The Effect of Serotonin Inhibition on Initial Microvessel Hemostasis and Platelet Aggregation In Vivo

The role of serotonin (5-HT) in initial microvascular hemostasis is not fully understood. This study was made to evaluate the effect on hemostatic plug formation and laser-induced arteriolar microembolism of different substances which counteract the effect of 5-HT. Hemostatic plug formation time and stability was measured in the rabbit mesenteric microcirculation and laserinduced embolism in the rabbit ear chamber. Ketanserine, a selective 5-HT2-receptor blocker shortened arteriolar hemostatic plug formation time. Dihydroergotamine, an unselective blocker (with 5-HT- and α-adrenergic receptor affinity) increased venular hemostatic plug formation time and also decreased the hemostatic plug stability. Laser-induced platelet embolism was unaltered after both ketanserine and dihydroergotamine administration. The magnitude of these changes seems to exclude an important effect of 5-HT in initial microvessel hemostasis or on platelet activity.

Single-center nonrandomized clinical trial to assess the safety and efficacy of irreversible electroporation (IRE) ablation of liver tumors in humans: Short to mid-term results

INTRODUCTION

A single-center nonrandomized clinical trial was performed to assess the safety and efficacy of IRE ablation of liver tumors in humans.

METHODS

38 malignant liver tumors on 30 patients were treated with IRE between September 2011 and September 2014. Treatment was with curative intent, and the diagnoses were colorectal cancer with liver metastases (CRLM) (n = 23), hepatocellular carcinoma (HCC) (n = 8) and other metastasis (n = 7). Patients were selected when surgery, radiofrequency ablation (RFA) or microwave ablation (MWA) was not an option, and when they met inclusion criteria (tumor size < 3 cm, 1-2 tumors). Patients were followed-up at 1 and 6 months with a contrast-enhanced computed tomography (CE-CT), and contrast-enhanced ultrasound (CE-US) at 3 months.

RESULTS

Ablation success was defined as no evidence of residual tumor in the ablated area as confirmed by CE-CT and CE-US. At 3 months ablation success was 78.9%, and 65.8% at 6 months. There was no statistically significant difference between tumor volume (<5 cm³ vs >5 cm³, p = 0.518), and between diagnosis (CRLM vs HCC, p = 0.084) in terms of local recurrence. Complications were classified according to the standardized grading system of Society of Interventional Radiology (SIR). A minor complication occurred in six patients (20%), one patient (3.3%) suffered from a major complication (bile duct dilatation and stricture of the portal vein and bile duct). No mortalities occurred at 30 days.

CONCLUSIONS

IRE appears to be a safe treatment modality for a selected group of patients with liver tumors and offers high local tumor control at 3 and 6 months.

Is Positron Emission Tomography Using 18F-Fluorodeoxyglucose and 11C-Acetate Valuable in Diagnosing Indeterminate Pancreatic Masses?

Background:

It can be impossible to differentiate a mass forming chronic pancreatitis from adenocarcinoma of the pancreas using standard anatomical imaging. Positron emission tomography using 2-[18F] fluoro-2deoxy-D-glucose (18FDG-PET) and 1-[11C]-acetate (11C-acetate-PET) are methods taking advantage of the metabolic differences between benign and malignant tissues.

Aims:

To determine the diagnostic accuracy of 18FDG-PET and 11C-acetate-PET in indeterminate pancreatic masses.

Methods:

Twenty patients with an indeterminate mass of the head of the pancreas were prospectively studied. All patients underwent 18FDG-PET and eighteen of them 11C-acetate-PET. Scans were evaluated qualitatively and quantitatively; the later by using regional standardised uptake value (SUV). Final diagnosis was established using histopathologic evaluation of resected specimen or biopsy.

Results:

Adenocarcinoma was diagnosed in twelve patients and chronic pancreatitis in eight. Qualitative evaluation of 18FDG-PET imaging revealed three false negative and one false-positive results. The sensitivity, specificity, and diagnostic accuracy were 75 %, 88 %, and 80 %, respectively. The cut-off SUV to differentiate malignant from benign disease was 3,5 demonstrating a sensitivity of 91.7 % and a specificity of 75 %.

Conclusion:

18FDG-PET imaging could not confirm or exclude malignancy in indeterminate masses of the head of the pancreas with high sensitivity and diagnostic accuracy. 11C-acetate-PET provided no additional diagnostic benefits.

Microbial translocation and inflammatory response in patients with acute peritonitis

BACKGROUND

In peritonitis, increased production of cytokines and changes in the splanchnic cellular immune system may cause translocation of bacteria and endotoxins. The aims of this study were to assess the frequency of translocation and relate translocation to the immune response in patients with acute peritonitis.

METHODS

Patients with local (LP, n=20) or general peritonitis (GP, n=15) were compared with controls (C, n=12). Blood was obtained preoperatively for cultures, and analyses of endotoxin and cytokines (tumour necrosis factor-alpha, interleukins 6 and 10). Mesenteric lymph nodes (MLNs) were excised for culturing and immunohistochemistry using antibodies CD4, CD8 and CD68.

RESULTS

Positive blood and MLN cultures were not obtained in controls. DNA typing proved bacterial translocation in one patient with local and one patient with general peritonitis. Thus translocation was proven to occur in 6% of patients with peritonitis. Endotoxaemia was predominantly found in the GP group. Cytokines increased during peritonitis and more so in patients with GP than in those with LP. More CD8 and CD68 cells were found in MLNs from LP patients than in C patients and more CD4 and CD8 cells in LP patients than in GP patients. There was no significant difference in this regard between the GP and C groups.

CONCLUSIONS

Bacterial translocation occurs during acute peritonitis but seems to be fairly infrequent. Peritonitis causes significant inflammatory cellular reactions.

Musculoskeletal pain in Europe: its impact and a comparison of population and medical perceptions of treatment in eight European countries

OBJECTIVES

To describe the impact of musculoskeletal pain (MP); to compare management of MP by the population and by primary care physicians; and to identify misconceptions about treatment.

METHODS

5803 people with MP and 1483 primary care physicians, randomly selected, in eight European countries were interviewed by telephone. A structured questionnaire was used to ask about usual management of MP and perceived benefits and risks of treatment. Current health status (SF-12) was also assessed.

