Laparoscopic sleeve gastrectomy for morbid obesity: role of intraluminal and intraperitoneal postoperative drainage

BACKGROUND AND AIMS

Bleeding and staple line leak are the most common postoperative complications of LSG. To prevent and/or to promptly identify such complications, conventional peri-operative protocols imply post-operative gastric decompression (NGT) and staple line drain (IAD). Our aim was to evaluate the role of naso-gastric tube (NGT) and intra-abdominal drain (IAD) in preventing and/or facilitating identification and treatment of post-operative complications after sleeve gastrectomy.

PATIENTS AND METHODS

A retrospective observational study on two consecutive series has been undertaken to evaluate the real utility of routine placement of NGT and IAD at the end of a LSG to prevent (primary end-point), promptly identify (secondary end-point) and manage (tertiary end-point) bleeding and staple line leakage. Collected outcome data of all consecutive cases, which underwent primary LSG at our Department, were analyzed. The first 100 consecutive patients (group A) received the standard perioperative protocol and the other consecutive 100 (group B) received a fast track protocol (no NGT neither IAD).

RESULTS

The two groups were not different in their outcome. Two bleeding occurred in Group A and were conservatively treated. One abscess developed in group B soon after surgery. It was diagnosed by an abdominal CT performed because patients presented fever, leucocitosis and tachycardia. It was successfully treated by percutaneous ultrasound-guided drainage. One fistula occurred in group B after discharge on 30th post-operative day. Fistula was suspected based on fever and tachycardia in absence of any abdominal discomfort and was confirmed by an abdominal CT. The patient was successfully treated in 40 days by endoscopic positioning of a gastric tube-prosthesis and percutaneous ultrasound-guided drainage of abdominal collection. A third patient in group B experienced bleeding suspected due to hemoglobin drop and confirmed by abdominal CT. He also was conservatively treated.

CONCLUSIONS

In conclusion, placement of drains does not facilitate detection of leak, abscess, or bleeding after primary LSG.

The Aquamantys® system as alternative for parenchymal division and hemostasis in liver resection for hepatocellular carcinoma: a preliminary study

OBJECTIVE

To evaluate the clinical feasibility and safety of a new technique for liver resection using a new saline-coupled bipolar sealing device (Aquamantys®) that has shown high performance in the animal setting.

PATIENTS AND METHODS

Twelve Child-Pugh A cirrhotic patients with hepatocellular carcinoma underwent partial hepatectomies using Aquamantys®. Our primary end-point was to observe occurrence of early specific surgical complications as bleeding, biliary leakage and abscess development. Our secondary end-point was to evaluate local recurrence along resection margin after a minimum follow-up of 1 year.

RESULTS

One bisegmentectomy, five monosegmentectomies and six atypical resections were performed. Mean resection time was 45 minutes (range, 30-100 min). Mean blood loss was 20 mL (range 5-80 mL). Mean post-operative stay was 6 days (range 5-16 days). All specimens presented negative margins (R0) at pathological examination. No blood transfusion were required both intra-operatively and post-operatively. No mortality was observed within 30-days post-operatively. One fluid collection occurred after  6-7 bisegmentectomy and was successfully treated by ultrasound-guided percutaneous drainage. At 1 year follow-up two patients died: one because of new lesions into the liver and one because of distant metastases and multifocal new liver disease. Ten patient are alive disease free at 1 year follow-up.

CONCLUSIONS

Liver resection using Aquamantys® is feasible and safe and allows to achieve almost bloodless parenchymal division with minimal necrosis and negative margins even in atipycal resection. Comparative trials are needed to confirm our preliminary results.

[Alcohol-addiction inpatient: characteristics of patients and rehabilitation program]

AIM

The treatment of alcohol addiction in Italy has had a progressive evolution of therapeutic structures for in-and outpatients. During the last 20 years there had been a crescent presence of short residential treatment facilities (1-6 months) characterized by a high level of medical and psychotherapeutic intervention. About two years ago 12 of them jointed together in an association called CORRAL (COordinamento of Residenzialità Riabilitive Alcologiche). The aim of this study was to describe the socio-demographic medical and other characteristics of the patients coming for this type of treatment and to describe the characteristics of the residential treatment itself including referring and aftercare.

