0.05) after IR resulted from the single period of 5 min IP. Renal blood flow was also higher than that in the control group (P < 0.01). No change of LPO levels was observed. 4. We conclude that IP may have an ability to ameliorate reperfused renal function and haemodynamics with a suitable period of preconditioned ischaemia, although this effect is independent of LPO.

Catecholamine and cytokine response to laparoscopic adrenalectomy in patients with pheochromocytoma

This study assesses the surgical stress of laparoscopic adrenalectomy (LA) in patients with pheochromocytoma using catecholamine and cytokine. The study was conducted on one patient who had laparoscopic adrenalectomy performed for pheochromocytoma, and three patients as controls who had undergone laparoscopic cholecystectomy (LC) for cholecystolithiasis. Catecholamines, tumor necrosis factor alpha (TNFalpha) and interleukin 6 (IL-6) were measured at 30-minute intervals intraoperatively, and on the first, third and fifth postoperative days (POD) respectively. Plasma TNFalpha and IL-6 were measured by a commercially available sandwich enzyme-linked immunosorbent assay test. During the operation. changes of catecholamine concentration in LA were far larger than those in LC. The changes of TNFalpha concentration in LA were also larger than those in LC. TNFalpha returned to basal value at the end of the operation in LC, but it did not in LA. TNFalpha concentration in LC changed a little after the surgery, whereas that in LA sharply increased and was maintained at a high level from 1 POD until 5 POD. Enhanced cytokine responses were observed in LA compared to LC during and after the surgery. We concluded that laparoscopic adrenalectomy may give those patients with pheochromocytoma more surgical stress than laparoscopic cholecystectomy for cholecystolithiasis, during and after the operation.

Endotoxin and antiendotoxin antibodies in patients with acute pancreatitis

OBJECTIVE

To elucidate the time course of endotoxaemia and antiendotoxin antibodies in patients with acute pancreatitis.

DESIGN

Prospective clinical study.

SETTING

University hospital, Germany.

SUBJECTS

25 patients with oedematous (n = 9) or necrotising (n = 16) pancreatitis, and 20 healthy controls.

MAIN OUTCOME MEASURES

Concentrations of endotoxin and immunoglobulins (classes G, M, and A) directed at two lipid A molecules, four lipopolysaccharides, and alpha-haemolysin of Staphylococcus aureus measurements in plasma during a 12 day period.

RESULTS

There were no differences in the degree of endotoxaemia between patients with oedematous and necrotising pancreatitis on admission. However, from the day after admission and throughout the observation period patients with necrotising pancreatitis had significantly higher concentrations of endotoxin than those with oedematous pancreatitis. Concentrations of IgM specific for endotoxin peaked at day 4, and then decreased in patients with oedematous pancreatitis while remaining high for those with necrotising pancreatitis. There was only a slight increase in IgA specific for endotoxin, and IgG and immunoglobulins to gamma-haemolysin remained steady throughout the observation period. There was strong cross-reactivity (r > 0.7) between IgM specific for endotoxin (70%), but this was less with IgA (52%), and IgG (20%).

CONCLUSIONS

Necrotising pancreatitis is accompanied by persistent endotoxaemia with an extended rise in antiendotoxin antibodies. Patients with oedematous pancreatitis have a transient endotoxaemia with a temporary increase of Ig specific for endotoxin. Endotoxin stimulates the synthesis of specific antibodies (IgM) despite general immunosuppression.

Release of endotoxin-binding proteins during major elective surgery: role of soluble CD14 in phagocytic activation

Our previous study demonstrated that soluble CD14 (sCD14) modulates the biologic activity of circulating endotoxin, which appears after surgery. In this study, we examined the behavior of endotoxin-binding proteins, such as sCD14, lipopolysaccharide-binding protein (LBP), and bactericidal/permeability-increasing protein (BPI), in patients' plasma after major abdominal surgery and the phagocytic secretion of sCD14 from peripheral blood mononuclear cells (PBMCs) throughout the observation period. In a prospective study, 15 patients undergoing major abdominal surgery (gastrectomy, n = 3; pancreatectomy, n = 10: colectomy, n = 2) were involved in this study. The endotoxin-binding proteins were perioperatively (preoperatively; postoperative hour 6; days 1, 2, 3, 4, 5, 7, and 10) measured by an enzyme-linked immunosorbent assay (ELISA). To exclude the hemodilution effect of samples, each parameter was corrected by dividing the respective value by the albumin concentration. The phagocytic activity at each time point was tested as an ex vivo sCD14 secretion from PBMCs in the presence and absence of exogenously added endotoxin, Escherichia coli 055B5 (1 ng/ml). Significant endotoxemia (0.35 +/- 0.13 EU/ml; p < 0.05) was observed 6 hours after the beginning of surgery. The sCD14/albumin value rapidly increased at 6 hours after surgery, peaked on day 1, and sequentially declined, whereas the BPI/albumin and LBP/albumin ratios increased more gradually and peaked on day 2. The secretion of sCD14 from 2 x 10(6) PBMCs was significantly enhanced from 6 hours after operation. The increased plasma level of sCD14 may be explained by the parallel-enhanced sCD14 PBMC production. Activated secretion of these endotoxin-binding proteins may play a role in regulating the biologic activity of circulating endotoxin.