RESULTS

From primary care physicians' perceptions, MP appears to be well managed. All presenting patients are offered some form of treatment, 90% or more doctors are trying to improve patients' quality of life, and most are aware and concerned about the risks of treatment with NSAIDs. From a population perspective, up to 27% of people with pain do not seek medical help and of those who do, several wait months/years before seeing a doctor. 55% or fewer patients who have seen a doctor are currently receiving prescription treatment for their pain. Communication between doctors and patients is poor; few patients are given information about their condition; and many have misconceptions about treatment.

CONCLUSIONS

Management of MP is similar across eight European countries, but there is discordance between physician and patient perspectives of care. Some people with pain have never sought medical help despite being in constant/daily pain. Those who do seek help receive little written information or explanation and many have misperceptions about the benefits and risks of treatment that limit their ability to actively participate in decisions about their care.

Long-term results of antireflux surgery indicate the need for a randomized clinical trial

Background

Well conducted, comparative trials of laparoscopic versus open antireflux surgery with an adequate patient enrolment are few and they do not demonstrate obvious advantages for the laparoscopic approach except for a marginal gain in shorter hospital stay. The aim of this study was to compare the effectiveness of laparoscopic and open procedures.

Methods

Two unselected groups of 230 patients were identified through a register of all inpatient public care in Sweden. Outcomes of laparoscopic and open antireflux surgery were compared using a disease-specific questionnaire 4 years after operation.

Results

Failure and dissatisfaction were significantly more common in the laparoscopy group than among patients having conventional open surgery. Treatment failure rates were 29·0 and 14·6 per cent respectively (P = 0·004). Dissatisfaction rates were 15·0 and 7·0 per cent respectively (P = 0·005). There was no other questionnaire item for which the proportion of failures differed significantly between the two groups.

Conclusion

This study does not support the presumption that laparoscopic antireflux surgery is to be preferred to the open procedure. It is strongly recommended that a randomized controlled trial be conducted.

Laparoscopic antireflux surgery in routine hospital care

BACKGROUND

The frequency of antireflux surgery has tripled since laparoscopic techniques were introduced. In Sweden, laparoscopic antireflux surgery is often done at local hospitals with a very low annual number of patients. Many surgeons. who may have limited experience with conventional antireflux surgery, have started to perform laparoscopic antireflux procedures, in spite of the well-known fact that there is a long learning curve for laparoscopic antireflux surgery.

METHODS

A random sample of 225 of 660 patients operated on at high-volume and all 220 patients from low-volume hospitals were identified through a nation-wide register. Outcome 4 years after laparoscopic antireflux surgery was studied using a disease-specific questionnaire.

RESULTS

Treatment failures were more common in the high-volume group than among patients operated on at low-volume hospitals, 29.0% and 19.7%, respectively. In the high volume group, medication (specifically to relieve heartburn or acid regurgitation) was taken at least once a week and revisional surgery was found in 19.5% and 6.0%, respectively. Corresponding results in the low-volume group were 11.1% and 2.9%, respectively. None of these differences was statistically significant at the overall 0.05 level.

CONCLUSION

A failure rate of almost 30% at 4 years' follow-up for patients operated on at relatively high-volume hospitals was disappointing, despite the fact that these results are population-based. Hospitals are encouraged to provide accounts of their results in an effort to identify the reasons for treatment failures, and for the public to have access to more objective information on different therapeutic options.

Long-term results of antireflux surgery indicate the need for a randomized clinical trial

BACKGROUND

Well conducted, comparative trials of laparoscopic versus open antireflux surgery with an adequate patient enrollment are few and they do not demonstrate obvious advantages for the laparoscopic approach except for a marginal gain in shorter hospital stay. The aim of this study was to compare the effectiveness of laparoscopic and open procedures.

METHODS

Two unselected groups of 230 patients were identified through a register of all inpatient public care in Sweden. Outcomes of laparoscopic and open antireflux surgery were compared using a disease-specific questionnaire 4 years after operation.

RESULTS

Failure and dissatisfaction were significantly more common in the laparoscopy group than among patients having conventional open surgery. Treatment failure rates were 29.0 and 14.6 per cent respectively (P = 0.004). Dissatisfaction rates were 15.0 and 7.0 per cent respectively (P = 0.005). There was no other questionnaire item for which the proportion of failures differed significantly between the two groups.

CONCLUSION

This study does not support the presumption that laparoscopic antireflux surgery is to be preferred to the open procedure. It is strongly recommended that a randomized controlled trial be conducted.

Turn structures in CGRP C-terminal analogues promote stable arrangements of key residue side chains

The 37-amino acid calcitonin gene-related peptide (CGRP) is a potent endogenous vasodilator thought to be implicated in the genesis of migraine attack. CGRP antagonists may thus have therapeutic value for the treatment of migraine. The CGRP C-terminally derived peptide [D(31),P(34),F(35)]CGRP(27-37)-NH(2) was recently identified as a high-affinity hCGRP(1) receptor selective antagonist. Reasonable CGRP(1) affinity has also been demonstrated for several related analogues, including [D(31),A(34),F(35)]CGRP(27-37)-NH(2). In the study presented here, conformational and structural features in CGRP(27-37)-NH(2) analogues that are important for hCGRP(1) receptor binding were explored. Structure-activity studies carried out on [D(31),P(34),F(35)]CGRP(27-37)-NH(2) resulted in [D(31),P(34),F(35)]CGRP(30-37)-NH(2), the shortest reported CGRP C-terminal peptide analogue exhibiting reasonable hCGRP(1) receptor affinity (K(i) = 29.6 nM). Further removal of T(30) from the peptide's N-terminus greatly reduced receptor affinity from the nanomolar to micromolar range. Additional residues deemed critical for hCGRP(1) receptor binding were identified from an alanine scan of [A(34),F(35)]CGRP(28-37)-NH(2) and included V(32) and F(37). Replacement of the C-terminal amide in this same peptide with a carboxyl, furthermore, resulted in a greater than 50-fold reduction in hCGRP(1) affinity, thus suggesting a direct role for the amide moiety in receptor binding. The conformational properties of two classes of CGRP(27-37)-NH(2) peptides, [D(31),X(34),F(35)]CGRP(27-37)-NH(2) (X is A or P), were examined by NMR spectroscopy and molecular modeling. A beta-turn centered on P(29) was a notable feature consistently observed among active peptides in both series. This turn led to exposure of the critical T(30) residue to the surrounding environment. Peptides in the A(34) series were additionally characterized by a stable C-terminal helical turn that resulted in the three important residues (T(30), V(32), and F(37)) adopting consistent interspatial positions with respect to one another. Peptides in the P(34) series were comparatively more flexible at the C-terminus, although a large proportion of the [D(31),P(34),F(35)]CGRP(27-37)-NH(2) calculated conformers contained a gamma-turn centered on P(34). These results collectively suggest that turn structures at both the C-terminus and N-terminus of CGRP(27-37)-NH(2) analogues may help to appropriately orient critical residues (T(30), V(32), and F(37)) for hCGRP(1) receptor binding.