METHODS

Two thousand sixty-one hospitalized patients of the 12 rehabilitative alcohol units were examined by using a questionnaire and collecting various sociodemographic variables and clinical diagnosis of the patients. Even it was asked who had referred the patients, the characteristics of the residential treatment and of the planned aftercare.

RESULTS

The present residential facilities are mainly distributed in the North of Italy. The typical patient is male, with a high school instruction and with a comorbidity regarding psychiatric and liver disorders. The majority of the patients were referred by the public ambulatory services for addictions (SerT/SerD). The characteristics of the residential treatment were medical, pharmacological and psychotherapeutic interventions with a high intensity and the presence of a general-purpose staff.

CONCLUSIONS

This study outlined a model of residential rehabilitation of alcohol disorders characterized by short duration and a complex, intense therapeutic intervention mainly addressed to patients with a severe clinical condition and a low level of social problems. Further research should be useful to understand better which sort of patient characteristics obtain a better clinical result and for that even economically a major effectiveness from this type of residential treatment.

Role of Th17 in the pathogenesis of cutaneous inflammatory diseases

Th17 cells are a new T-cell subtype characterized by the capability of producing IL-17. They are reported to be involved in a wide range of cutaneous immune-mediated conditions and, particularly in this review, we sought to elucidate the Th17 role in the pathogenesis of some common inflammatory diseases including psoriasis, allergic contact dermatitis and atopic dermatitis.

New insights into the pathogenesis of cutaneous autoimmune disorders

T helper 17 (Th17) cells are characterized by the secretion of IL-17, a proinflammatory cytokine. They represent a newly described T helper subpopulation that is distinct from Th1 and Th2 lineages. Because of their pleiotropic activity on fibroblasts, keratinocytes, endothelial cells, neutrophils and memory T cells, Th17 cells are thought to be crucial in mediating tissue inflammation and autoimmunity. Autoimmune diseases were classically considered as Th1-mediated disorders such as rheumatoid arthritis or mixed Th1/Th2 diseases such as inflammatory bowel diseases, systemic lupus erythematosus, bullous diseases, but new evidence suggests the deep involvement of Th17 cells in their pathogenesis that, potentially, may address a selective therapeutic approach targeting the IL23/Th17 pathway. This review summarizes the current knowledge of the pathogenic contribution of Th17 cells in select cutaneous autoimmune disorders, including lupus erythematosus, scleroderma, dermatomyositis, bullous pemphigoid and pemphigus vulgaris.

Lymphocyte reconstitution in multiple myeloma patients after allogeneic G-CSF-mobilized hematopoietic progenitor cells transplantation from HLA-identical siblings

7098

Background: Allogeneic transplantation of G-CSF-mobilized hematopoietic progenitor cells (HPC) results in rapid and complete engraftment in a large proportion of patients and in relatively fast immune recovery. Methods : We have analyzed by flow cytometry the immune reconstitution in 19 patients (pts) affected by multiple myeloma undergone to allogeneic HPC transplant from HLA-identical related donors after nonmyeloablative conditioning regimen with fludarabine 90 mg/m2 and cyclophosphamide 900 mg/m2. In each patient a comparable number of mononuclear cells, CD3+ T lymphocytes and CD34+ progenitor cells was infused. To evaluate the kinetics of the immune reconstitution, the overall number of total lymphocytes, T, B and NK cells of each patient were assessed before and 1, 2, 3, 6, 12, 18, 24, 30, 36 months after allogeneic HPC transplant. Results: Overall T cell reconstitution was in all the pts at 3 months, since at that time the CD3+ T cell median number was 880 cells/microl (r. 589–1,357). However, in all pts high numbers of CD3+ T cells were achieved at 12 months after transplant (median 1,326 cells/microl, r. 850–2,309). The CD4+ T cell median number was 281 cells/microl (r. 185–433) at 6 months, 391 cells/microl (r. 303–505) at 12 months, 603 cells/microl (r. 433–736) at 18 months. The CD8+ T cell median number was increased from the transplant to 18 months in which it was 1,489 cells/microl (r. 760–1,976). The decrease of CD8+ T cells with the normalization of CD4+/CD8+ ratio was observed at 30 months when CD4+ T cells were 650 cells/microl (r. 370–989) and CD8+ T cells were 690 cells/microl (r. 445–1,743). B cells recovery was observed at 18 months with a median number of 194 cells/microl (r. 40–404). The faster reconstitution was documented for NK cells with a median number of 314 cells/microl (r. 61–647) at 2 months. Conclusions: the complete immune reconstitution in our pts was achieved at 30 months after transplant. Our objective is to evaluate if this slow immune recovery is associated with a high incidence of infectious diseases and a low incidence of chronic GVHD.

