Oxidonitrergic and antioxidant effects of a low molecular weight peptide fraction from hardened bean (Phaseolus vulgaris) on endothelium

About 3000 tons of beans are not used in human food due to hardening. Several studies on bean-derived bioactive peptides have shown potential to treat some diseases, including those relying on oxidative dysfunctions. We assessed the effects of peptides extracted from hardened bean Phaseolus vulgaris (PV) on reactive oxygen species (ROS) and nitric oxide (NO) production, cytotoxic and cytoprotective effects in endothelial cells, and oxidonitrergic-dependent vasodilating effects. Extract was composed by peptide fraction <3 kDa (PV3) from hardened common bean residue. PV3 sequences were obtained and analyzed with bioinformatics. Human umbilical vein endothelial cells were treated with 10, 20, 30, and 250 µg/mL PV3. Oxidative stress was provoked by 3% H₂O₂. Cytotoxicity and cytoprotective effects were evaluated by MTT assay, whereas, ROS and NO were quantified using DHE and DAF-FM fluorescent probes by confocal microscopy. NO- and endothelium-dependent vasodilating effects of PV3 were assessed in isolated aortic rings. We found 35 peptides with an average mass of 1.14 kDa. There were no cell deaths with 10 and 20 μg/mL PV3. PV3 at 30 μg/mL increased cell viability, while cytotoxicity was observed only with 250 μg/mL PV3. PV3 at 10 μg/mL was able to protect cells from oxidative stress. PV3 also increased NO release without causing cell death. It also reduced relative ROS production induced by H₂O₂. PV3 vasodilating effects relied on endothelium-dependent NO release. PV3 obtained from low-commercial-value bean displays little cytotoxicity and exerts antioxidant effects, whereas it increases endothelial NO release.

P4519Sleep Apnea screening in Heart Failure: an exploratory analysis

Background

Sleep Apnea (SA) is increasingly recognized in patients (pts) with Heart Failure (HF). Nocturnal polysomnography (PSG) is the gold-standard to diagnose SA. Currently, portable devices have been thoroughly validated in HF cohorts.

Purpose

To determine the correlation between clinical, laboratory and respiratory measurements with the presence of SA (defined as apnea-hypopnea index (AHI) >15/h) and desaturation time with SpO2 <90% (T90) ≥22 minutes, a strong mortality predictor in HF with reduced ejection fraction (HFrEF); and to compare the features of pts with HFrEF vs HF with preserved ejection fraction (HFpEF).

Methods

Our work is based on a single-center retrospective cohort of pts hospitalized for decompensated HF during 2013–2018. All pts were screened for SA with ApneaLinkTM after compensation the night preceding discharge. HF was defined as recommended by the European Society of Cardiology guidelines. A left ventricular ejection fraction ≤45% and >45% was used to define HFrEF and HFpEF, respectively, as per SERVE-HF trial.

Results

A total of 228 pts were included in the analysis (mean age 75.3±10.5 years, 48.9% male). SA was present in 135 (59.2%) pts and 41.2% had HFrEF. Mean AHI was 24.5±19.2/h, mean O2 desaturation index (ODI) was 24.4±21.0/h and mean T90 was 169.6±151.2 minutes. In multivariate models, ODI, gender and ischemic HF were predictors of AHI >15/h (R2 65.8%), with ODI being the strongest predictor (standardized coefficient 64.8%). Similarly, mean SpO2 was the only predictor of T90 ≥22minutes (R2 65.8%) (Figure 1). HFrEF pts had more often AHI>15/h (73.4% vs 48.5%, p<0.001), more total apneas (62±148 vs 16±79, p<0.001), obstructive apneas (28±76 vs 8±43, p<0.001) and central apneas (6±20 vs 0±5, p<0.001) than those with HFpEF. In multivariate models, ODI (OR 1.14, CI 1.03–1.26, p=0.013 for HFrEF; OR 1.21, CI 1.11–1.33, p<0.0001 for HFpEF) and mean SpO2 (OR 0.29, CI 0.14–0.60, p=0.001 for HFrEF; OR 0.23, CI 0.10–0.52, p<0.0001 for HFpEF) were the only predictors of AHI >15/h and T90 ≥22 minutes in both groups, respectively.