Changes in endotoxin-binding proteins during major elective surgery: important role for soluble CD14 in regulation of biological activity of systemic endotoxin

Assessment of circulating endotoxin during the perioperative period, which is only demonstrated by the Limulus amebocyte lysate (LAL) test, may be modulated by several endotoxin-binding proteins. Endotoxin-neutralizing capacity (ENC) and the plasma levels of soluble CD14 (sCD14), lipopolysaccharide-binding protein, and bactericidal/permeability-increasing protein (BPI) were determined in 40 patients 6 h prior to skin incision for major abdominal surgery. The bioactivity of plasma endotoxin was tested by the polymyxin B-inhibited stimulatory activity of the plasma samples on healthy monocytes as measured by the release of tumor necrosis factor alpha. Plasma endotoxin levels in almost all patients increased from 0.05 +/- 0.01 to 0.23 +/- 0.03 experimental units (EU) per ml (P < 0.001); more specifically, 17 of 40 samples showed endotoxin levels of greater than 0.2 EU per ml and corresponding reductions in ENC. Soluble CD14 plasma levels were decreased from 5. 6 +/- 0.3 to 4.6 +/- 0.3 microg per ml (P < 0.05). ENC was strongly correlated with the sCD14 plasma concentration throughout the period of observation. The addition of sCD14-neutralizing monoclonal anti-sCD14 antibodies reduced ENC both pre- and postoperatively. No correlation could be established between ENC and the plasma levels of BPI, high-density lipoproteins, or low-density lipoproteins determined by measuring the concentrations of apoprotein A and apoprotein B. Biologically active endotoxin was found in only 6 of 17 samples with endotoxin levels greater than 0.2 EU per ml in the LAL test. These samples could be characterized by their perioperative loss of at least 35% of their sCD14. No change in sCD14 was detected in the remaining 11 samples. The perioperative loss of ENC is partly caused by the loss of sCD14 resulting from its consumption by endotoxin reaching the bloodstream. This study demonstrated the role of sCD14 on the bioactivity of circulating endotoxin in a human model of endotoxemia after major abdominal surgery.

Tumor of the ampulla of Vater: experience with local or radical resection in 171 consecutively treated patients

HYPOTHESIS

This study was designed to evaluate prospectively oncological factors determining survival after resection of tumors of the papilla, comparing local and radical oncological resection. We hypothesized that, in malignant lesions of the ampulla, the T and N stages are major determinants of the patient's long-term outcome.

BACKGROUND DATA

The frequency of malignant lesions in adenomas of the papilla is about 26%. Villous adenoma of the ampulla is considered a premalignant lesion. Local excision has been recommended for benign adenoma and pancreatoduodenectomy for malignant lesions.

PATIENTS AND METHODS

From January 1, 1982, through June 30, 1997, 171 patients with tumors of the ampulla of Vater were surgically treated. Demographics, intraoperative factors, tumor pathological findings, and postoperative short- and long-term follow-up data were documented prospectively. Of the patients, 45 had adenoma of the papilla and 126 had malignant lesions of the ampulla.

RESULTS

Local resection was performed in 40 of the 45 patients with adenoma. In 98 of the 126 patients with malignant lesions, a radical Kausch-Whipple resection or pylorus-preserving pancreatoduodenectomy was used. Of the patients with benign adenoma, 40 had local resection and 5 had pylorus-preserving pancreatic head resection, with a hospital mortality of 0%. Thirty of 35 patients had villous adenoma, 9 (30%) of the 30 with severe dysplasia. Of the 126 patients with malignant lesions, 98 had partial pancreatoduodenectomy and 10 had ampullectomy, with an overall hospital mortality of 3.1% for patients who underwent resection. Seventy-eight of the 98 patients had an R0 resection. The 5-year survival probability for all patients who underwent resection was 84% for cancer stage I, 70% for stage II, and 27% for stage III. In 8 patients with villous adenoma and carcinoma in situ and in 10 patients with cancer in the adenoma, ampullectomy with local lymph node dissection was performed. In 4 of the patients who had villous adenoma and a carcinoma in stage pT1 N0, an R0 resection was performed, resulting in cure of cancer. On the basis of a multivariate regression analysis, the prognosis after oncological resection of cancer of the ampulla is determined by the absence of lymph node metastasis (P<.05), the absence of infiltration into the pancreatic head tissue (P<.05), and the application of an R0 resection.

