Glycemic variability and hypoglycemia before and after Roux-en-Y Gastric Bypass and Sleeve Gastrectomy - A cohort study of females without diabetes

BACKGROUND

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) lead to lower fasting glucose concentrations, but might cause higher glycemic variability (GV) and increased risk of hypoglycemia. However, it has been sparsely studied in patients without preoperative diabetes under normal living conditions.

OBJECTIVES

To study 24-hour interstitial glucose (IG) concentrations, GV, the occurrence of hypoglycemia and dietary intake before and after laparoscopic RYGB and SG in females without diabetes.

SETTING

Outpatient bariatric units at a community and a university hospital.

METHODS

Continuous glucose monitoring and open-ended food recording over 4 days in 4 study periods: at baseline, during the preoperative low-energy diet (LED) regimen, and at 6 and 12 months postoperatively.

RESULTS

Of 47 patients included at baseline, 83%, 81%, and 79% completed the remaining 3 study periods. The mean 24-hour IG concentration was similar during the preoperative LED regimen and after surgery and significantly lower compared to baseline in both surgical groups. GV was significantly increased 6 and 12 months after surgery compared to baseline. The self-reported carbohydrate intake was positively associated with GV after surgery. IG concentrations below 3.9 mmol/L were observed in 14/25 (56%) of RYGB- and 9/12 (75%) of SG-treated patients 12 months after surgery. About 70% of patients with low IG concentrations also reported hypoglycemic symptoms.

CONCLUSIONS

The lower IG concentration in combination with the higher GV after surgery, might create a lower margin to hypoglycemia. This could help explain the increased occurrence of hypoglycemic episodes after RYGB and SG.

Lower Interstitial Glucose Concentrations but Higher Glucose Variability during Low-Energy Diet Compared to Regular Diet-An Observational Study in Females with Obesity

This is an observational study of interstitial glucose (IG) concentrations, IG variability and dietary intake under free-living conditions in 46 females with obesity but without diabetes. We used continuous glucose monitoring, open-ended food recording and step monitoring during regular dietary intake followed by a low-energy diet (LED). Thirty-nine participants completed both study periods. The mean BMI at baseline was 43.6 ± 6.2 kg/m2. Three weeks of LED resulted in a mean weight loss of 5.2% with a significant reduction in diurnal IG concentration but with greater glycemic variability observed during LED. The mean 24 h IG concentration decreased from 5.8 ± 0.5 mmol/L during the regular diet period to 5.4 ± 0.5 mmol/L (p < 0.001) during LED, while the mean amplitude of glycemic excursion increased from 1.5 ± 0.7 to 1.7 ± 0.7 mmol/L (p = 0.031). The positive incremental area under the curve at breakfast was significantly larger for LED compared to regular diet. The daily fiber intake and the glycemic index of breakfast meals were significantly associated with the glycemic variability during regular dietary intake. In conclusion, the 24 h mean IG concentration was lower but with more pronounced glycemic variability during LED compared to a regular diet.

Gastrointestinal quality-of-life after cholecystectomy: indication predicts gastrointestinal symptoms and abdominal pain

BACKGROUND

Despite the fact that cholecystectomy is a common surgical procedure, the impact on long-term gastrointestinal quality of life is not fully known.

METHODS

All surgical procedures for gallstone disease performed at Mora County Hospital, Sweden, between 2 January 2002 and 2 January 2005, were registered on a standard database form. In 2007, all patients under the age of 80 years at follow-up were requested to fill in a form containing the Gastrointestinal Quality-of-Life Index (GIQLI) questionnaire and a number of additional questions. The outcome was analysed with respect to age, gender, smoking, surgical technique, and original indication for cholecystectomy.

RESULTS

A total of 627 patients (447 women, 180 men) underwent cholecystectomy, including laparoscopic cholecystectomy (N = 524), laparoscopic cholecystectomy converted to open cholecystectomy (N = 43), and open cholecystectomy (N = 60). The mean time between cholecystectomy and follow-up with the questionnaire was 49 months. The participation rate was 79 %. Using multivariate analysis in the form of generalised linear modelling, the original indication for cholecystectomy in combination with gender (p = 0.0042) was found to predict the GIQLI score. Female gender in combination with biliary colic as indication for cholecystectomy correlated with low GIQLI scores. Female gender also correlated with a higher risk for pain in the right upper abdominal quadrant after cholecystectomy (p = 0.028).