Conclusions

SA was highly prevalent in HFrEF and HFpEF. ODI and mean SpO2 were highly predictive of AHI >15/h and T90 ≥22minutes, respectively, both prognostic markers validated in a population with HFrEF, and equally so in HFrEF and HFpEF. These findings hypothesize a similar pathophysiology of SA in HF, regardless of left ventricular systolic function. Also, whether simple pulse oximetry can be routinely used for SA screening, since PSG and portable devices are often not widely available, is a finding worth being prospectively assessed.

Acknowledgement/Funding

None

P5008Empagliflozin in a real-world chronic heart failure population

Introduction

Heart Failure (HF) is a burdensome syndrome with significant mortality, morbidity and costs. Its prognosis is further aggravated by diabetes mellitus (DM). The EMPA-REG OUTCOME trial suggested that empagliflozin significantly reduced HF hospitalizations compared to placebo in patients with DM.

Purpose

We aimed to investigate which patients with chronic HF and DM in the outpatient setting could have been enrolled in the main empagliflozin trial.

Methods

This analysis is based on a retrospective cohort enrolling chronic HF patients who consecutively attended the HF appointment between January and July 2018. Of these, those with concomitant DM were selected and further analysed. The key EMPA-REG OUTCOME trial inclusion criteria [(i.e., hemoglobin A1c 7–10%, high cardiovascular (CV) risk and glomerular filtration rate [GFR] ≥30mL/min/1,73m2) were considered. Further, the European Medicine Agency (EMA) restriction (GFR>60mL/min/1,73m2) was also considered in an additional analysis.

Results

Of 316 patients with HF, 114 (36%) concomitantly had DM. Mean age was 74±10 years, 63% were male and most (54%) had preserved left ventricular ejection fraction. Ischemic (51%) and hypertensive (27%) HF were the most often observed etiologies. According to the inclusion criteria, 21 (18.4%) (or 5.3% when further considering the EMA restriction) HF patients could have been potentially enrolled in the main trial and derive a HF hospitalization reduction benefit from starting empagliflozin. The remainder would be excluded due to GFR<30mL/min/1.73m2 (2.6%), absence of “high CV risk” as per trial's definition (7%), HbA1c off target (18,4%) or a combination of the above criteria (53.6%). In light of the new Standards of Medical Care in Diabetes 2019, controlled patients with HbA1c off target (i.e., <7% or >10%) could be switched to a SGLT2 inhibitors, hence possibly expanding the indication to start empagliflozin to 36.8% of our HF cohort.

Figure 1

Conclusions

Roughly 1 in every 5 patients with HF and DM could have been enrolled in the main empagliflozin trial, as per key inclusion criteria, and potentially derive CV benefit from it. Thus, only a minority of our cohort shared the features for EMPA-REG OUTCOME trial inclusion, limiting the extrapolation of the trial's observed CV benefits to our HF cohort. Indeed, whether these benefits also expand to overall HF cohort is eagerly awaited by ongoing trials.

Acknowledgement/Funding

None

Role of routine pre-operative screening venous duplex ultrasound in morbidly obese patients undergoing bariatric surgery

BACKGROUND/AIMS

It is well established that obesity is a strongly associated risk factor for post-operative deep vein thrombosis (DVT). Physical effects and pro-thrombotic, pro-inflammatory and hypofibrinolytic effects of severe obesity may predispose to idiopathic DVT (pre-operatively) because of which bariatric patients are routinely screened before surgery. The aim of this study was to audit the use of routine screening venous duplex ultrasound in morbidly obese patients before undergoing bariatric surgery.

METHODS

We retrospectively reviewed 180 patients who underwent bariatric surgery from August 2013 to August 2014 who had undergone pre-operative screening bilateral lower-extremity venous duplex ultrasound for DVT. Data were collected on patient's demographics, history of venous thromboembolism, prior surgeries and duplex ultrasound details of the status of the deep veins and superficial veins of the lower limbs.

RESULTS

No patients had symptoms or signs of DVT pre-operatively. No patient gave history of DVT. No patient was found to have iliac, femoral or popliteal vein thrombosis. Superficial venous disease was found in 17 (8%). One patient had a right lower limb venous ulcer.

CONCLUSION

Thromboembolic problems in the morbidly obese before bariatric surgery are infrequent, and screening venous duplex ultrasound can be done in high-risk patients only.