No significant financial relationships to disclose.

r-HuEPO 40,000 U one time/week before high-dose melphalan allows a tandem autologous peripheral stem-cell transplantation without red blood cell transfusion in multiple myeloma patients: A pilot study

7103

Purpose: To decrease red blood cell (RBC) transfusion requirements during a tandem high-dose melphalan (HDM) for multiple myeloma (MM) patients (PTS), we conducted a pilot study to assess the effect of high-dose of recombinant human erythropoietin (rHuEpo) started during chemotherapy before the first HDM and autologous peripheral blood stem-cell transplantation (APBSCT). Patients and Methods: After induction chemotherapy with VAD, 14 consecutive PTS with MM, stage III, median age 58 years (range 42–62), were mobilized with cyclophosphamide (3–4 g/m2) to collect peripheral blood stem cells (PBSC) and entered a study consisting of two HDM (200 mg/m2) with APBSCT. Enrolled patients received rHuEpo (40,000 U subcutaneously one time/week) as soon as their hemoglobin (Hb) level fell <11 g/dl during induction chemotherapy. rHuEpo was continued at the same dose during PBSC collection and was reintroduced at the time of discharge after the first transplant up to the admission for the second one. If the Hb level exceeded 13 g/dl at any time, rHuEpo was withheld until the concentration decreased to <11 g/dl, at which time it was restarted. Results were compared to those of 20 tandem HDM and APBSCT performed in 15 consecutive historical MM controls matched for hematological parameters. Results: rHuEpo increased the hemoglobin (Hb) level from 10.1 ± 2.5 g/dl at diagnosis to 12.8 ± 2 g/dl at the time of the first HDM; no major adverse effects occurred. Compared to historical controls (46.6%, 7/15), RBC transfusion requirements were significantly lower for rHuEpo recipients (6.6%, 1/14) (P=0.00001). After the tandem HDM and APSCT, fewer RBC transfusions were needed: 3.3 and 1 RBC units for controls and rHuEpo recipients, respectively (P=0.006). Conclusion: The administration of high dose of rHuEpo during induction chemotherapy and interval beetween the first and second HDM cycle permit the realitazion of tandem chemotherapic program with a reduction of blood product support.

No significant financial relationships to disclose.

Harvesting peripheral blood progenitor cells from healthy donors with a short course of recombinant human granulocyte-colony-stimulating factor

A short-course administration of non-glycosylated granulocyte-colony-stimulating factor (G-CSF) was investigated in 68 healthy donors (HDs) in order to collect > or = 4 x 10(6) CD34+ cells per kilogram of recipient's body weight. G-CSF was given at 10 microg/kg per day administered in two divided doses for 3 days. Leukapheresis was scheduled on day 4, 12 h after the last dose of G-CSF. A median of 35.6 circulating CD34+ cells microL(-1) (range, 3.1-185) was found on the day of leukapheresis. This allowed a median collection of CD34+ cells of 4.2 x 10(6) per kilogram of recipient's weight (range, 1.0-17.4). One single procedure was sufficient to reach the target level of CD34+ cells in 36 (53%) of 68 donors; significant correlations were found between the number of CD34+ cells collected on day 4 and the patient's sex, body-weight and volume of blood processed. A retrospective analysis was made with a historical group of HDs collected on day 5. The day 5 schedule allowed a more consistent achievement of the target cell dose with one leukapheresis (P = 0.005) and resulted in the initial collection of a significantly larger number of CD34+ cells (P = 0.006).