CONCLUSIONS

We found the original indication for cholecystectomy, together with gender, to predict gastrointestinal symptoms and abdominal pain after cholecystectomy. Careful evaluation of symptoms is important before planning elective cholecystectomy.

The Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks): A nationwide registry for quality assurance of gallstone surgery

OBJECTIVES

To describe the process of initiating and organizing a nationwide validated web-based quality registry of gallstone surgery and endoscopic retrograde cholangiopancreatography (ERCP) and to present some clinical data and the impact the registry has had on the clinical treatment of gallstones.

DESIGN

Observational, population-based registry study.

SETTING

Data from the nationwide Swedish Registry of Gallstone Surgery and ERCP (GallRiks).

PATIENTS

From May 1, 2005, to December 31, 2011, 63 685 cholecystectomies (laparoscopic and open) and 37 860 ERCPs have been prospectively registered in GallRiks.

INTERVENTIONS

Cholecystectomies, laparoscopic or conventional, as well as ERCP in a population-based setting.

MAIN OUTCOME MEASURES

Registrations of all cholecystectomies and ERCPs are performed online by the surgeon or endoscopist. Thirty-day follow-up of both gallstone surgery and ERCP is mandatory, as is an additional 6-month follow-up of the cholecystectomies. Scores on the 36-Item Short Form Health Survey are registered preoperatively and 6 months postoperatively in elective cholecystectomies at selected units.

RESULTS

The 30-day overall complication rate is 6.1% in elective cholecystectomy, 11.2% in urgent cholecystectomy, and 12.0% following ERCP. The use of antibiotic and thromboembolic prophylaxis in elective laparoscopic cholecystectomy in Sweden has decreased by 8.7% and 17.8% (2006-2011), respectively, mainly owing to presentation of GallRiks data both at meetings and published in peer-reviewed publications. The large database has also enabled several research projects, including one demonstrating that the intention to perform intraoperative cholangiography reduced the risk of death after cholecystectomy. The database has reached greater than 90% national coverage and is continuously validated.

CONCLUSIONS

GallRiks is a validated national quality registry for gallstone surgery and ERCP, serving as a base for audit of gallstone disease treatment. It also provides a database for clinical research.

Registration of health-related quality of life in a cohort of patients undergoing cholecystectomy

Background. Assessment of gallstone surgery's impact on quality of life (QoL) requires a reliable instrument with sufficient responsiveness. The instrument should also enable estimation of each individual's expected condition in an unaffected state. Materials and Methods. The Swedish Register for Gallstone Surgery and ERCP (GallRiks) registers indications, complications, results, and QoL-outcome of gallstone surgery. In 2008, 68 hospitals were registered in GallRiks. Between 2007 and 2008, SF-36 (a short form health survey) was filled in 1-2 weeks pre- and 6–9 months postoperatively at five of the units. Expected scores were determined from an age- and gender-matched Swedish population (AGMSP). Results. Of the 330 patients, 212 responded to SF36 pre- and postoperatively (RR = 64%; 212/330). Standardized response means ranged from 0.20 to 0.93 for the SF-36 subscores. Highest responsiveness was seen for bodily pain. Preoperatively, all subscores were significantly lower than in the AGMSP (all P < .05). Six months postoperatively, there was no significant difference between any of the observed and expected quality of life subscales. Conclusion. SF-36 is a useful instrument for measuring the impact of gallstone surgery on QoL. The postinterventional health status equalled or even exceeded the AGMSP for all subscales.

Effectiveness of prophylactic antibiotics in a population-based cohort of patients undergoing planned cholecystectomy

BACKGROUND

In the absence of randomized controlled trials with sufficient power to assess the effectiveness of prophylactic antibiotics (PA), the best evidence is provided by large population-based register studies.