First Virtual Live Conference in Healthcare

BACKGROUND

Conferences and meetings bring together thousands of doctors from diverse locations. However, the traveling, accommodation, and arrangement of venues for conferences and meetings are expensive and a lot of time needs to be devoted to these logistics. The purpose of this article was to present our own virtual live conference experience using web conferencing and to briefly outline the basics and advantages of this technology in organization of healthcare conferences.

METHODS

Web conferencing technology was used to organize an international bariatric surgery conference, allowing a large number of attendees to participate and interact from wherever they were, using merely an Internet connection with a video player on their personal computers, laptops, or smartphones.

RESULTS

A virtual live conference saves a lot of time and cost and simplifies the logistics needed to organize a learning conference with worldwide participation.

CONCLUSION

As far as we know, this is the first report of a virtual live conference in healthcare. We see it as the future of organizing experts as well as medical teaching conferences.

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm

BACKGROUND:

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed ‘standalone’ bariatric procedure in India. Staple line gastric leaks occur infrequently but cause significant and prolonged morbidity. The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at our institution.

PATIENTS AND METHODS:

From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to our institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed.

RESULTS:

Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality.

CONCLUSION:

Leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.

Predictors of outcome after reconstructive hepatico-jejunostomy for post cholecystectomy bile duct injuries

INTRODUCTION

Reconstructive hepatico-jejunostomy is recommended for major bile duct injuries (BDIs) during cholecystectomy. Complications of biliary leak, cholangitis, bleeding, anastomotic strictures and biliary cirrhosis remain a major concern affecting a patient's outcome after surgery. The aim of this study was to analyse the results of surgical repair of major BDIs at our institution and identify predictors for the development of major complications.

METHODS

A retrospective study of 57 patients with major BDI after cholecystectomy referred to a tertiary hepato-biliary centre from July 1999 to July 2011 and subsequently managed with reconstructive bilio-enteric anastomosis was performed.

RESULTS

Of 57 patents 35 (61.4%) were primary referred. 22 (38.6 %) were secondary referred, of which 17 were for correct reconstructive surgery performed elsewhere and 5 were following attempted endoscopic management. 17 (29.8%) had local and systemic perioperative complications. 13 (22.8%) had major complications (bile leak, bleed, stricture and/or biliary cirrhosis). No association was found between age, type of cholecystectomy, type of injury, vascular injury and occurrence of major complications. Secondarily referred patients after therapeutic interventions (p = 0.010) and reconstructive surgery after repair performed by non-specialists suffered an increased incidence of major complications (p = 0.032). Secondary referral was also an independent predictor of major complications (p = 0.024).

CONCLUSION

Early referral of patients with no previous intervention to a tertiary hepato-biliary center and specialist surgical repair is recommended for improved outcome after reconstructive hepatico-jejunostomy for major BDIs during cholecystectomy.

Comparison of weight loss outcomes 1 year after sleeve gastrectomy and Roux-en-Y gastric bypass in patients aged above 50 years

INTRODUCTION:

Safe, effective weight loss with resolution of comorbidities has been convincingly demonstrated with bariatric surgery in the aged obese. They, however, lose less weight than younger individuals. It is not known if degree of weight loss is influenced by the choice of bariatric procedure. The aim of this study was to compare the degree of weight loss between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients above the age of 50 years at 1 year after surgery.

MATERIALS AND METHODS:

A retrospective analysis was performed of all patients more than 50 years of age who underwent LSG or LRYGB between February 2012 and July 2013 with at least 1 year of follow-up. Data evaluated at 1 year included age, sex, weight, body mass index (BMI), mean operative time, percentage of weight loss and excess weight loss, resolution/remission of diabetes, morbidity and mortality.

RESULTS:

Of a total of 86 patients, 54 underwent LSG and 32 underwent LRYGB. The mean percentage of excess weight loss at the end of 1 year was 60.19 ± 17.45 % after LSG and 82.76 ± 34.26 % after LRYGB (P = 0.021). One patient developed a sleeve leak after LSG, and 2 developed iron deficiency anaemia after LRYGB. The remission/improvement in diabetes mellitus and biochemistry was similar.

CONCLUSION:

LRYGB may offer better results than LSG in terms of weight loss in patients over 50 years of age.