Inguino-crural hernias: preoperative diagnosis and post-operative follow-up by high-resolution ultrasonography. A personal experience

BACKGROUND

Hernia is an important pathology with an incidence of 5% in world population. The more affect region is the inguino-femoral. Normally the diagnosis was based on the clinical exam. A short time ago the high resolution ultrasonographic study was introduced. The purpose of our study was to value the sensitivity of US-HR in the preoperative diagnosis, in the postoperative follow-up and to compare the results to clinical exam.

METHODS

140 patients affect by inguino-femoral hernia underwent this study, 112 inguinal hernias, 28 femoral, 8 pediatric patients. 106 patients underwent repair through the prosthesis, in 34 Halstad-Postempsky's technique was carried out. Ultrasonography studied: a) inguino-femoral region, cord and scrotum (the study was effected in basal condition and through Valsalva's manoeuver, decubitus changes); b) hernia content (omenutm, bowel); c) hernial orifice and of hernial content's transit (direct or indirect); d) the relation with the inguinal ligament; e) the vascularization (power-doppler) and the pathological situation (presence or absence of liquid in the sac, parietal thickness, presence/absence of peristalsis), in case of hernia complication; f) the presence/absence of simultaneous pathologies (hydrocele, varicocele, cord's cyst). The postoperative study was effected after 7 days, 1-6-12 months we have observed: a) haematomas and seromes (under the skin, under the aponeurosis, scrotal); b) prosthesis displacement; c) prosthesis infection; d) prosthesis reject; e) recurrence (importance, site); f) we have carried out the treatment of the complications (echoguided drainage of serous and hematic collection).

RESULTS

The sensitivity of US-HR in the diagnosis of hernia was 87.5%. The clinical exam arrived at an average of 72%, the comparison was favourable to US-HR (15.5%). The sensitivity in the diagnosis of complication arrived at an average of 85.5% for US-HR, and of 36% for clinical exam; the gap between the two techniques was elevated (49.5%).

CONCLUSIONS

The US-HR showed an important accuracy and sensitivity thus to cover today an important role, after the clinical exam, in the preoperative diagnosis and in the postoperative follow-up of the inguino-femoral hernias.

[Periampullar tumors: role of intraoperative color-Doppler ultrasonography in the evaluation of vascular invasion. Methods available to the surgeon and personal experience]

BACKGROUND

Tumors of the head of the pancreas and of the periampullary region, similar nosologic entity, represent the fourth most common cause of cancer death. These tumors are characterized bt high mortality rate associated with a low percentage of surgical resectability. Vascularly involvement is, in our experience, one of the criteria of exclusion for curative surgical resection. For this reason regional pancreasectomy don't show, in several case records, comforting datas about survival.

METHODS

From 1995 to 1998 we introduced in the operative practice the color--doppler ultrasonography to diagnose vasculary involvement. We evaluated twenty patients that previously were candidated for surgical therapy consisting in a duodenal-pancreasectomy. All the patients were staged by preoperative abdominal ultrasound, E.R.C.P., CT, and angio M.R.I.. In no one of these patients were founded signs of vascularly involvement. We recognized by intraoperative color-doppler ultrasound three microscopic invasions of spleno-mesenteric-portal vasculary axis.

RESULTS

U.S. I.O. C.D. in our case reports has underlined a sensibility and specificity of 100%. It has discovered, also, a false positive for neoplastic thrombosis, and a case of false negative.

CONCLUSIONS

Intraoperative ultrasound shows a high sensibility about the intraoperative staging for the bibliopancreatic tumors. The study about the possible vascularly involvement is helped by the application of the colour in terms of an high sensibility and diagnostic care.

[Short- and long-term monitoring with high-resolution ultrasonography of postoperative thyroid residue. Personal experience with 200 thyroidectomies]

BACKGROUND

After having abandoned conservative operations of the thyroid (partial resection, enucleal resection) today total thyroidectomy and sub-total thyroidectomy and near total thyroidectomy are the operations of choice. Cause the frequent post-operative scintigraphic signs, on the 3rd month, of thyroidal residue of significative size, founded in our patients operated for sub-total thyroidectomy, we begun to study the echografical monitoring of the thyroidal recess.