METHODS

The Swedish Register of Gallstone Surgery and ERCP (GallRiks) started in May 2005 and reached 75% national coverage in 2007. During 2006 and 2007, a total of 16,400 operations were registered in GallRiks. In the present study, all elective procedures performed in 2006-2007 in units performing at least 25 operations annually were included in an analysis of the risk for postoperative infectious complications

RESULTS

Altogether 10,927 procedures were performed 2006-2007. Univariate logistic regression analysis revealed a paradoxical increase in postoperative infectious complications requiring antibiotic treatment and postoperative abscess if PA were given (p < 0.05). This increase disappeared in multivariate analysis with adjustment for age, gender, presence of cholecystitis, accidental gallbladder perforation, and presence of bile duct stones.

CONCLUSION

No benefit from PA was seen in this study on elective cholecystectomy. Although a randomized controlled trial could possibly show a reduction in the risk for postoperative infectious complications not detected in this study, such a reduction must be weighed against the risk of promoting drug resistance by the widespread use of PA.

Massive fundic gland polyposis in a patient receiving protracted proton-pump inhibitor medication

A case of massive fundic gland polyposis (MFGPsis) in a female patient receiving protracted proton-pump inhibitor (PPI) medication is described. At gross examination the majority of the polyps were overlapping, confluent, some of them having a "cauliflower-like" configuration. The fundic gland polyps (FGP) arose in the gastric acid secretory mucosa. The confluence of these polyps impeded their enumeration. The gross and histological characteristics of this case seemed to be at variance with syndromic or sporadic cases having multiple FGP, inasmuch as in this case, the FGP had a propensity to agglutinate, to overlap and to develop confluent macrocysts. Another difference was that this disease, refractory to antacid treatment, required surgical intervention. This case substantiates the notion that protracted PPI medication may encourage the development of MFGPsis in susceptible individuals.

Inflammatory response in patients with malignant obstructive jaundice

OBJECTIVE

Surgery in patients with malignant obstructive jaundice is associated with increased risks for postoperative septic complications. The aim of this study was to investigate the inflammatory and the local cellular immune response in patients accepted for surgery because of tumours in the hepatic-pancreatic-biliary (HPB) tract.

MATERIAL AND METHODS

Patients with obstructive jaundice (group HPB(+)) were compared with those without (HPB(-)). Patients undergoing surgery for benign abdominal disorders served as controls. Obstructive jaundice was present in 18 out of 33 HPB patients. Preoperatively, blood was analysed for bacteria, endotoxins and cytokines (TNF-alpha, IL-6 and IL-10). At operation, mesenteric lymph nodes (MLNs) were excised for bacterial cultures using standard microbiological techniques, and immunohistochemistry, using antibodies CD4 and CD8 (mainly staining T lymphocytes), CD68 (macrophages), and anti-caspase-3 (to determine the rate of apoptosis).

RESULTS

Bacterial translocation was not demonstrated in any of the patients. Increased preoperative concentrations of endotoxins were found in group HPB(+). The number of macrophages and the rate of apoptosis in MLNs were increased in jaundiced patients, while the number of T lymphocytes was decreased.

CONCLUSIONS

Malignant obstructive jaundice causes increased blood concentrations of endotoxins and cytokines, an increased number of macrophages in MLNs, a higher rate of apoptosis in MLNs, but a decreased number of T lymphocytes in MLNs. The lymphocyte depletion is probably due to the increased rate of apoptosis, and might reduce the ability of jaundiced patients to eradicate infection.

Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair

BACKGROUND

Laparoscopic herniorrhaphy has emerged as a recognized operative method for inguinal hernia repair. This study compared the short-term results of two tension-free methods of repair: totally extraperitoneal (TEP) laparoscopic patch repair and the open Lichtenstein mesh technique.

METHODS

A total of 1513 men from 11 hospitals who presented with a primary unilateral inguinal hernia were randomized to one of the two methods. Operating time, short-term complications, reoperations, postoperative pain, consumption of analgesics, sick leave and time to resumption of normal physical activities were recorded.