Prevalence and Predictors of Non-Alcoholic Fatty Liver Disease in Morbidly Obese South Indian Patients Undergoing Bariatric Surgery

BACKGROUND

Numerous studies worldwide have identified a high prevalence of non-alcoholic fatty liver disease (NAFLD) among morbidly obese subjects. Several predictors have been found to be associated with NAFLD and its histological high-risk components. Similar data from India is lacking. We aimed to determine the prevalence and the predictors of NAFLD and its histological high-risk components in a cohort of Indians with morbid obesity undergoing bariatric surgery. Safety of a routine intraoperative liver biopsy was also assessed.

METHODS

There were 134 morbidly obese patients who underwent bariatric surgery with concomitant liver biopsy. These were assessed for NAFLD and its histological high-risk components. Clinical, biochemical, and histological features were evaluated, and predictors of NAFLD, non-alcoholic steatohepatitis (NASH), fibrosis, and advanced fibrosis were identified.

RESULTS

Mean BMI was 44.66 ± 9.81. Eighty-eight (65.7 %) showed NAFLD. Forty-five (33.6 %) showed NASH and 42 (31.3 %) showed fibrosis both not mutually exclusive. Nineteen (14.1 %) showed advanced fibrosis. Higher alanine aminotransferase (ALT) independently predicted NAFLD and was significantly associated with NASH and fibrosis. Type 2 diabetes mellitus (T2DM) and the metabolic syndrome were significantly associated with fibrosis. Systemic hypertension (HT) independently predicted NASH and fibrosis. There were no intraoperative or postoperative complications related to the liver biopsy.

CONCLUSIONS

NAFLD has a high prevalence among morbidly obese patients. Elevated ALT, HT, T2DM, and the metabolic syndrome are predictors for NAFLD and its high-risk histological components. Routine intraoperative liver biopsy is safe in morbidly obese undergoing bariatric surgery for diagnosing NAFLD.

Ligation of the intersphincteric fistula tract for the treatment of fistula-in-ano: experience of a tertiary care centre in South India

AIM

Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing surgical technique increasingly used to treat fistulae-in-ano yielding good results. The aim of this study was to evaluate its effectiveness in the treatment of complex fistulae-in-ano and to determine factors associated with recurrence and its subsequent management.

METHOD

A prospective observational study was performed of 167 patients with complex fistula-in-ano treated by LIFT from June 2013 to January 2014. In all patients a LIFT with partial core-out of the fistula tract was performed.

RESULTS

There were 167 patients of mean age 43.6 ± 12.8 years. Thirty-three fistulae were recurrent. 150 were trans-sphincteric, 16 were intersphincteric and one was a suprasphincteric fistula. The median postoperative stay was 2 (range: 1-14) days (mean = 2.4 days). At follow up there was no change in continence. The median healing time was 4 (range: 1-8) weeks. Two patients developed an intersphincteric abscess needing surgical drainage healing uneventfully. The mean follow up was 12.8 [median = 12 (range: 4-22)] months. The healing rate was 94.1%. Ten (5.9%) patients developed a recurrent fistula that was managed by a second LIFT procedure in seven, a sinus tract excision with curettage in two and seton placement in one. Recurrence was significantly associated with diabetes mellitus and perianal collections and showed an increased incidence with tract abscesses and multiple tracts.

CONCLUSION

LIFT has a high success rate in complex fistulae-in-ano. Recurrence is related to diabetes mellitus, perianal collections, tract abscesses and multiple tracts and a second LIFT procedure may be feasible and efficient.

Management of Type 2 Late Sleeve Leak by Laparoscopic Suturing and Conversion to Roux-en-Y Gastric Bypass: Video Report

BACKGROUND

Laparoscopic sleeve forming gastrectomy (SFG) is a commonly performed bariatric procedure for the surgical management of morbid obesity. Staple line gastric leaks occur infrequently but are the most feared complication causing prolonged morbidity (Burgos et al., Obes Surg 19(12):1672-7, 2009; Márquez et al., Obes Surg 20(9):1306-11, 2010). Roux-en-Y diversion is an accepted management (Baltasar et al., Surg Obes Relat Dis 4(6):759-63, 2008). The aim of this video was to demonstrate the operative management of a late sleeve leak by laparoscopic suturing & conversion to a RYGB.

