Prebiotic supplementation over a cold season and during antibiotic treatment specifically modulates the gut microbiota composition of 3-6 year-old children

Supplementing kindergarten children during a cold season with a prebiotic inulin-type fructans product with shorter and longer fructan chains has been shown to reduce febrile episodes requiring medical attention and to lower the incidence of sinusitis. These beneficial effects may be connected to the specific modulation of children’s gut microbiota. By applying quantitative and qualitative microbiota analysis this study aimed at characterising the gut microbiota composition and at exploring effects of prebiotic intervention on the gut microbiota during a 24-weeks intervention and during antibiotic treatment in healthy children. The study was a randomised, placebo-controlled trial with 258 healthy children aged 3 to 6 years consuming 6 g/day prebiotic inulin-type fructans or maltodextrin. During the course of the study, faecal samples were collected and subject to targeted qPCR analysis and phylogenetic profiling by multiplexed high throughput sequencing of the prokaryotic 16S rRNA gene PCR amplicons. The microbiota composition of the cohort could be clustered into three distinct constellations (enterotypes). Prebiotic intake resulted in a selective modulation of the gut microbiota composition. Relative abundance of Bifidobacterium was significantly higher in the prebiotic group (n=104) compared to control group (n=105) and this effect was found for all three enterotypes. Antibiotic administration decreased the relative abundance of Bifidobacterium in both groups. Nonetheless, children of the prebiotic group receiving antibiotic treatment displayed significantly higher levels of Bifidobacterium than children receiving the placebo control. Prebiotic supplementation induced specific changes in the gut microbiota composition of children aged 3 to 6 years. Moreover, it attenuated antibiotic-induced disturbances in the gut microbiota composition as shown by higher relative abundance of bifidobacteria at the end of the antibiotic treatment in the prebiotic group. With the previously reported benefits on immune function, the study contributes to the evidence on the immune-modulating effects of prebiotics through gut microbiota modifications. The study was registered as NCT03241355 ( https://clinicaltrials.gov/show/NCT03241355 ).

A Case of Carcinoid of Meckel's Diverticulum Associated with Gastric Adenocarcinoma

Meckel's diverticulum is an uncommon gastrointestinal congenital anomaly that occurs in 1-3% of the population. It is sometimes associated with complications related to the presence of ectopic tissue (obstruction, ulceration, hemmorhage, inflammation, perforation, fistula and tumors). Neoplastic degeneration of Meckel's diverticulum mucosa is rare, developing in only 1-5% of all diverticula, usually asymptomatic and occasionally discovered. Disease is metastatic, usually to the liver, in 25% of cases. We report a case of asymptomatic unsuspected carcinoid of Meckel's diverticulum with ileal, hepatic and mesenteric metastasis discovered during a gastrectomy performed for gastric adenocarcinoma. The patient underwent ileal and Meckel diverticulum resection, excision of mesenterial metastasis and liver bisegmentectomy. Furthermore, total gastrectomy with esophago-jejunal anastomosis was performed. After an 18-month follow-up period, the patient is alive and disease free. Owing to possible neoplastic degeneration, Meckel's diverticulum should be resected when occasionally discovered. In the presence of a carcinoid tumor, even if associated with metastatic disease, extended resection is recommended.

Surgical management of hepatocellular carcinoma within and beyond BCLC indications in a middle volume center

AIM OF THE STUDY

Current criteria for hepatic resection in patients with hepatocellular carcinoma (HCC) according to Barcellona Clinic Liver Cancer (BCLC) classification is debated. Actually, patients with multinodular or large HCC>5cm are excluded from surgical treatment following the algorithm, but several studies from referral centers showed that such patients may benefit from surgical resection in the clinical practice. The aim of this study was to compare short- and long-term outcomes after liver resection for HCC in stage 0/A or B in a middle volume center.

PATIENTS AND METHODS

Patients were grouped according to BCLC classification. Postoperative mortality, morbidity, overall and disease-free survival, univariate analysis of prognostic factors on survival was analyzed.

RESULTS

Among 66 surgical procedures in 64 patients included in the study, 41 were BCLC stage 0/A (62.1%) and 25 BCLC stage B (37.9%). The overall 30- and the 90-days mortality rates were 1.5% and 3%. Patients in BCLC stage B had higher transfusion rate (P=0.04) but similar morbidity and mortality compared to patients in BCLC stage 0/A. After a median follow-up of 35 months (range: 14-147), the overall survival at 1, 3 and 5 years resulted 95%, 61.1%, 46.2% for stage 0-A and 83.3%, 50%, 41.2% for stage B (P=0.73). Univariate analysis identified poorly differentiated tumors (P=0.02) and positive margin (P=0.02) as negative prognostic factors on survival.