RESULTS

Some 1371 of the 1513 men underwent surgery, 665 in the TEP group and 706 in the Lichtenstein group. The median duration of operation was 55 min for both procedures and 91.0 percent of the patients in both groups were discharged on the day of operation. Patients in the TEP group experienced less postoperative pain (P<0.001), consumed fewer analgesics (P<0.001), had a shorter period of sick leave (7 versus 12 days; P<0.001) and a shorter time to resumption of normal physical activity (20 versus 31 days; P<0.001).

CONCLUSION

The TEP technique took no longer to perform, and was associated with less postoperative pain, a shorter period of sick leave and a faster recovery, compared with open Lichtenstein hernia repair.

Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia

Background

This randomized trial examined whether lightweight (LW) polypropylene mesh (large pore size, partially absorbable) could have long-term benefits in reducing chronic pain and inflammation after inguinal hernia repair.

Methods

Six hundred men with a primary unilateral inguinal hernia were randomized to Lichtenstein repair using a standard polypropylene mesh or a LW mesh in one of six centres. The patients were blinded to which mesh they received. Clinical examination was performed and a pain questionnaire completed 3 years after surgery.

Results

Of the 590 men who had surgery, 243 (82·7 per cent) of 294 in the standard mesh group and 251 (84·8 per cent) of 296 in the LW mesh group were examined in the clinic, a median of 37 (range 30-48) months after hernia repair. There were nine recurrent hernias in each group (3·7 per cent with standard mesh and 3·6 per cent with LW mesh). Patients who had LW mesh had less pain on examination, less pain on rising from lying to sitting, fewer miscellaneous groin problems and felt the mesh less often than patients with standard mesh.

Conclusion

Use of LW mesh for Lichtenstein hernia repair did not affect recurrence rates, but improved some aspects of pain and discomfort 3 years after surgery.

Feed-borne outbreak of Salmonella cubana in Swedish pig farms: risk factors and factors affecting the restriction period in infected farms

In 2003, a feed-borne outbreak of Salmonella Cubana occurred in Sweden as a result of contamination in a feed plant. Salmonella Cubana was detected in 49 out of 77 pig farms having received possibly contaminated feed. In this study, potential risk factors for farms being salmonella positive were examined, and a survival analysis was performed to investigate risk factors affecting the restriction period for salmonella positive farms.

The median restriction time for all 49 farms was 17 weeks. An increased risk for farms being salmonella infected (positive in feed and/or faeces) was seen for fattening farms and farms feeding soy. The survival analysis showed that herds with a low level of infection and farms with a high hygiene level had shorter restriction times.

This study is unique as it investigates a real outbreak of feed-borne salmonella, where the source of infection was reliably identified, the period of exposure could be defined and data were collected from all exposed farms.

INFLUENCE OF CYCLOOXYGENASE INHIBITORS ON GUT IMMUNE CELL DISTRIBUTION AND APOPTOSIS RATE IN EXPERIMENTAL SEPSIS

The aim of this study was to determine if cyclooxygenase (COX) inhibitors influence immune cell distribution in the small intestinal mucosa and mesenteric lymph nodes (MLNs), the grade of mucosal damage, and the rate of apoptosis in septic rats. The effects induced by a selective COX-2 inhibitor (SC-236) were compared with those of a nonselective COX-1 and -2 inhibitor (indomethacin). Cecal ligation and puncture (CLP), CLP + SC-236 p.o, and CLP + indomethacin p.o, were evaluated. Animals were harvested 6 and 24 h after CLP, respectively. The concentration of proinflammatory cytokines was higher in ascitic fluid than in blood. CLP + SC-236 attenuated IL-6 in plasma and in ascitic fluid and CLP + indomethacin augmented TNF-alpha in ascitic fluid compared with CLP at 6 h. CLP + SC-236 gave a lesser degree of mucosal damage compared with CLP alone or with indomethacin at 6 and 24 h (P < 0.05). Untreated CLP had significant reductions in the number of T lymphocytes in the villi and increases of macrophages in the mucosa and MLNs compared with controls (P < 0.05). CLP + indomethacin decreased T lymphocytes in the villi and MLNs. CLP caused an enhanced apoptosis in the mucosa compared with controls (P < 0.05), pretreatment with COX inhibitors did not significantly change this. Both COX inhibitors enhanced apoptosis in MLNs and attenuated the increase of macrophages in mucosa and MLNs (P < 0.05). It is proposed that the increased apoptosis and the decrease in T cells in the mucosa may be causally related. Apoptosis of lymphocytes may impair the immunologic defense in sepsis. Furthermore, loss of intestinal epithelial cells may compromise bowel wall integrity and facilitate translocation.