METHODS

We present the case of an 18-year-old woman with a BMI of 44.68 kg/m(2) with hypothyroidism and polycystic ovarian disease who underwent laparoscopic sleeve gastrectomy and presented with a leak on postoperative day 13. She was diagnosed to have a type 2, late leak just beyond the esophagogastric junction (Csendes et al., Hepatogastroenterology 37 Suppl 2:174-7, 1990) RESULTS: In this multimedia high-definition video, we present step-by-step the operative management of a late sleeve leak by laparoscopic suturing and conversion to a RYGB. Procedure included mobilization of the gastric sleeve, identification and suturing of the fistulous opening, creation of a gastric pouch, creation of an ante-colic Roux limb, gastrojejunal anastomosis and jejuno-jejunal anastomosis. Drainage of fistula gradually decreased with absence of a leak on imaging in 12 days. This patient was diagnosed with a gastric sleeve leak on the 13th postoperative day, and the time to fistula closure from diagnosis was 1 month.

CONCLUSIONS

Sleeve leak fistula repair with conversion to a RYGB aids healing by providing surgical decompression and better drainage. It may be considered as an alternative management technique in sleeve leaks.

Laparoscopic Undo of Fundoplication with Roux-en-Y Gastric Bypass in a Morbidly Obese Patient with Prior Nissen's Fundoplication: A Video Report

BACKGROUND

Roux-en-Y gastric bypass (RYGB) may be a better option for morbidly obese patients with gastroesophageal reflux (GERD) for long-term reflux control. It is recommended after fundoplication if a patient is morbidly obese with GERD with failed fundoplication or if bariatric surgery is planned with a prior successful fundoplication (Kim et al., Am Surg 80(7):696-703, 2014; Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). Complete takedown of the wrap to avoid stapling over the fundoplication creating an obstructed, septated pouch is needed (Kambiz Zainabadi, Surg Endosc. 22(12):2737-40, 2008). The aim of this video was to demonstrate the technical aspect of dissection and undo of Nissen's fundoplication followed by performance of a RYGB in a morbidly obese patient with GERD with prior successful Nissen's fundoplication opting for bariatric surgery after a year.

METHODS

We present a case of a 50-year-old woman with a BMI of 36.14 with previous laparoscopic Nissen's fundoplication for severe GERD (controlled after surgery) and a prior laparoscopic intraperitoneal onlay mesh repair who presented for bariatric surgery 1 year after fundoplication. She was successfully treated by laparoscopic undo of the fundoplication with RYGB.

RESULTS

In this multimedia high-definition video, we present step-by-step the laparoscopic undo of a Nissen's fundoplication followed by RYGB. The procedure included lysis of all adhesions between the liver and the stomach, dissection of the diaphragmatic crura, complete takedown of the wrap, repair of the hiatal hernia, creation of a gastric pouch, creation of an antecolic Roux limb, gastrojejunal anastomosis, and jejuno-jejunal anastomosis.

CONCLUSION

Laparoscopic RYGB after fundoplication in morbidly obese patients with GERD is a technically difficult but feasible option.

Diagnostic Yield and Clinical Implications of Preoperative Upper Gastrointestinal Endoscopy in Morbidly Obese Patients Undergoing Bariatric Surgery

BACKGROUND AND AIMS

Upper gastrointestinal (UGI) endoscopy in patients undergoing bariatric surgery is controversial. It is recommended routinely by some authors to detect benign or malignant pathology that mostly remains asymptomatic. Others recommend selective use, suggesting not much impact on surgical management of detected pathology, especially in asymptomatic patients. The aim of this study was to evaluate the diagnostic yield and impact of pathological findings on routine UGI endoscopy before bariatric surgery in a cohort of morbidly obese Indian patients.

MATERIALS AND METHODS

We retrospectively reviewed preoperative screening UGI endoscopy reports of 283 patients who underwent bariatric surgery from February 2012 to August 2014. Data were collected on clinical information, UGI endoscopic findings, Helicobacter pylori testing, and management.

RESULTS

Ten patients gave a history of gastroesophageal reflux, and the rest had no specific UGI complaints. Fifty-four had no abnormal findings. One hundred ninety-six had a lax lower esophageal hiatus, hiatal hernias of <5 cm, Grade I-II esophagitis, or mild to moderate gastritis or duodenitis that did not have an impact on surgery. Thirty-one had severe erosive gastritis or duodenitis, or polyposis that delayed surgery for treatment and review of biopsies. A large hiatal hernia >5 cm changed surgical plan to Roux-en-Y gastric bypass from a sleeve gastrectomy in 2 cases. None had varices or malignancy.