The Swedish Council on Technology Assessment in Health Care (SBU) systematic overview of chemotherapy effects in some major tumour types--summary and conclusions

This report by The Swedish Council on Technology Assessment in Health Care (SBU) reviews, classifies, and grades the scientific literature on cancer chemotherapy in some major tumour types, describes the practice of chemotherapy in Sweden, compares practice with scientific knowledge, and analyses the costs and cost-effectiveness of chemotherapy. The report is intended primarily for decision-makers at various levels, both practitioners and administrators. It is also of interest for the medical profession. The extensive body of scientific literature was reviewed according to strict criteria that reflected the scientific weight of the literature. Sixteen experts representing different disciplines (oncology, surgery, internal medicine, health economy and quality of life research) participated in the literature review. Each section was discussed within the project group and was reviewed by at least one, but usually two international researchers. Additional input was provided by national experts representing different scientific disciplines. For the final evaluation to be as close to the objective truth as possible, a concerted effort was made to guarantee objectivity and thorough assessment of current knowledge about the effects of chemotherapy on the selected cancers. The tumour types selected for this assessment include firstly those types where three investigations had shown an increased use of chemotherapy in Sweden during the latest decade. These were non-small cell lung cancer (NSCLC), gastric cancer, pancreatic cancer, colorectal cancer and urinary bladder cancer. Secondly, the two tumour types comprising the greatest number of patients treated with chemotherapy in Sweden, breast cancer and haematological malignancies, were included. Among the haematological malignancies, the most prevalent ones, acute myeloid leukaemia (AML), chronic lymphocytic leukaemia (CLL), Hodgkin's disease (HD), aggressive non-Hodgkin's lymphoma (NHL) of the large B-cell type and indolent NHL of follicular type were evaluated. These constitute about 75%, of all haematological malignancies. Thirdly, ovarian cancer was included since chemotherapy has been extensively used and since, at the time of the planning of this overview, a group of very expensive drugs, the taxanes, had preliminarily shown promising results. A wealth of scientific literature has been published on cancer therapy. The review presented in this report is limited to scientific studies judged to be important for evaluating chemotherapy efficacy. Assessments of the content and quality of these studies, and a critical summary of the results in all stages of the selected tumours, have never before been attempted in this way. However, similar comprehensive overviews of certain stages of the tumours have previously been made. These overviews were also critically evaluated. Totally 1,496 studies involving 558,743 patients were reviewed. The survey of practice of chemotherapy use involved all departments of surgery, urology, gynaecology, internal medicine including haematologic units, pulmonary medicine and general and gynaecologic oncology at 16 hospitals in two health care regions in Sweden, covering 39% of the Swedish population. During the 4 weeks of the survey, all patients with the diagnoses concerned who received chemotherapy were registered. The study included 1,590 patients. The working group's general conclusions are summarised in the following points: The literature on the effects of chemotherapy is extensive. Chemotherapy has a well-documented role in the curative and palliative treatment of patients with several types of cancer. The use of chemotherapy is of utmost importance for the possibility of cure in certain tumour types. In other tumours, chemotherapy increases the possibility of cure when added to local and regional treatments, particularly surgery. In the instances of no possibility of cure, chemotherapy may to a variable extent improve both patient survival and well-being. In Sweden chemotherapy is largely used in accordance with that documented in the scientific literature. The extent of both over- and under-treatment seems to be limited but cannot be excluded at the individual patient level. The literature-based knowledge is scientifically of lower quality in the most chemotherapy sensitive tumours than in tumours showing more limited sensitivity. In the more sensitive tumours, positive effects on a symptomatic stage and survival were seen several decades ago. In those days, clinical treatment studies did not fulfil the current high quality requirements. Small life-prolonging effects of chemotherapy are sometimes very well documented in large, high quality scientific studies. Some of these s

Economic burden of NSAID-induced gastropathy in Sweden

BACKGROUND

Gastrointestinal side effects carry a significant cost related to the use of NSAID medications.

METHODS

The economic burden of NSAID-induced gastric side effects is estimated using the cost-of-illness methodology. Costs are calculated using both a prevalence (top-down) approach and an incidence (bottom-up) approach.

RESULTS

Using the top-down approach, the total cost in 1998 of NSAID-induced ulcers was MSEK 329-586, direct costs accounting for 76%-83%. The bottom-up approach gives an estimate of MSEK 320, of which MSEK 290 was direct cost. About one-quarter of total costs for ulcer disease can be attributed to the use of NSAIDs.

CONCLUSIONS

Gastrointestinal side effects carry a significant cost from the use of NSAIDs, costs that are as important as the price of NSAIDs. This should be considered when choice of drug and prophylaxis is being made.

Immune cell distribution in gut-associated lymphoid tissue and synthesis of IL-6 in experimental porcine peritonitis

This study aimed to evaluate the possibility to detect early changes in gut-associated lymphoid tissue related to an inflammatory response. Anaesthetised pigs were subjected to faecal peritonitis (n = 9) or to a sham procedure (n = 8). Blood from the vena cava and the superior mesenteric vein was repeatedly sampled, and the levels of interleukin-6 (IL-6) were analysed. Biopsies of the small intestine and mesenteric lymph nodes (MLNs), harvested at 300 min, were incubated with monoclonal antibodies specific for CD2 (T lymphocytes), IgM (B lymphocytes) and CD11a/CD18 (leucocyte adhesion molecule). The number of positive (+) cells was scored. During peritonitis, IL-6 increased significantly. Compared to controls, the number of CD2+ cells decreased, IgM+ cells tended to increase and CD11a/CD18+ cells increased in the mucosa during peritonitis. In MLNs, the number of cells positive for all studied markers increased during peritonitis. We conclude that peritonitis causes an inflammatory response in the gut reflected by changes in the distribution of immune cells in gut-associated lymphoid tissue and release of IL-6 to venous blood.