METHODS

From January 1995 to December 1997 we operated 200 patients for Thyroidectomy. The kinds of operations were: total thyroidectomy for 96 patients (48%), sub-total thyroidectomy for 64 patients (32%), and near total thyroidectomy for 40 patients (20%). We controlled all the patients by ecografical monitoring of the thyroidal recess to detect and to determinate the possible thyroidal residue, that it will be monitorized on the 7th day, on the 1st month, on the 6th month and on the 12th month. We measured the thyroidal residual dimensions and volume. We recorded all the examinations by VCR or film and after we elaborated the results by exponential graphics. The patients that showed the thyroidal residues underwent to a scintigraphy.

RESULTS

The thyroidal residuals were measured within the 7Th post-operative day. In the following controls we have noted a thyroidal residue hypertrophy. Multinodular goither was the disease with the highest degree of growth (until the 200% of the first measure of the residue). After an initial phase of growth almost all the patients showed a trend to the stabilization, with the exception only of the patient that suffered from multinodular goither. The scintigraphic examination was not realiable, in our experience, about the mathematic measurement of the thyroidal tissue, showing always an overvaluation of the residue. The best specificity was showed by US-HR.

CONCLUSIONS

The patient that undergoes to total thyroidectomy needs an adequate suppressive and substitutive therapy. We identify the presence of several stimulating factors the growth of the residual thyroidal tissue that could arise to promote the hyperplasia and the hypertrophy of the parenchyma (EGF, TSG, TSI, PG). There are factors that are unidentified and are not subject to the suppression caused by substitutive therapy.

[Palliative treatment of neoplasms of the bilio-pancreatic area. Surgical diversion treatment versus endoscopic-percutaneous approach]

Bilio-pancreatic (BPD) tumours are pathologies with an overall resectability rate of 20-25%, with a high percentage of patients directed towards palliative treatment (70-90%). One hundred and twenty-eight patients underwent palliative treatment for BPD tumours. The M:F ratio was 1:1.5 and the mean age 61 years. The tumours were topographically divided into: 84 (63%) localised in the pancreatic head region; 34 (25%) biliary duct tumours and 6 arising in the ampulla of Vater. 42 patients (30%) underwent palliative surgical treatment (group 1) and 86 (70%) received non-surgical treatment (endoscopic percutaneous) (group 2). We also performed 6 gastrointestinal by-passes (GEA). The early morbidity rate was 36% in the first group and 12.8% in the second. The incidence of late morbidity in the first group was nil, with a mean survival of 10 months. Mortality was nil in both groups. Surgical by-pass is advisable in the presence of patients with a longer life expectancy and in good clinical condition but presents a high rate of early morbidity and a low percentage of late complications. The authors conclude that validity of the methods is similar. They believe that, in selected cases, surgical treatment remains the therapy of choice for BPD tumours.

[Sensitivity and specificity of transrectal ultrasonography in the preoperative staging and postoperative follow-up in rectal neoplasms. Experience with 100 clinical cases]

Preoperative staging plays an important role in the surgical treatment of rectal cancer. The most sensitive imaging techniques currently available are CT, MRI and transanal ultrasound (TAUS). The aim of the study was to evaluate the sensitivity and specificity of TAUS in the preoperative staging and postoperative follow-up of rectal cancer.

METHODS

From January 1992 to May 1999, TAUS was used to study 100 patients with rectal cancer.

RESULTS

Patients were staged according to the Astler-Coller classification: 1) A: 8 patients; 2) B1: 16 patients; 3) B2: 22 patients; C1: 30 patients; C2: 24 patients. The sensitivity and specificity of TAUS in the preoperative staging of these tumors were 96% for the T parameter, and 100% for the N parameter. The N but not the T parameter results are in line with the values reported in the international literature.

CONCLUSION

Transanal ultrasound, in our personal experience, has proved to be a very accurate imaging technique in the preoperative staging and postoperative follow-up of rectal cancer.

[Minimally invasive percutaneous ultrasonography-guided treatment of postoperative splenic abscess. Personal experience with 5 clinical cases]

INTRODUCTION

Splenic abscesses are very rare pathologies encountered in daily clinical practice. The treatment, after failure of other medical treatments, has basically been surgical, in spite of large diffusion of percutaneous echo and CT techniques. The initial hesitation in applying this sort of method was caused by an unfounded fear of difficult management of haemorrhagic complications.