CONCLUSIONS

In patients with villous adenoma of the ampulla, ampullectomy was an adequate surgical treatment. In patients with a low-risk cancer in stages pTis and pT1 N0 M0, G1 or G2, a local resection with ampullectomy including local lymph node dissection is justified. An oncological resection of cancer of the ampulla by means of a pylorus-preserving partial pancreatoduodenectomy or the Kausch-Whipple resection is the surgical procedure of choice; the 3- and 5-year survival rates were 72% and 52%, respectively, in patients with R0 resections.

Endotoxin binding and elimination by monocytes: secretion of soluble CD14 represents an inducible mechanism counteracting reduced expression of membrane CD14 in patients with sepsis and in a patient with paroxysmal nocturnal hemoglobinuria

Little is known about the role of peripheral blood mononuclear cells (PBMCs) in lipopolysaccharide (LPS) elimination. We studied the endotoxin elimination capacities (EEC) of PBMCs of 15 healthy volunteers, 13 patients with sepsis, and 1 patient suffering from paroxysmal nocturnal hemoglobinuria (PNH). Although expression of CD14, the best-characterized receptor for LPS to date, was reduced from 93.6% +/- 0.8% in healthy subjects to 50.5% +/- 6.5% in patients with sepsis and was 0.3% in a patient with septic PNH, EEC were found to be unchanged. There was no difference in the amount of tumor necrosis factor alpha (TNF-alpha) released by PBMCs of healthy donors and patients with sepsis. Anti-CD14 antibodies (MEM-18) completely suppressed EEC, binding of fluorescein isothiocyanate-labeled LPS to monocytes as determined by FACScan analysis, and TNF-alpha release in all three groups studied. The concentrations of soluble CD14 (sCD14) secreted by endotoxin-stimulated PBMCs from healthy donors and patients with sepsis amounted to 4.5 +/- 0.4 and 20.1 +/- 1.8 ng/ml, respectively. Based on our results, we suggest that PBMCs eliminate LPS by at least two different mechanisms; in healthy subjects, the membrane CD14 (mCD14) receptor is the most important factor for LPS elimination, while in patients with sepsis (including the septic state of PNH), increased sCD14 participates in LPS elimination. Secretion of sCD14 is strongly enhanced under conditions of low expression of mCD14 in order to counteract the reduction of mCD14 and maintain the function of monocytes. This sCD14 may substitute the role of mCD14 in LPS elimination during sepsis. The elimination of LPS by PBMCs correlates with the binding reaction and the secretion of TNF-alpha.

Atrial natriuretic peptide has no potential to protect against endotoxin-induced acute renal failure in the absence of renal nerves

Atrial natriuretic peptide (ANP) has been shown to have the potential to restore renal function after ischemic injury, an underlying component of endotoxin (Et)-induced acute renal failure, and is known to counteract renal sympathetic nerve activity in renal function. We have recently found that renal denervation restores the Et-induced renal dysfunction. The purpose of this study was to examine effects of ANP infusion on the Et-induced acute renal failure in the absence of renal nerves. Ten to 14 days after bilateral renal denervation (DNX), Wistar rats (250 to 300 g body wt) were used in the acute experiment. Rats with intact renal nerves (INN) served as controls. Following control clearance measurements, rats were intravenously injected with 4 mg/kg Et (Escherichia coli, 055: B5). During endotoxemia, rats were infused with 10 microg/kg/h ANP or saline vehicle. Et injection reduced the glomerular filtration rate (GFR) significantly in saline-infused INN and DNX rats. ANP infusion restored the greatly reduced GFR to the pre-endotoxemia level in DNX rats but not in INN rats. There was significant difference between the ANP- and saline-infused DNX rats in the percentage change relative to the basal GFR value during the ANP infusion period. ANP infusion did not improve the hyponatriuresis and oliguria after Et administration, which is independent of renal nerves. In conclusion, ANP infusion has a minor reno-protective effect in rats with Et-induced acute renal failure in the absence of the renal nerves.