CONCLUSIONS

Preoperative UGI endoscopy yielded a high proportion of endoscopic abnormalities even in asymptomatic patients. Surgery was delayed to treat severe mucosal lesions and to investigate polypoidal findings in the majority. A change in surgical approach and surveillance for malignancy was needed in a few cases.

The effect of surgically induced weight loss on nonalcoholic fatty liver disease in morbidly obese Indians: "NASHOST" prospective observational trial

BACKGROUND

Surgically induced weight loss improves nonalcoholic fatty liver disease (NAFLD) in morbidly obese Caucasian patients. Similar data are lacking from India.

OBJECTIVE

To compare the histologic features of NAFLD in morbidly obese Indian patients before and 6 months after bariatric surgery. Histologic changes were also separately assessed according to the type of bariatric intervention.

SETTING

Teaching institution, India; private practice.

METHODS

All patients undergoing bariatric surgery from July 2012 to July 2013 underwent a routine liver biopsy at the time of bariatric surgery. If the biopsy specimen indicated NAFLD, patients were asked to undergo a second biopsy after 6 months. Baseline anthropometry, clinical data, biochemistry, and pathology were recorded and repeated at follow-up.

RESULTS

Eighty-eight of 134 index biopsy specimens indicated NAFLD. Thirty patients had paired liver biopsies. Steatosis was present in all, 14 had lobular inflammation, 10 had ballooning degeneration, and 14 had fibrosis. Mean time between the biopsies was 7.1 months (range 6-8 months). At the second biopsy, steatosis had resolution in 19 and improvement in 11, lobular inflammation had resolution in 12 and improvement in 2, ballooning had resolution in 9 and improvement in 1 and fibrosis had resolution in 11 and improvement in 3 (P<0.05 for all). Improvement was greater among those who underwent a sleeve gastrectomy in comparison to a Roux-en-Y gastric bypass, although this difference was not statistically significant. None had worsening of liver histologic results.

CONCLUSIONS

Surgically induced weight loss significantly and rapidly improves liver histology in morbidly obese Indians with NAFLD.

Sporadic giant mesenteric fibromatosis

Mesenteric fibromatosis is an uncommon tumour which is locally aggressive without any metastatic potential and can occur as a sporadic event or in association with familial adenomatous polyposis syndrome. Giant mesenteric fibromatosis is very rare and is a diagnostic and therapeutic challenge. This is a case report of a rare presentation of deep fibromatosis as a sporadic giant intrabdominal mesenteric tumour in a 29 year old male managed by surgical excision and definitive diagnosis made on the basis of immunohistochemical findings.

Implantation metastasis from adenocarcinoma of the sigmoid colon into a perianal fistula: a case report

Implantation metastasis from a colorectal cancer into a perianal fistula is very rare. Such lesions are commonly mistaken as benign perianal abscesses or fistulas and diagnosed only after pathological analysis of surgically excised fistulas. Once diagnosed, the management of this condition remains controversial. We report a case of perianal fistula that was unexpectedly found to harbor adenocarcinoma on biopsy. Further investigation by colonoscopy and computed tomography scan revealed a sigmoid adenocarcinoma. Abdominoperineal resection was performed. Histology and immunohistochemical staining was identical in both primary and metastatic tumors. We herein review the literature on the metastasis of colorectal cancer to a benign perianal fistula presumably acquired through implantation of viable malignant cells shed from the primary tumor and discuss the approach to this rare scenario in colorectal cancer surgery.

Three level risk assessment for pancreatic fistula formation after distal pancreatectomy with a strategy for prevention

BACKGROUND

Distal pancreatectomy (DP) has a high post-operative morbidity predominantly due to pancreatic fistula though the mortality is very low. Data on distal pancreatectomy was reviewed to analyse the risk factors that contribute to this morbidity.

METHODS

Thirty three patients underwent distal pancreatectomy with sutured closure of the remnant, over a 5-year period between May 2006 and April 2011. Pancreatic fistula (PF) was defined according to the International Study Group on Pancreatic Fistula definition. Patient and surgical risk factors were subdivided as those reflecting a poorer pre-morbid status, those associated with increased complexity of surgery and those related to pancreas gland and were analyzed for incidence of pancreatic fistula.