METHODS

In our Clinic we treated 6 postoperative abscesses, observed in 5 patients. One of these (16%) was double and 3 concomitant with other intraperitoneal abscessual septic collections, which received priority in percutaneous treatment. In four cases (67%), Van-Sonnemberg drainage catheters were placed which caliber varied from 12 to 14 F. In the remaining two cases, we evacuated the abscess using an echo-guided needle puncture. In two cases we applied fibrinic glue; in one case as a haemostatic agent and in the other, to protect the wide abscessual cavity.

RESULTS

We recorded the resolution of the symptomatology and instrumental findings in all patients. One patient died two weeks later due to unrelated causes. We recorded one minor complication which involved an intra-abscessual haemorrhage, which was then treated by fibrinic glue (Tissucol).

CONCLUSION

Echo-guided percutaneous treatment, at present, is the treatment of choice for both multiple or single splenic abscesses. This treatment is not used for the miliaric form because we believe that in this case, the most appropriate choice is intensive medical treatment, which if fails, may require splenectomy.

[Echo-guided percutaneous drainage of abscesses and abdominal fluid collections]

Abdominal abscesses are pathologies characterized by an high decree of mortality and morbidity. The pathology was once dealt with surgery evacuation the percentage of success reaches 60% while mortality runned around 24%. Today this technic has been substituted by the echo-guided treatment. The minimal invasive approach reduced dramatically the cases of complications (4-6%) and mortality (4%); it is highly suggested in the majority of the cases of visceral or endoperitoneal abscesses. Our study case counts 57 echo-guided drainages due to multiply surgery pathologies. The number of successful ends runs on 93%, this perfect agrees with the data given by literature that states a decree of success around 90%. We did no test an higher or lower decree of complications nor mortality. According to our opinion the echo-guided drainage is a primary technic in abdominal septic collections. Surgery drainage has to be aside for patients with general good health or for collections accompanied with divertcular disease of the large intestine, crohn disease, rectocolitis ulcerosis and periappendix abscess.

[Preoperative diagnosis using color Doppler flowmetry in focal and diffuse thyroid pathology]

Color-doppler was first used in the study and classification of specific pathologies in 1992. One hundred and eighteen patients with focal and diffuse thyroid pathologies underwent color-doppler, flowmetry analysis and peak systolic velocity measurement (CD-FM-PSV). The PSV results allowed us to identify two subclasses a and b in class three and four (a: = < or = 30 cm/sec., b: = > 30 cm/sec.). Class 3a and 3b lesions are the most likely to represent neoplastic nodules. Based on our results, we assigned 58 patients to type 2 (follicular hyperplasia), 20 patients to type 3a (follicular adenoma and carcinomas), 16 patients to type 3b (carcinomas and Plummer's adenoma), 15 patients to type 4a (autoimmune thyroiditis and hypothyroidism) and 12 patients to type 4b (Graves' disease). Preliminary results were compared with FNAB, intra-operative and post-operative histological data. The specificity of CD-FM-PSV in diagnosis is 86%. We have concluded that CD-FM-PSV is an effective imaging technique for pre-operative diagnosis of thyroid pathologies and along with FNAB, a adequate predictive tool for thyroid nodules.

In vitro drug-induced cytotoxicity predicts clinical response to fludarabine in B-cell chronic lymphocytic leukaemia

We investigated the possible value of an in vitro drug-induced cytotoxicity assay in predicting clinical response to fludarabine (FAMP) in chronic lymphocytic leukaemia (CLL). The median FAMP-LD50 values for cases designated as complete response (CR), partial response (PR), no response (NR) and progressive disease (PD) were 1.43, 2.05, 24.8 and 77.9 microg/ml, respectively (P=0.013). A significant lower mean FAMP-LD50 value was observed in the in vivo responding cases as compared to non-responding ones (3.0 +/- 0.82 SEM v 42.3 +/- 12.6 SEM, P=0.001). Only FAMP-LD50 < or = 2.5 microg/ml and more than four FAMP courses significantly influenced the response rate in univariate and multivariate analyses. The MTT assay may be of value in predicting clinical response to FAMP in CLL patients.