The mesenteric hemodynamic response to circulatory shock: an overview

The mesenteric hemodynamic response to circulatory shock is characteristic and profound; this vasoconstrictive response disproportionately affects both the mesenteric organs and the organism as a whole. Vasoconstriction of post-capillary mesenteric venules and veins, mediated largely by the alpha-adrenergic receptors of the sympathetic nervous system, can effect an "autotransfusion" of up to 30% of the total circulating blood volume, supporting cardiac filling pressures ("preload"), and thereby sustaining cardiac output at virtually no cost in nutrient flow to the mesenteric organs. Under conditions of decreased cardiac output caused by cardiogenic or hypovolemic shock, selective vasoconstriction of the afferent mesenteric arterioles serves to sustain total systemic vascular resistance ("afterload"), thereby maintaining systemic arterial pressure and sustaining the perfusion of non-mesenteric organs at the expense of mesenteric organ perfusion (Cannon's "flight or fight" response). This markedly disproportionate response of the mesenteric resistance vessels is largely independent of the sympathetic nervous system and variably related to vasopressin, but mediated primarily by the renin-angiotensin axis. The extreme of this response can lead to gastric stress erosions, nonocclusive mesenteric ischemia, ischemic colitis, ischemic hepatitis, ischemic cholecystitis, and/or ischemic pancreatitis. Septic shock can produce decreased or increased mesenteric perfusion, but is characterized by an increased oxygen consumption that exceeds the capacity of mesenteric oxygen delivery, resulting in net ischemia and consequent tissue injury. Mesenteric organ injury from ischemia/reperfusion due to any form of shock can lead to a triggering of systemic inflammatory response syndrome, and ultimately to multiple organ dysfunction syndrome. The mesenteric vasculature is therefore a major target and a primary determinant of the systemic response to circulatory shock.

The Swedish ACCES model: predicting the health economic impact of celecoxib in patients with osteoarthritis or rheumatoid arthritis

The Arthritis Cost Consequence Evaluation System (ACCES) pharmacoeconomic model was used to evaluate the economic and health impact of the recent introduction of celecoxib for treatment of osteoarthritis (OA) and rheumatoid arthritis (RA) in Sweden. The model demonstrates that use of celecoxib can be expected to reduce the incidence of gastrointestinal adverse events, resource utilization and treatment costs. In a cost-effectiveness analysis, celecoxib demonstrated economic dominance (i.e. improved health at reduced cost) compared with the currently available alternatives for OA, and demonstrated economic dominance against a clinically relevant base-case scenario for RA. In sensitivity analyses, the results were shown to be relatively robust; celecoxib demonstrated economic dominance or favourable cost-effectiveness ratios in all analyses. Based on these data, it can be concluded that the use of celecoxib in Sweden will provide societal benefits by improving health care at reduced cost for patients with OA and RA.

Selective inhibitors of COX-2--are they safe for the stomach?

NSAIDs are widely used and beneficial for patients with inflammatory pain. However, NSAIDs cause significant adverse upper gastrointestinal effects, including increased mortality from serious ulcer complications. NSAIDs exert their anti-inflammatory effects by inhibiting the activity of the COX enzyme, which was recently shown to exist in two isoforms, a constitutive COX-1 and an inducible COX-2. The latter isoform is induced in inflammation, while the former is responsible for prostaglandin effects on platelet function and gastric mucosal defense. Two specific COX-2 inhibitors have recently been introduced into the market. The available data from clinical trials indicate that these new drugs have anti-inflammatory and analgesic effects similar to those of conventional NSAIDs, but reduced rates of adverse upper gastroduodenal effects, which are similar to those observed with placebo. This difference in rates of adverse effects might imply improved safety for patients requiring anti-inflammatory treatment. It has, however, to be kept in mind that specific COX-2 inhibitors lack cardiovascular protective effects. Considering the high consumption rate of NSAIDs to achieve pain relief in arthritis and other musculo-sceletal diseases, the reduced risk of gastrointestinal ulcers and ulcer complications may have a positive impact on population health and health economy.

Intramucosal pH and pCO(2) do not strictly correlate with intestinal energy metabolism in experimental peritonitis

This study aimed to investigate tissue hypoxia on the cellular level in sepsis. Eighteen pigs weighing 18-27 kg were studied. Intramucosal-arterial PCO(2) gradient (PCO(2)-gap) and intramucosal pH (pH(i)) were calculated using tonometry. A blind loop of the small intestine was constructed for repeated tissue biopsies to measure intestinal energy-related metabolites and lactate concentration. Six animals served as controls. In 12 animals, faecal peritonitis was induced. Six of these animals were studied without further interventions, while the others were resuscitated with dextran to maintain cardiac index at baseline level. Untreated peritonitis caused an increase in PCO(2)-gap and a drop in pH(i). The intestinal energy metabolism was not disturbed until the end of the experimental period, with a decreased energy charge value and a moderately increased lactate concentration. In peritonitis-dextran animals, PCO(2)-gap and pH(i) remained at baseline level and the energy metabolism was not disturbed. We conclude that in peritonitis, PCO(2)-gap - like pH(i) - can be influenced by other factors than strictly anaerobic tissue metabolism.

[Guidelines for management of patients with acute pancreatitis]

During recent years new concepts and methods have been introduced in the management of acute pancreatitis. Severity and risk of complications show wide variation. Outcome is also dependent on the physician's experience and on his local resources. In this light the Swedish Society of Upper Abdominal Surgery has elaborated national guidelines for management. Attention is paid to diagnosis, severity assessment and etiology. Furthermore, guidelines are offered for treatment of mild and severe pancreatitis, as well as for the management of pseudocysts. The role of multidisciplinary intensive care specialist teams in the management of severe disease is emphasized. The guidelines are supported by the Swedish Society of Gastroenterology, the Swedish Society of Gastroenterology, the Swedish Society of Anesthesiology and Intensive Care and by experts from other Nordic countries.

Antireflux surgery in Sweden, 1987-1997: a decade of change

BACKGROUND

The aim of this study was to analyse whether new therapeutic options--the introduction of proton-pump inhibitors (PPI) in 1989 and the laparoscopic technique in 1992--altered the surgical treatment of gastro-oesophageal reflux disease (GORD) in Sweden.