CONCLUSIONS

Surgical treatment of HCC in BCLC stage B offers similar results than the ones in BCLC stage 0/A and consequently should not be considered contraindicated for such patients.

In vivo and in vitro liver cancer metabolism observed with hyperpolarized [5-(13)C]glutamine

Glutamine metabolism is, with its many links to oncogene expression, considered a crucial step in cancer metabolism and it is thereby a key target for alteration in cancer development. In particular, strong correlations have been reported between oncogene expression and expression and activity of the enzyme glutaminase. This mitochondrial enzyme, which is responsible for the deamidation of glutamine to form glutamate, is overexpressed in many tumour tissues. In animal models, glutaminase expression is correlated with tumour growth rate and it is readily possible to limit tumour growth by suppression of glutaminase activity. In principle, hyperpolarized (13)C MR spectroscopy can provide insight to glutamine metabolism and should hence be a valuable tool to study changes in glutaminase activity as tumours progress. However, no such successful in vivo studies have been reported, even though several good biological models have been tested. This may, at least partly, be due to problems in preparing glutamine for hyperpolarization. This paper reports a new and improved preparation of hyperpolarized [5-(13)C]glutamine, which provides a highly sensitive (13)C MR marker. With this preparation of hyperpolarized [5-(13)C]glutamine, glutaminase activity in vivo in a rat liver tumour was investigated. Moreover, this marker was also used to measure response to drug treatment in vitro in cancer cells. These examples of [5-(13)C]glutamine used in tumour models warrant the new preparation to allow metabolic studies with this conditionally essential amino acid.

Free-from-progression period and overall short preoperative immunotherapy with IL-2 increases the survival of pancreatic cancer patients treated with macroscopically radical surgery

BACKGROUND

The treatment of pancreatic cancer is still rudimentary, even in the case of locally limited tumors, because of the high frequency of recurrence due to severe suppression of the anticancer immunity that is further amplified by surgery-induced immunosuppression, evidenced by a decline in lymphocyte numbers during the postoperative period. Previous studies in colorectal cancer demonstrated that surgery-induced lymphocytopenia may be abrogated by a brief preoperative administration of IL-2.

MATERIALS AND METHODS

The study included 30 consecutive patients who were randomized to be treated by radical surgery alone as a control group or by a preoperative immunotherapy with IL-2 (12 MIU/day SC for 3 consecutive days) plus surgery.

RESULTS

Mean lymphocyte numbers significantly decreased in patients treated with surgery only, whereas it significantly rose in the IL-2-treated group. After a follow-up of 36 months, both the free-from-progression period (FFPP) and the overall survival were significantly higher in patients treated with IL-2.

CONCLUSION

These preliminary results suggest that a short-period preoperative immunotherapy with IL-2 is sufficient to modify host tumor interactions in operable pancreatic cancer, with a subsequent abrogation of postoperative lymphocytopenia and a prolongation of FFPP and overall survival time.

Pylephlebitis and mesenteric thrombophlebitis in sigmoid diverticulitis: medical approach, delayed surgery

A 57-year-old woman presented with fever, vomiting and arthralgia, with a history of rheumatoid arthritis. Laboratory tests showed leucocytes, anaemia and elevation of C-reactive-protein (CRP). Blood cultures were positive for Gram negative bacteria and Streptococcus viridans. Patient underwent abdominal Computed Tomography (CT) scan revealing sigmoid acute diverticulitis with peridiverticular abscesses and thrombophlebitis within the inferior mesenteric and portal veins. She started antibiotic and anticoagulant therapy. After 20 days, a second CT revealed a thrombosis involving the superior mesenteric vein also. After 22 days of therapy the patient was discharged with the resolution of the septic status. Two months after discharge the patient underwent left hemicolectomy for a histopathologically documented diverticulitis with an uneventful postoperative course. This is a description of a rare association of septic thrombosis within the portal, inferior mesenteric and superior mesenteric veins during acute sigmoid diverticulitis with abdominal abscesses. Our therapeutic strategy was a first line medical approach and delayed surgery.

Pylephlebitis and mesenteric thrombophlebitis in sigmoid diverticulitis: medical approach, delayed surgery

A 57-year-old woman presented with fever, vomiting and arthralgia, with a history of rheumatoid arthritis. Laboratory tests showed leucocytes, anaemia and elevation of C-reactive-protein (CRP). Blood cultures were positive for Gram negative bacteria and Streptococcus viridans. Patient underwent abdominal Computed Tomography (CT) scan revealing sigmoid acute diverticulitis with peridiverticular abscesses and thrombophlebitis within the inferior mesenteric and portal veins. She started antibiotic and anticoagulant therapy. After 20 days, a second CT revealed a thrombosis involving the superior mesenteric vein also. After 22 days of therapy the patient was discharged with the resolution of the septic status. Two months after discharge the patient underwent left hemicolectomy for a histopathologically documented diverticulitis with an uneventful postoperative course. This is a description of a rare association of septic thrombosis within the portal, inferior mesenteric and superior mesenteric veins during acute sigmoid diverticulitis with abdominal abscesses. Our therapeutic strategy was a first line medical approach and delayed surgery.