[Abdominal compartment syndrome in video laparoscopic surgery. Etiopathogenetic aspects, physiopathology and personal experience]

The abdominal compartment syndrome (ACS) is a very seven pathology, consequence oh abdominal injuries and traumatism, acute pancreatitis, aortic aneurism rupture, acute peritonitis. The etiopatogenesis is the increase of intra-abdominal pressure with systemic consequences for cardiorespiratory and renal failure. The authors after careful physiopathologic consideration, describe, a case report of ACS in the laparoscopic cholecystectomy for acute cholecystitis. To conclusion, we report very important the accurate intraoperative monitoring of vital parameters (PCO2, PO2, Pa, Fc, PVC, Ph, Diuresis) and immediate decision at laparotomic conversion for abdominal decompression.

In vitro improvement of chlorambucil-induced cytotoxicity by deflazacort and 6-methylprednisolone in B-cell chronic lymphocytic leukaemia

We examined whether CLL cell chemosensitivity to in vitro exposure to chlorambucil (CLB) might be improved by the presence of deflazacort (DFZ) in comparison to 6-methylprednisolone (PDN). The PDN lethal dose (LD)50 values were low in 5 samples, intermediate in 4 and high in 7. Low, intermediate and high DFZ-LD50 values were detected in 3, 2 and 11 samples, respectively. The CBL-LD50 mean values were significantly reduced at all PDN and at the 4 highest DFZ concentrations. However, a dose-response effect was seen only in the DFZ group. Both CLB-DFZ and CLB-PDN interactions were analysed in 16 samples at 25 different dose-combinations, resulting in 400 comparisons between expected and observed leukaemic cell survival (LCS) values for each group. In particular, 45.75% and 40% dose combinations were synergistic in CLB-DFZ and CLB-PDN groups, respectively. A relatively higher number of antagonistic interactions were observed among CLB-PDN dose combinations, while analogous number of additive interactions were detected. At concentrations of CLB x1 microgram/ml the phenomenon of synergism, regardless of the steroid concentration, did occur more frequently. On the other hand, a more elevated number of antagonistic interactions were counted at CLB 100 micrograms/ ml. In conclusion, both DFZ and PDN synergize in vitro with CLB, especially at low concentrations of the alkylating agent.

Recombinant human erythropoietin inhibits the cutaneous vasodilatation induced by acetylcholine

We investigated by means of telethermography the contractile response of cutaneous vessels to recombinant erythropoietin (rHuEPO) and the effects of this hormone on the vasodilatation induced by either acetylcholine, which is endothelium-dependent, and nitroprusside, which is endothelium-independent. Experiments were carried out in 12 healthy volunteers. Graded doses of rHuEPO (25, 50, 500 U/min), acetylcholine (7.5 and 15 micrograms/min), sodium nitroprusside (3 and 10 micrograms/min), and saline solution (sodium chloride 0.9%) were infused in the dorsal pedal artery of the lower limb. rHuEPO reduced the cutaneous temperature in a dose-dependent manner compared to the saline solution, thus suggesting that the hormone causes vasoconstriction. In contrast graded doses of acetylcholine and nitroprusside provoked vasodilatation: in fact both increased the cutaneous temperature compared to controls in a dose-dependent manner. The infusion of vasoconstrictive doses of rHuEPO in association with acetylcholine (15 micrograms/min) reverted the increase in the cutaneous temperature induced by the endothelium-dependent vasodilator. In contrast rHuEPO administered in combination with nitroprusside failed to block the vasodilatation induced by the endothelium-independent vasodilator. Therefore our data suggest that rHuEPO exerts an indirect vasoconstrictive effect and that acetylcholine-induced vasodilatation, which is endothelium-dependent, is blunted by the vasoconstrictive activity of rHuEPO, thus demonstrating that the hormone may impair the synthesis of endothelial nitric oxide.

[A case of primary intestinal lymphoma]

The authors examine primary small bowel tumours, dealing at some length with problems of a diagnostic and clinical nature. The difficulties often encountered in reaching an early diagnosis and the feasibility of radical surgery frequently prove to be factors conditioning prognosis. The importance is then stressed of thorough evaluation of those vague symptoms which may be the only manifestation of this disease.