METHODS

Data obtained from the Centre for Epidemiology (EpC) on patients undergoing surgery for GORD from 1987 to 1997 was analysed, and the information was validated with a questionnaire to all surgical departments.

RESULTS

The questionnaire gave a response rate of 94%, and the figures corresponded well with those obtained from the EpC. In 1987, 456 antireflux procedures were performed. Ten years later this figure had increased to 1303. This approximately threefold increase started before the introduction of PPI and was even more pronounced during the following few years. The development of laparoscopic antireflux surgery did not alter this increase. In 1997, 76% of the procedures were performed laparoscopically. The fundoplication rate rose from 5.5 to 12.7 procedures/100,000 inhabitants. The rates varied greatly among different counties; 7 of 23 still had a fundoplication rate of less than 10 in 1997. The median number of procedures per hospital in 1997 was 10. Only two departments accomplished more than 50 antireflux procedures.

CONCLUSION

Within 5 years the laparoscopic technique replaced the open procedure as the method of choice. However, the increase in the frequency of antireflux surgery was apparent even before the introduction of laparoscopy.

Bacterial translocation in experimental shock is dependent on the strains in the intestinal flora

BACKGROUND

Enteric microorganisms are responsible for a significant proportion of post-surgical infections. Intestinal mucosal injury may permit translocation of bacteria and endotoxin. This study investigates translocation in peritonitis and ischemia/reperfusion by inoculating different bacterial species into the small intestine.

METHODS

Twenty-five pigs were monitored hemodynamically and divided into three groups: controls (C), ischemia/reperfusion (I/R), and peritonitis (P). Intramucosal pH (pHi) was calculated tonometrically. A perfusion tube was positioned in the ileum for inoculation of the bacterial strains. In a first study period a non-pathogenic bacterium was used, whereas Escherichia coli strains with known ability to translocate were used in a second. Blood and mesenteric lymph nodes (MLNs) were obtained for bacterial culture and endotoxin analyses.

RESULTS

Mesenteric arterial blood flow and pHi decreased in groups I/R and P. Endotoxin levels increased in these groups in period 1, whereas in period 2 an increase over time was only observed in group P. No bacterial translocation to blood or MLNs occurred in period 1. In period 2 bacteria translocated to MLNs in all animals, including controls. Translocation to central and/or mesenteric venous blood was found in all groups, but mainly in I/R and P. The incidence of mucosal injury was similar in the two periods.

CONCLUSIONS

Since positive blood and MLN samples were only found in period 2, we conclude that translocation of bacteria seems to be more dependent on the presence of translocating strains in the intestinal bacterial flora than on the mucosal insult.

Intraarterial chemoembolisation with lipiodol and epirubicin in hepatocellular cancer--improved survival in some patients?

BACKGROUND AND AIMS

Arterial chemoembolisation with lipiodol and a cytotoxic drug is reported to give equivocal results in irresectable primary hepatocellular cancer (HCC). In order to further elucidate the possible response to this treatment, we analysed the results of all patients with irresectable HCC treated with chemoembolisation at our hospital.

MATERIAL AND METHODS

58 consecutive patients with HCC were treated with lipiodolepirubicin chemoembolisation between February 1988 - October 1994 and followed until death or October 1998.

RESULTS

The average survival was 11.7 months and median survival was 6 months. 17 patients had only one treatment mostly due to death within 6 weeks after the first treatment. Patients with an open portal system at inclusion (50% of all) were found to have significantly increased survival after 6 and 12 months compared to those with portal obstruction. The subgroup of patients displaying a decrease in tumour size as judged by repeated CT scan 6 months after inclusion had significantly increased survival; all survived more than 12 months (median survival 30 months).

CONCLUSIONS

Chemoembolisation with lipiodol-epirubicin may have an impact on survival on selected patients with irresectable hepatocellular cancer. The treatment may justifiably be offered patients with an open portal venous system and without liver failure.

[Intestinal ischemia after abdominal aorta surgery. A dreaded complication surveyed by a combination of different methods]

The article consists of a review of findings in previously published reports on intestinal ischaemia after abdominal aortic surgery. In a combined cohort and case-control study of 2,824 patients from the Swedish vascular registry, the incidence of intestinal ischaemia was 2.8%. The independent risk factors identified were preoperative shock, emergency surgery, renal insufficiency, advanced age, operation at a regional hospital, aortabifemoral grafting, ligation of one or both internal iliac arteries, bleeding > 10 litres, and operating and cross-clamping time. Cardinal symptoms were unreliable predictors. Sigmoidoscopy was potentially diagnostic in 95 per cent of cases. In a clinical study of 34 patients, sigmoid colon pHi was highly predictive of ischaemic colitis and other life-threatening complications. In a por-cine model of ischaemic colitis, blood flow in the superior mesenteric artery, colonic pHi and histological mucosal damage were unaffected by dobutamine.

Intestinal ischemia -- the basics

INTRODUCTION

In this review the physiology of the intestinal circulation of importance for the understanding of intestinal ischemia is briefly outlined.

PERSPECTIVES

The potential threat of massive intestinal vasoconstriction causing nonocclusive intestinal ischemia is discussed, as is the clinical importance of the reperfusion component of the ischemic injury. The clinical causes of intestinal ischemia are outlined. The delay in the usual clinical diagnostic process and its severe consequences are emphasized. Emphasis is made to discuss the special situation with sigmoid gangrene following surgery for ruptured aortic aneurysm. Laparotomy upon clinical suspicion of intestinal ischemia is generally recommended. The various therapeutic surgical measures available if diagnosis is made before massive intestinal gangrene are discussed.

Intestinal blood flow and intramucosal pH in experimental peritonitis

BACKGROUND AND AIMS

Experimental peritonitis causes gut intramucosal acidosis indicating intramucosal ischemia. However, tissue acidosis may reflect other conditions than ischemia. An increased mucosal-arterial Pco2 difference ( Pco2-gap) is suggested to be a more adequate measure of tissue ischemia than intramucosal pH (pHi). This study was performed to elucidate whether keeping cardiac index (CI) and splanchnic blood flow normal or supranormal by administration of colloids and an inotropic drug could prevent the acidosis as well as reduce the Pco2-gap. A secondary aim was to study to what degree the low pHi in peritonitis really reflects ischemia.