One year results of a randomised controlled multi-centre study comparing Prolene and Vypro II-mesh in Lichtenstein hernioplasty

A standard polypropylene mesh used in Lichtenstein's operation induces a strong foreign tissue reaction with potential harmful effects. A mesh with less polypropylene could possibly be beneficial. Six hundred men with primary unilateral inguinal hernias were randomised to Lichtenstein's operation using a Prolene- or Vypro II-mesh in six centres. The patients were blinded to which mesh they received. A validated questionnaire assessing recurrence and pain along with SF-36 Health Survey was sent after 1 year to all patients and a selected group was clinically examined. Of the 591 operated patients, 526 (89.0%) returned the questionnaire. 188 patients had some complaints or sensations of which 111 patients were clinically examined. The mean follow-up time was 13.6 (SD. 4.0) months. The incidence of hernia recurrence (four vs. four patients) and neuralgia (three vs. four patients) did not differ between Prolene and Vypro II-groups, respectively. One Vypro II-patient was re-operated due to neuralgia. There was no difference in the SF-36 scores. The results of Lichtenstein's operation with either Prolene or Vypro II do not seem to differ significantly.

Early results of a randomised trial comparing Prolene and VyproII-mesh in endoscopic extraperitoneal inguinal hernia repair (TEP) of recurrent unilateral hernias

The purpose of this study was to compare a lightweight mesh to a standard polypropylene hernia mesh in endoscopic extraperitoneal hernioplasty in recurrent hernias. A total of 140 men with recurrent unilateral inguinal hernias were randomised to a totally extraperitoneal endoscopic hernioplasty (TEP) with Prolene or VyproII in a single-blinded multi-center trial. The randomisation and all data handling were performed through the Internet. 137 patients were operated as allocated. Follow-up was completed in 88% of the patients. The median operation times were 55 (24-125) min and 53.5 (21-123) min for the Prolene and VyproII groups, respectively. The meshes had comparable results in the surgeon's assessment of the handling of the mesh, return to work, return to daily activities, complications, postoperative pain and quality of life during the first 8 weeks of rehabilitation, except in General Health (GH) SF-36, where the VyproII-group had a significantly better score (P=0.045). The use of Prolene and VyproII-meshes in endoscopic repair of recurrent inguinal hernia seems to result in similar short-term outcomes and quality of life.

Early results of a randomized multicenter trial comparing Prolene and VyproII mesh in bilateral endoscopic extraperitoneal hernioplasty (TEP)

BACKGROUND

The use of mesh in inguinal hernia surgery has become increasingly popular despite the potentially harmful effects that foreign material may exert on human tissue. The purpose of this study was to compare the use of a lightweight mesh vs a standard hernia mesh in bilateral endoscopic hernioplasty.

METHODS

This single-blinded multicenter trial, 140 men with bilateral inguinal hernias were randomized to undergo totally extraperitoneal endoscopic hernioplasty (TEP) with either Prolene or VyproII. The randomization and all data management were done via the Internet.

RESULTS

A total of 139 patients were operated on as allocated. The follow-up was complete in 94% of the patients. The median (range) operating times were 85 min (45-140) and 73 min (35-165) for the Prolene and VyproII groups, respectively. (p = 0.01). The difference was due to uneven distribution of the allocated patients to study groups among individual surgeons. The time to return to work was similar (11 vs 9 days, p = 0.08). The time to return to normal daily activities was 19 days (1-133) in the Prolene group and 12.5 days (0-237) in the VyproII group (p = 0.06). There were no significant differences between the groups in their scores on the Visual Analogue Scale or SF-36 Health Scores during the 8-week follow-up.

CONCLUSIONS

The use of Prolene and VyproII meshes in bilateral endoscopic repair of inguinal hernia seems to result in similar short-term outcome and quality of life. However, there was a tendency toward faster return to normal activity among VyproII patients.