Cellular labeling with Gd(III) chelates: only high thermodynamic stabilities prevent the cells acting as 'sponges' of Gd3+ ions

MR-labeling of cells may be carried out by adding a Gd-based contrast agent to the incubation media. The amount of gadolinium internalized in HTC and C6 cells upon incubation with Gd-DTPA-BMA is circa one order of magnitude higher than those found with Gd-DTPA, Gd-DOTA and Gd-HPDO3A, respectively. The comparison of relaxometric and mass spectrometry determinations allows us to establish that only a minor fraction of intact Gd-DTPA-BMA is internalized into the cells. Moreover the binding/uptake behavior shown by Gd-DTPA-BMA resembles that found when GdCl(3) is added to the incubation medium. We suggest that the lower stability of Gd-DTPA-BMA is responsible for a shift in the dissociation equilibrium that results in the net transfer of Gd(3+) ions on the cell membrane followed by a slower internalization process. The transmetallation process is mediated by components of the incubation media, among which a dominant role is represented by phosphate anions. The uptake of Gd(3+) ions is clearly reflected in the drastic decrease of cell viability observed for cells labeled with Gd-DTPA-BMA.

A responsive MRI contrast agent to monitor functional cell status

It has been shown that insoluble Gd chelates are suitable MRI contrast agents for conditional activation by intracellular lipases. The DTPA-based, insoluble, inactive contrast agent was internalized into dendritic cells by phagocytosis. Cleavage of long aliphatic side chains by intracellular lipase activity leads to the contrast agents solubility and hereby its activation depending on the enzyme expression. Uptake and activation of the contrast agent was much reduced in Flt3+ CD11b+ progenitor cells. Detectability limits in the T(1)-weighted MR images were estimated in phantoms and in vivo in the rat brain. Marginal toxic effects were only observed at very high concentrations of the contrast agent. The chelate can easily be modified to be targeted by enzymes expressed during specific change of cell status like activation or differentiation. Such a system is suitable for functional cellular in vivo MR imaging.

Palliative surgery for recurrent bowel obstruction due to advanced ovarian cancer

AIM

Intestinal obstruction is a frequent event in patients affected by ovarian carcinoma. Little data on repeat palliative surgery for recurrent bowel obstruction are available. The aim of this study was to analyze postoperative and long term outcomes of ovarian cancer patients who underwent reoperation for recurrent intestinal obstruction.

METHODS

We retrospectively evaluated the records of these patients treated at our Department between 1992 and 2002.

RESULTS

Nine women with a mean age of 56 years (range 37-72) were identified. All patients had undergone previous abdominal surgery for bowel obstruction from ovarian cancer. All patients underwent exploratory laparotomy. In 4 patients (Group A) because of advanced disease, only exploratory surgery was carried out. A surgical correction was achieved in the other 5 patients (Group B), but only 3 patients had a successful palliation, defined as the ability to tolerate an oral intake for at least 60 days postoperatively. Postoperative mortality was nil, morbidity was 44.4%; particularly 2 patients developed an enterocutaneous fistula. Mean survival of Group A and B patients were 36.7 and 96.2 days respectively. The 3 successful palliated patients died of disease after 3.5, 4 and 5 months, in 2 cases for recurrent bowel obstruction.

CONCLUSIONS

Repeat surgery for recurrent bowel obstruction in advanced ovarian carcinoma may achieve successful palliation in few cases and is associated with high postoperative morbidity and limited survival. In these patients non surgical approaches based on medical treatment, percutaneous endoscopic gastrostomy and stent placement should be considered.

Sutureless and stapleless laparoscopic splenectomy using radiofrequency: LigaSure device

BACKGROUND

Bleeding is the main complication and cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the LigaSure vessel sealing system added to the lateral approach for achieving safe vascular control.

METHODS

We performed 63 consecutive LS in a 3-year period using LigaSure in two affiliated university hospitals. We employed a right semilateral position technique with dissection of the spleen and vessel sealing using LigaSure. Forty-two patients had benign hematological disease, 19 had malignant disease, and two had splenic cysts.

RESULTS

A total of 58 LS were completed with five conversions due to hilar bleeding (three cases), difficult dissection (one), and massive splenomegaly (one). In all but five patients, blood loss was less than 100 ml. No transfusions were needed. There were five postoperative complications: portal thrombosis (one case), hemoperitoneum (two), surgical wound infection (one), and pleural effusion (one).