SUBJECTS

24 anesthetized pigs (18-27 kg) divided into four groups.

MODELS

A Swan-Ganz catheter, transonic flow meters and catheters for blood sampling were applied. pHi was calculated using tonometry. Standardized fecal peritonitis was induced, except in controls. One peritonitis group was given dextran (Group P(DEX)) and another in addition dobutamine (Group PDOB) to keep CI normal or supranormal, respectively.

RESULTS

After 4 h, a significant drop in pHi was found in all peritonitis groups, most pronounced in untreated peritonitis (to 7.09+/-.02). Corresponding values in Group P(DEX) and Group P(DOB) were 7.22+/-.03 and 7.22+/-.01, respectively, and in controls 7.30+/-.02. The Pco2-gap and the mucosal-arterial [H+] difference ([H+]-gap) increased significantly in untreated peritonitis but did not increase in groups given dextran and dextran + dobutamine.

CONCLUSION

Maintaining CI in peritonitis attenuated the reduction in pHi and prevented the increased Pco2- and [H+]-gap. It seems justified from these data to conclude that the somewhat reduced pHi in treated peritonitis groups did not reflect tissue ischemia.

3D surface rendering of images from multiple MR pulse sequences in the pre-operative evaluation of hepatic lesions

PURPOSE

To develop a method for making three-dimensional (3D) reconstructions of liver vessels and hepatic lesions from different MR data sets.

MATERIAL AND METHODS

To reduce the time required for segmentation and reconstructions, we used T1, T2 and phase contrast angiography, optimised for liver, lesion and vessels respectively. Following segmentation and reconstruction, the different volumes were combined on the same workstation and presented to the surgeon.

RESULTS AND CONCLUSION

Segmentation and reconstruction took 1-2 h. To be able to combine the volumes from the different data sets, certain criteria had to be fulfilled: a) the field of view had to be constant; b) the same volume had to be scanned every time which meant that the slice thickness and the number of slices could be adjusted as long as the volume covered was the same; and c) the positioning of each volume had to be identical between every scan. The resulting 3D reconstruction gave the surgeon a clear appreciation of the different lesions and their relation to the different liver segments in the pre-operative planning of hepatic resections.

Laparoscopic common bile duct exploration

OBJECTIVE

To explore the feasibility of laparoscopic techniques for the removal of common bile duct (CBD) stones.

DESIGN

Retrospective analysis.

SETTING

University hospital, Sweden.

SUBJECTS

39 patients who underwent laparoscopic common bile duct exploration, either by a transcystic technique or by choledochotomy, between September 1992 and April 1995.

INTERVENTIONS

Cholecystectomy, intraoperative cholangiography, and removal of CBD-stones by a transcystic technique (n=22), laparoscopic choledocholithotomy (n=11), or after conversion to open choledocholithotomy (n=6).

MAIN OUTCOME MEASURES

Stone clearance rates, operative time, complications, and postoperative hospital stay.

RESULTS

Stone removal was achieved in 32/39 patients (82%) by a laparoscopic approach. Reasons for failure were early in our experience, and the result of technical difficulties or stones that were too large for the transcystic approach, or with impacted stones at choledochotomy. Postoperative morbidity was low (n=4, 10%) with no mortality.

CONCLUSIONS

Common bile duct stones can be removed in a large proportion of patients undergoing laparoscopic cholecystectomy, either by a laparoscopic transcystic technique or through a laparoscopic choledochotomy. The laparoscopic techniques need further evaluation, preferably in prospective multicentre trials comparing other treatment strategies including endoscopic sphincterotomy.

A survey of surgical treatment of gallstone disease and the diffusion of laparoscopic surgery in Sweden 1992-93

OBJECTIVE

To study the diffusion of laparoscopic biliary surgery in Sweden, 1992-93.

DESIGN

A prospective survey of all biliary surgery for gallstone disease recorded for 8 weeks in 1992 and the same period in 1993.

SETTING

All surgical departments in Sweden.

SUBJECTS

A consecutive series of 1938 patients in 1992 and 1748 patients in 1993.

MAIN OUTCOME MEASURES

The changing indications, diffusion, morbidity, mortality, postoperative and hospital stay after laparoscopic cholecystectomy (LC) in Sweden in 1992 compared with 1993.

RESULTS

Despite the spread of LC, the indications did not change between 1992 and 1993 (p=0.31). The total number of cholecystectomies decreased from 1938 in 1992 to 1748 in 1993. The overall percentage of laparoscopic cholecystectomies (LCs) increased from 74.7% to 81.2% (p <0.001) between 1992 and 1993. Postoperative morbidity and mortality after LC did not differ between 1992 and 1993, but the total morbidity was 9.0% in 1992 and 7.0% in 1993 (p=0.02). Mortality for all cholecystectomies did not change over the periods, being 0.6% in 1992 and 0.2% in 1993 (p=0.07). The numbers of LCs done in any hospital were divided in two groups, 20 or fewer and 21-80. In the smaller group, the postoperative morbidity was 7.1% and in the larger group it was 7.0%, (p=0.9). The postoperative mortality was 0.1% in both groups. The postoperative and total hospital stays of all cholecystectomies decreased from 3.4 days in 1992 to 2.9 days in 1993 (p=0.001) and from 5.0 in 1992 to 4.4 days in 1993 (p < 0.001), respectively. The postoperative and total hospital stays of LCs decreased from 2.0 in 1992 to 1.8 days in 1993 (p=0.009) and from 3.3 in 1992 to 2.9 days in 1993 (p=0.007), respectively.

CONCLUSION

Despite the introduction and diffusion of the new technology, LC, the indications for surgery did not change and the number of cholecystectomies did not increase from 1992 to 1993. The morbidity and mortality of LC and the mortality of all cholecystectomies were unchanged between 1992 and 1993, but the morbidity for all cholecystectomies decreased. The number of LC or all cholecystectomies done in any particular hospital were not related to morbidity or to mortality.

The effect of dobutamine on distal colon ischaemia in the pig

OBJECTIVE

To test the hypotheses that dobutamine increases intestinal blood flow, it reduces mucosal acidosis and it prevents mucosal injury in an experimental porcine model of distal colonic ischaemia. And the hypothesis that mannitol prevents reperfusion injury.

DESIGN

Randomised animal experiment.

SETTING

University Hospital, Department of Experimental Research.

MATERIALS

Twenty-four pigs.