Effect of renal denervation on phosphate excretion in endotoxemic rats

Our previous studies showed that endotoxin (Et) administration causes hypophosphaturia in the presence of PTH. In this study, we tested the hypothesis that enhanced renal nerve activity during endotoxemia is responsible for hypophosphaturia. Two weeks after bilateral renal denervation, phosphate excretion was examined in endotoxemic Wistar rats (300 g body weight). Renal clearance studies were performed before and after 4 mg/kg body weight Escherichia coli Et administration. Et administration resulted in a marked fall in glomerular filtration rates of innervated rats (n=12, from 2.09 +/- 0.11 ml/min to 0.89 +/- 0.15 ml/min, P<0.005) compared to saline-treated innervated rats (n=7, from 1.98 +/- 0.19 ml/min to 1.76 +/- 0.16 ml/min). The glomerular filtration rate of renal denervated rats was the same for saline-treated rats (n=9, from 2.67 +/- 0.92 ml/min to 1.69 +/- 0.12 ml/min) and Et-treated rats (n=10, from 2.37 +/- 0.19 ml/min to 1.52 +/- 0.07 ml/min). Fractional phosphate excretion was significantly reduced after Et challenge in innervated rats (from 24.0 +/- 3.3% to 11.8 +/- 2.2%, P<0.0001) compared to saline injection in innervated rats (from 26.9 +/- 3.9% to 33.0 +/- 1.6%). Although renal denervation improved the hypophosphaturia in comparison to the innervated rats, fractional phosphate excretion was still lower in Et-treated rats (from 28.8 +/- 5.0% to 18.0 +/- 4.7%, P<0.005) than in saline-treated rats (from 30.2 +/- 6.1% to 38.7 +/- 4.2%). In conclusion, our data did not support the hypothesis that renal nerves have an important role in reducing renal phosphate excretion during acute endotoxemia.

Plasma concentrations of endotoxin and antiendotoxin antibodies in patients with multiple injuries: a prospective clinical study

OBJECTIVE

To investigate the time course of endotoxaemia and its effects on the synthesis of antiendotoxin antibodies in patients with multiple injuries.

DESIGN

Prospective clinical study.

SETTING

University hospital, Germany.

PATIENTS

40 Patients with multiple injuries and 20 healthy volunteers who served as controls.

INTERVENTIONS

Blood samples were collected up to 10 days after injury and the concentrations of endotoxin, antiendotoxin antibodies to four endotoxins, and for anti-alpha-haemolysin of Staphylococcus aureus were measured. The kinetics of endotoxaemia and antiendotoxin antibodies were investigated.

RESULTS

Endotoxaemia peaked 0-3 hours after injury at 0.425 EU/ml and decreased thereafter to 0.04 EU/ml within five days. Total concentrations of IgM, IgA, and IgG increased continuously after day 3 (p < 0.05), but the specific IgM response to all endotoxins was only temporary and the relative content of specific antibodies to all endotoxins peaked at day 3 (p < 0.05). Antiendotoxin antibodies of IgM class cross-reacted among themselves. There was no general increase in specific antiendotoxin antibodies of IgA and IgG class. The relative content of specific antibodies to alpha-haemolysin of S aureus of all classes of immunoglobulins (IgM, IgA, IgG) remained on the same level from day 0-10.

CONCLUSION

Multiple injuries are associated with early and temporary endotoxaemia which causes specific increases in antiendotoxin antibodies of the IgM-class. IgM antibodies to endotoxins cross-react among themselves.

Endotoxemia and specific antibody behavior against different endotoxins following multiple injuries

The aim of this study was to establish the incidence of endotoxemia and the influence of endotoxin on specific antibody response after multiple injury. Blood samples were collected from 39 patients (median Injury Severity Score: 20.5) at 0-3 and 6-12 hours, and 1, 3, 5, and 10 days after admission. The endotoxin plasma levels were high at the first time point (mean = 0.421 endotoxin units/mL) and decreased in the later course. Total immunoglobulin levels of IgM, IgG, or IgA were low and increased throughout the observation period. Specific antibodies of the IgM class against two lipid A and four lipopolysaccharide preparations increased transiently but significantly on day 3 and/or day 5. No changes of specific antibody content against endotoxin or lipid A was seen in the IgG or IgA class. The specific antibody content of the different classes against alpha-hemolysin of Staphylococcus aureus did not differ during 10 days after trauma. The specific antibodies of the IgM class reacted with all lipid A and LPS lipopolysaccharide preparations demonstrating cross-reactivity. These results suggest that endotoxin may be a specific stimulator of IgM antiendotoxin antibody secretion following trauma.