RESULTS

Indications for DP included 16 (51.5%) pancreatic tumours, 13 (39.4%) chronic pancreatitis and 3 (9.1%) trauma. Spleen was preserved in 12 patients (36.4%). There was no mortality while the morbidity rate was 45.5% (n = 15). Incidence of pancreatic fistula was 30.3% (n = 10); eight were grade A (80%) and two were grade C (20%). Incidence of clinically significant pancreatic fistulae was 6.1%. PF was significantly more common if the pancreatic duct was not identified (p = 0.024) was significantly less with extensive peri-pancreatic adhesions (p = 0.036).

CONCLUSIONS

Identification and ligation of main pancreatic duct can help reduce the incidence of pancreatic fistulae. The identification of patients at high risk of developing a PF helps to implement prevention strategies.

Reliable entanglement detection under coarse-grained measurements

We derive reliable entanglement witnesses for coarse-grained measurements on continuous variable systems. These witnesses never return a "false positive" for identification of entanglement, under any degree of coarse graining. We show that even in the case of Gaussian states, entanglement witnesses based on the Shannon entropy can outperform those based on variances. We apply our results to experimental identification of spatial entanglement of photon pairs.

No 72-hour pathological boundary for safe early laparoscopic cholecystectomy in acute cholecystitis: a clinicopathological study

BACKGROUND

The pathological boundary of acute cholecystitis (AC) between early edematous and late chronic fibrotic inflammation beyond 72 h is well-described. Early laparoscopic cholecystectomy (ELC) is safe in AC but the timing still remains controversial. The aim of this study was to analyze the impact of the duration of symptoms on clinical severity, pathology and outcome in patients who underwent laparoscopic cholecystectomy (LC) for AC during the urgent admission.

METHODS

A retrospective analysis of a prospectively collected database of 61 patients who underwent LC for AC over a 6-month period was performed.

RESULTS

Of 61 patients 21 (34.43%) received ELC at <72 h and 40 (65.57%) received late LC (LLC) at >72 h. Clinically in the ELC group the majority were mild and in the LLC group the majority were moderate and severe in severity grading as per Tokyo guidelines (P<0.001). Surgical findings and histopathology showed no significant difference in the distribution of simple, phlegmonous and gangrenous cholecystitis between both groups (P=0.94). The majority were completed by a standard four port technique and only one required subtotal cholecystectomy. There was no significant difference between operating time, return to normal activities or hospital stay between both groups. There were no conversions to open cholecystectomy, no wound infections, no intra-abdominal collections, no biliary tract injury or mortality in either group.

CONCLUSIONS

The degree of inflammatory change in AC is not dependent on time. LC can be safely performed in AC regardless of timing with a standardized surgical strategy in experienced units.

Torsion of pedunculated accessory liver lobe with acute acalculous cholecystitis

Accessory lobes of the liver are very uncommon and rarely symptomatic. We report the occurrence of torsion and infarction of a pedunculated accessory lobe of the liver with acute cholecystitis. The speculated possibilities of the coexistent pathologies and its management are discussed.

Early exposure to a high-fat diet has more drastic consequences on metabolism compared with exposure during adulthood in rats

The aim of this study was determine whether the introduction of a high-fat diet during the peripubertal phase induces significant changes in body weight control, glucose homeostasis and the parasympathetic tonus compared with the administration of this diet to adult rats. High-fat diet was offered to male Wistar rats at weaning or during adulthood. A group of rats received high-fat diet for 60 days, from weaning to 81-day-old (HF81) or from 60 to 120-day-old (HF120), whereas 2 other groups received a normal-fat diet (i. e., NF81 and NF120). We analyzed adiposity, glucose homeostasis, insulin sensitivity, and vagal nerve activity. High-fat diet increased the accumulation of adipose tissue in all of the rats, but the difference was greater in the rats that were fed the high-fat diet since weaning (p<0.001). The HF rats showed glucose intolerance with high levels of insulin secretion during the glucose tolerance test (p<0.01). Rats that were fed the high-fat diet presented severe insulin resistance, indicated by a low K itt (p<0.01). Interestingly, the HF81 rats exhibited greater insulin resistance compared with the HF120 rats (p<0.05). The recordings of vagus nerve activity showed that the HF rats had higher parasympathetic activity than the NF rats irrespective of age (p<0.01). Our results show that a high-fat diet offered to rats just after weaning or in adulthood both cause impairment of glycemic homeostasis and imbalance in parasympathetic activity. Importantly, the consumption of high-fat diet immediately after weaning has more drastic consequences compared with the consumption of the same diet during adulthood.