INTERVENTIONS

Twenty-one pigs were subjected to 7 h of controlled non-occlusive intestinal ischaemia of the distal colon, consisting of an occlusion of the inferior mesenteric artery (IMA) and a constriction of the superior mesenteric artery (SMA). At 3.5 h six pigs were treated with dobutamine, six with mannitol (0.18 g/kgBW), six with dobutamine and mannitol and three served as controls. Three non-ischaemic pigs were treated with dobutamine.

MEASUREMENTS AND RESULTS

All animals were haemodynamically stable throughout the experiment. There was no difference in any variable between the animals treated with mannitol and those not treated. The ischaemic dobutamine-treated animals increased their cardiac output (CO) by 14% compared to baseline and by 59% compared to controls. The median final dosage of dobutamine was 13.2 micrograms/kg per min (range 8.6-25.8). The blood flow in the restricted SMA, the intramucosal pH of the colonic mucosa (pHi) and the degree of histological mucosal injury were identical in animals treated with dobutamine and controls. The pH gap (pHa-pHi) correlated well (r = 0.97) with the PCO2 gap (aPCO2-intestinal PCO2). The non-ischaemic animals treated with dobutamine increased CO by 37% and blood flow of the SMA by 16%.

CONCLUSIONS

Dobutamine increased CO but did not ameliorate or deteriorate colonic ischaemia in this experimental model. The PCO2 gap correlated well with the pH gap.

Increased frequency of chromosome abnormalities in fibroblasts from hairy cell leukemia patients

A hereditary component is implicated in many different cancers, including hairy cell leukemia (HCL), and may involve an instability of the genome. We have previously documented recurrent clonal and non-clonal chromosomal abnormalities in hairy cells. To ascertain whether this instability of the genome is restricted to the malignant cells or if it might also include normal cells we performed cytogenetic investigations on skin fibroblasts and hairy cells from eight HCL patients and skin fibroblasts from eight referents. The frequency of chromosome abnormalities, regardless of clonality, was significantly increased in the fibroblasts from patients compared to referents. Also, five patients compared to one referent showed clonal abnormalities in their fibroblasts. Immunohistochemical investigations excluded the possibility that the fibroblast cultures were contaminated with hairy cells. Two patients had constitutional abnormalities, inv(5)(p13.1q13.3) and t(13;14), and one additional patient, possibly mosaic, showed the same abnormality, inv(9)(p21-22q22), in both fibroblasts (17/30) and blood (5/21) cells. Aberrations in patient fibroblasts also included sporadic inv(5), del(6)q, inv(19), and del(20)q, abnormalities previously shown to occur in hairy cells. A clonal expansion with trisomy 7 occurred in vitro as documented by fluorescence in situ hybridization (FISH). The only clonal abnormality occurring in a referent was -Y/-Y,+15 in an elderly male. In conclusion, a constitutional chromosomal instability may precede chromosome abnormalities and be of importance in the development of hairy cell leukemia.

An experimental porcine model of partial ischaemia of the distal colon

OBJECTIVE

Ischaemia of the colon is a major challenge in aortoiliac surgery. The aim was to establish an animal model of partial distal colonic ischaemia to study interventional strategies.

DESIGN

Randomised experiment.

SETTING

University Hospital. Department of Experimental Research.

MATERIAL

19 pigs.

INTERVENTIONS

11 Pigs were subjected to ischaemia consisting of total occlusion of the inferior mesenteric artery and partial occlusion of the superior mesenteric artery. Eight animals were sham controls. Dextran was given.

MAIN OUTCOME MEASURES

Haemodynamic measurements, intramucosal pH-measurements (pHi) and histological grading.

RESULTS

Both ischaemic animals and controls remained haemodynamically stable. It was possible to maintain stable ischaemia in the distal colon in the pHi-range of 6.9-7.1. There was histological mucosal damage of the distal colon in ischaemic animals but not in controls.

CONCLUSIONS

The model could be of value when studying interventional strategies to reduce or reverse ischaemia.

Randomized comparison between chemotherapy plus best supportive care with best supportive care in advanced gastric cancer

BACKGROUND

The extent to which chemotherapy may relieve tumour-related symptoms, improve quality of life and prolong survival in patients with gastric cancer is not known in spite of the extensive use of this treatment modality. The aim of this study was to estimate any gain in the quantity and quality of life produced by chemotherapy in these patients.

PATIENTS AND METHODS

Between January 1991 and February 1995, 61 patients with gastric cancer were randomized to either chemotherapy in addition to best supportive care or to best supportive care. Chemotherapy was allowed in the latter group if the supportive measures did not lead to palliation. Chemotherapy was the ELF-regimen consisting of 5-fluorouracil, leucovorin and etoposide, or, in elderly patients with poor performance, a 5-fluorouracil/leucovorin regimen (FLv). Quality of life was evaluated with the EORTC-QLQ-C30 instrument.

RESULTS

More patients in the chemotherapy group (45%, 14/31) had an improved or prolonged high quality of life for a minimum period of 4 months compared to those in the best supportive care group (20%, 6/30, P < 0.05). A similar difference was seen in the treating physician's evaluation of whether the patient was subjectively improved or continued to do well for at least 4 months (17/31, 55% versus 6/30, 20%, P < 0.01). Overall survival was longer in the chemotherapy group (median 8 vs. 5 months) although the difference was not statistically significant (P = 0.12). After corrections for imbalances in pretreatment characteristics, chemotherapy treatment was, however, associated with a survival benefit (P = 0.003). Also, the quality-adjusted survival time and time to disease progression were longer for patients randomized to chemotherapy (median 5 vs. 2 months, P = 0.03).

CONCLUSIONS

The results show that chemotherapy can add to both quantity and quality of life in advanced gastric cancer. The number of patients who benefit from treatment is, however, still rather limited.

Hemodynamic changes in the inferior caval vein during pneumoperitoneum. An experimental study in pigs

BACKGROUND

Laparoscopic procedures of increasing difficulty and duration are becoming more and more common. This may cause significant challenges to the circulatory system and possibly influence thrombogenicity.

METHODS

Experimental study of carbon dioxide pneumoperitoneum in pigs.

RESULTS

Inferior caval vein blood flow remained unchanged, whereas inferior caval vein pressure increased during pneumoperitoneum. Inferior caval vein, pulmonary, and systemic vascular resistance increased during pneumoperitoneum and remained increased after exsufflation.