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.

Early results of a single-blinded, randomized, controlled, Internet-based multicenter trial comparing Prolene and Vypro II mesh in Lichtenstein hernioplasty

BACKGROUND

The standard polypropylene mesh used in Lichtenstein's operation induces a strong foreign-tissue reaction with potentially harmful effects. A mesh with less polypropylene could possibly be beneficial.

PATIENTS AND METHODS

Six hundred men with inguinal hernias were randomized to Lichtenstein's operation with Prolene or Vypro II in a single-blinded multicenter trial. The randomization was performed by a computer algorithm in a database through the Internet. All data were entered and directly validated in the database through the Internet.

RESULTS

The meshes had comparable results in return to work, return to daily activities, complications, postoperative pain, and quality of life during the first 8 weeks of rehabilitation.

CONCLUSIONS

Lichtenstein's operation with either Prolene or Vypro II is safe and well tolerated with an acceptable postoperative rehabilitation time and a high quality of life 2 months after surgery. The study was facilitated by the use of a database through the Internet.

Effect of linomide on gut immune cell distribution and on TNF-alpha in plasma and ascites: an experimental study in the septic rat

A significant reduction of the pan T lymphocytes as well as CD4+ and CD8 subsets of cells in the gut mucosa of the septic rats has previously been demonstrated. In contrast, the populations of major histocompatibility complex (MHC) class II-positive cells and macrophages increased. The aim of this study was to evaluate if the immunomodulator Linomide influenced the immune cell distribution in the small intestinal mucosa in sepsis and, furthermore, if these changes coincide with changes in the concentration of tumor necrosis factor-alpha (TNF-alpha) in plasma or ascites. Polymicrobial sepsis was induced in rats by cecal ligation and puncture (CLP). Three different experimental groups were used: CLP, Linomide p.o. + CLP, and Linomide i.p.+ CLP, with adequate controls. Specimens were taken from the small bowel for immunohistologic staining and grading of mucosal injury. The following monoclonal antibodies were used: W3/25, OX8, R73, OX6, and ED1. All slides were examined by one "blinded" examiner. Mucosal injury was graded from 0 to 5. The immunostained tissues were also analyzed by an automatic color-based image system. All controls had a normal appearance of the mucosa (grade 0-1), whereas the septic animals had a median grade of III (II-IV) mucosal injury. Linomide i.p. + CLP decreased mucosal damage to median I (0-IV, P < 0.05). Linomide had no effects on the immune cell distribution in controls. In CLP rats, a significant reduction in both CD4+ and CD8+ T lymphocytes as well as an increased number of macrophages and MHC class II-positive cells was seen in the villi as compared with sham-operated controls (P < 0.05). Linomide attenuated these changes for CD8+ and T lymphocytes and macrophages. Sepsis caused increased concentrations of TNF-alpha in portal blood and ascites 3 h from CLP induction. This increase was attenuated by Linomide.

[Abdominal sarcomas--rare tumors requiring multidisciplinary approach. Evaluation of surgical management in a sarcoma team]

Retroperitoneal sarcomas and gastrointestinal stromal tumors are rare malignant tumors with a high recurrence rate. Due to their localization, and to the fact that they give rise to non-specific symptoms, these tumors are usually large at diagnosis. From 1990 to 1998 thirty-one patients (16 men and 15 women, mean age 45 years; range 15-77 years) went through surgical treatment. Patients were evaluated by a team consisting of an oncologist, a pathologist, a radiologist and a surgeon both pre- and postoperatively. Forty-five operations were performed (23 for primary tumors and 22 for recurrences). The resectability and radical resection rate were 89% and 59% respectively in primary tumors (4 patients with benign histological diagnoses were excluded) and 68% and 47% respectively in local recurrences. Other organs were removed in 50% of the procedures. Vascular and orthopedic surgeons participated when necessary. Morbidity and in-hospital mortality were 18% and 7% respectively. The overall recurrence rate was 70%. It is our belief that a multidisciplinary approach is mandatory for optimal treatment in these patients.

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.