Revealing hidden Einstein-Podolsky-Rosen nonlocality

Steering is a form of quantum nonlocality that is intimately related to the famous Einstein-Podolsky-Rosen (EPR) paradox that ignited the ongoing discussion of quantum correlations. Within the hierarchy of nonlocal correlations appearing in nature, EPR steering occupies an intermediate position between Bell nonlocality and entanglement. In continuous variable systems, EPR steering correlations have been observed by violation of Reid's EPR inequality, which is based on inferred variances of complementary observables. Here we propose and experimentally test a new criterion based on entropy functions, and show that it is more powerful than the variance inequality for identifying EPR steering. Using the entropic criterion our experimental results show EPR steering, while the variance criterion does not. Our results open up the possibility of observing this type of nonlocality in a wider variety of quantum states.

Observation of a nonlocal optical vortex

We report the observation of an optical vortex in the correlations of photons produced from spontaneous parametric down-conversion. The singularity appears in a nonlocal coordinate plane consisting of 1 degree of freedom of each photon.

[Pulmonary embolism--mortality risk]

We conducted a retrospective analysis on 311 patients with clinical diagnosis of pulmonary embolism (PE) in a period of 3 years. 163 patients were excluded based on clinical-laboratorial criteria. The remaining 146 patients had a median age of 69 years (range: 30-91 years). 54% of the patients were male. We found dyspnea (94%), abnormal cardiopulmonary observation (89%), risk factors for venous thromboembolism (74%), tachycardia (53%), cyanosis (49%), and neck vein distension (45%) to be the most frequent findings. 64% of the patients had heart failure, 32% had myocardial ischemia, 13% had cancer, and 11% had myocardial infarction. Lactic dehydrogenase (LDH) was higher than two-fold in 54% of the patients. There was severe hypoxemia in 55% of the cases and hypocapnia in 43% of the cases. Creatinine phosphokinase (CPK) was elevated in 16% of the cases. Electrocardiography was suggestive of PE in 37% of the cases. Echocardiography showed right heart dysfunction in 30% of the cases, 92% of the patients were treated with heparin, 37 patients (25%) died, 54% of which during the first 4 days after admittance. Trying to define an index of mortality in PE we evaluated all patients by discriminant analysis coming up with 14 items with good discriminative power. By approximation of their odds-ratios we determined how many points would correspond to each item in the total sum.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coxsackie B4 infection, myopericarditis and diabetes mellitus]

The authors described a case of acute miopericarditis with evolution towards dilated cardiomiopathy, secondary to Coxsackie B4 infection, in a patient developing a concomitant insulin dependent diabetes (DIDM), admitted to be also an expression of this infection. The pathogenesis and the immunological basis of this aggression is discussed and some therapeutic considerations made.

[Neoplastic hypercoagulability. Apropos of 2 cases with Trousseau syndrome]

The authors describe two cases with venous thromboembolism and neoplasia (ovary and stomach), which also showed evidence of arterial thromboembolic phenomena--cerebrovascular disease in the 1st case and acute myocardial infarction in the 2nd case--favouring the existence of nonbacterial thrombotic endocarditis. This presentation of neoplastic hypercoagulability is frequently underrated in clinical practice. Pathogenesis, clinical manifestations, etiology, and therapeutics of these syndromes are discussed in relation to the presented cases.

[Growth control of experimental tumour. I. Host protection against tumour by previous inoculation of plasmatic membrane of tumour cell (author's transl)]

Proteins from plasmatic membrane of ascites and solid 20-methylcholantrene induced tumours cells in inbred mice and rats were obtained by isolation of vesicles of tumor cell membranes produced in glycerol solution. The tumour cells were not broken. In a syngeneic system the inoculation of the prepared protein with adjuvant resulted in protection of 50 to 100% of animals against challenge with a syngeneic tumour cells. The same results were obtained with Ehrlich ascites tumour. The lymphocyte cytotoxicity and blastic transformation of lymphocytes in immunized animals suggested a cellular cytotoxic immunity mediated by tumour specific antigen or perhaps by fetal antigen.