CONCLUSIONS

Pneumoperitoneum leads to an increased inferior caval vein pressure, which could cause a dilation of peripheral veins. The similar patterns of vascular resistance in the inferior caval vein, pulmonary artery, and systemic arteries (a gradual increase remaining elevated after exsufflation) suggest a common humoral factor or increased sympathetic nerve activity.

Alterations in mucosal immune cell distribution in septic rats

A reduced cell-mediated immunity in the intestinal mucosa might promote gut barrier failure and bacterial translocation in shock. This study was performed to investigate changes from the normal distribution of cellular components of the immune system within the intestine during sepsis. Intra-abdominal sepsis was induced by cecal ligation and puncture. After 24 h, the animals were killed and specimens were taken from the small bowel. Immunohistochemical stainings were performed on frozen sections using monoclonal antibodies reactive with MHC class II positive cells (OX6), the alpha/beta antigen receptor on T lymphocytes (R73), CD4+ T lymphocytes (W3/25), CD8+ T lymphocytes (OX8), and macrophages (ED1). There was a significant reduction in the number of pan T lymphocytes as well as both CD4+ and CD8+ subsets in the mucosa of the septic rats as compared with sham operated rats (p < .01). In contrast, the populations of MHC class II positive cells and macrophages increased in sepsis (p < .01). We conclude that 24 h after the induction of peritonitis, there is an altered pattern of immunocompetent cells within the intestinal mucosa.

Small intestinal mucosal pH and lactate production during experimental ischemia-reperfusion and fecal peritonitis in pigs

The aim of this study was to investigate mucosal pH and lactate production in a porcine model of ischemia/reperfusion and sepsis using both tonometry and a technique for segmental intestinal perfusion. Eighteen pigs (17-23 kg) were anesthetized and mechanically ventilated. They were divided into three groups and followed for 4 h. Group C (n = 6) served as controls. In the ischemia/reperfusion group (I/R; n = 6), the superior mesenteric artery was totally occluded for 60 min. In group P (n = 6), sepsis was induced by fecal peritonitis. Cardiac index (CI) was determined by thermodilution and blood flow in the superior mesenteric artery (QSMA), using a Transonic flow probe. Intramucosal pH (pHi) was calculated using tonometry. A special balloon tube for segmental perfusion was introduced in the midileum for lactate measurement. Lactate and oxygen saturation were measured in arterial blood and in the superior mesenteric vein. CI, QSMA, pHi, and lactate in blood and perfusate remained unchanged in controls. Occlusion of intestinal blood flow induced a fall in pHi from 7.28 +/- .02 to 6.76 +/- .04, a marked rise in lactate in the perfusate, and an increased arteriovenous lactate difference. During reperfusion, pHi tended to return to baseline values. Lactate in the perfusate and the arteriovenous lactate difference decreased. In sepsis there was a continuous reduction in CI and QSMA to 45 +/- 13% and 40 +/- 20% of baseline, respectively. pHi decreased moderately from 7.22 +/- .09 to 6.98 +/- .25. Lactate remained unchanged in blood and perfusate. Microscopic mucosal injury was observed in all animals subjected to ischemia/reperfusion and in three of six pigs in group P. A good association between pHi and lactate production was seen in ischemia/reperfusion. However, in sepsis, lactate in superior mesenteric venous blood or in intestinal perfusate did not increase, despite the fall in pHi. The mechanism causing ischemic mucosal injury has different characteristics in sepsis and in ischemia caused by arterial occlusion.

Randomized comparison between chemotherapy plus best supportive care with best supportive care in advanced gastric cancer

BACKGROUND

The extent to which chemotherapy may relieve tumour-related symptoms, improve quality of life and prolong survival in patients with gastric cancer is not known in spite of the extensive use of this treatment modality. The aim of this study was to estimate any gain in the quantity and quality of life produced by chemotherapy in these patients.

PATIENTS AND METHODS

Between January 1991 and February 1995, 61 patients with gastric cancer were randomized to either chemotherapy in addition to best supportive care or to best supportive care. Chemotherapy was allowed in the latter group if the supportive measures did not lead to palliation. Chemotherapy was the ELF-regimen consisting of 5-fluorouracil, leucovorin and etoposide, or, in elderly patients with poor performance, a 5-fluorouracil/leucovorin regimen (FLv). Quality of life was evaluated with the EORTC-QLQ-C30 instrument.

RESULTS

More patients in the chemotherapy group (45%, 14/31) had an improved or prolonged high quality of life for a minimum period of 4 months compared to those in the best supportive care group (20%, 6/30, P < 0.05). A similar difference was seen in the treating physician's evaluation of whether the patient was subjectively improved or continued to do well for at least 4 months (17/31, 55% versus 6/30, 20%, P < 0.01). Overall survival was longer in the chemotherapy group (median 8 vs. 5 months) although the difference was not statistically significant (P = 0.12). After corrections for imbalances in pretreatment characteristics, chemotherapy treatment was, however, associated with a survival benefit (P = 0.003). Also, the quality-adjusted survival time and time to disease progression were longer for patients randomized to chemotherapy (median 5 vs. 2 months, P = 0.03).

CONCLUSIONS

The results show that chemotherapy can add to both quantity and quality of life in advanced gastric cancer. The number of patients who benefit from treatment is, however, still rather limited.

A cost-minimization analysis of laparoscopic cholecystectomy versus open cholecystectomy

BACKGROUND

Earlier economic analyses have evaluated charges but not costs, and have not considered the cost of production losses associated with open and laparoscopic cholecystectomy. This study attempted to accomplish an economic evaluation of open versus laparoscopic cholecystectomy from the point of view of society.

METHODS

A cost-minimization analysis, using a clinical decision model, was performed. The data used were taken from different clinical studies, Swedish national registers, local patient statistics, and hospital accounting systems. The direct and indirect costs were measured.

RESULTS

Laparoscopic cholecystectomy resulted in cost savings per patient amounting to about 2,400 SEK (as of 31 August 1994, Pound = 11.90 SEK; $1 = 7.76 SEK) compared with open surgery.

CONCLUSIONS

From the point of view of society, laparoscopic cholecystectomy was a cost-saving strategy if at least 68 patients were operated on yearly. However, with regard to hospital costs, open cholecystectomy was less expensive than laparoscopic cholecystectomy.