CONCLUSIONS

The use of LigaSure, and the semilateral position, results in a gain of time and safety. Furthermore, average intraoperative bleeding is very low.

Immunodeficiency in different histotypes of radically operable gastrointestinal cancers

Cell-mediated immunodeficiency, with Total and T lymphocytes count decrease, is well established in cancer patients and it predicts a poor prognosis and poor survival rates. Furthermore, major surgery induces a transient immunodeficiency, too. Nevertheless, cell-mediated immunity in pancreatic cancer, which has a very poor prognosis, has not been completely outlined. Aim of this study is to evaluate the cell-mediated IL-2 dependent immune status in operable pancreatic cancer patients and to compare it with other gastrointestinal tumors. One hundred and twenty-one cancer patients (22 pancreatic, 48 gastric and 51 colorectal), with a median age of 66 years (range 42-83), 55 males and 66 females, were enrolled. Total lymphocyte count and lymphocytes subset (T helper count - CD4+) were assessed preoperatively and on the 14th and 50th postoperative day. Results obtained were compared between the groups and related to nodal involvement (N0 versus N+). Colorectal and gastric cancer patients showed quantitative lymphocyte deficiency at baseline in 29% and 41% of cases, respectively. Fourteen days after surgery values below normal range were found in 44% and 54% (Total) and 53% and 67% (T helper), respectively. Recovery of postoperative surgery-related lymphocytopenia occurred late only in patients with normal count at baseline. According to regional nodal involvement (pN0/N+) T helper deficiency was significantly more frequent in patients with nodal involvement than in patients without. In pancreatic cancer, percentage of immunodepressed patients at baseline was higher compared to the other two groups (71%). Lymphocyte count was significantly different between pancreatic and gastric/colorectal cancer, reaching a statistical significance at baseline and on the 14th and 50th postoperative day. No differences of T helper deficiency were noted according to nodal involvement (N0 versus N+) neither at baseline nor in the postoperative period. In conclusion, the degree of immunosuppression varies among different tumor types: since initial stages of disease, immunodepression was significantly greater in pancreatic cancer which should be considered always a systemic disease even in early stages and indipendently from the nodal involvement and from tumor load.

Gastrointestinal carcinoids. Prognosis and survival

BACKGROUND

Gastrointestinal carcinoid tumors are rare and little is known about factors related to prognosis in patients with carcinoid disease. Aim of this study is to determine the impact of clinical presentation variables on the management and survival.

METHODS

We have evaluated 31 consecutive patients with gastrointestinal carcinoid tu-mours who underwent surgical intervention at the I Department of Surgery of Milano-Bicocca University over 15 years (1985-1999). Tumor distribution, hormone production, prognostic factors and survival were analysed.

RESULTS

Carcinoid syndrome was the only clinical pattern diagnostic of carcinoid tumour. Most common symptoms were abdominal pain (64%), nausea and vomiting (48%). High levels of urinary 5-hydroxyindolacetic acid were significantly associated with carcinoid syndrome and metastatic disease. Tumor size, depth and gender were significant predictors of metastases. Age, gender, tumor size, metastatic spread and location were statistically significant predictors of death.

CONCLUSIONS

Clinical presentation was non specific except for those patients affected by carcinoid syndrome. Ten years overall survival was 43%, with 52% metastatic spread incidence. The extent of surgical resection should be modulated on patient related risk factors. Poor prognostic factors affecting survival were: age, gender, metastatic disease, depth of invasion and tumour size.

Alteration of hypothalamus-pituitary-adrenal gland axis in colorectal cancer patients. Preliminary report

AIM

In advanced cancer patients a cell-mediated immunological impairment, both at baseline and during postoperative period, is often found and is associated with poor prognosis. Cortisol is strictly involved in the response to major surgical stress, is an immunosuppressor and causes a redistribution of immunological population cells in different tissues. The aim of the study was to verify serum levels and circadian rhythm of cortisol in patients with colorectal cancer at baseline before surgery and in the postoperative period, and relate it to the immune status.

METHODS

In 21 patients with colorectal cancer undergoing surgery we evaluated the assessment of total lymphocytes, CD4+, cortisolemia, circadian rhythm of cortisol (11 p.m. and 8 a.m.) at baseline and in 3(rd) and 7(th) postoperative days.

RESULTS

Increase of cortisolemia, as decrease of total and CD4+ lymphocytes in the postoperative period versus baseline was statistically significant. Patients with an altered circadian rhythm were 47% and 36% at 3rd and 7th postoperative days, respectively. At baseline 19% of patients had an altered cortisol circadian rhythm and it was more frequent in patients with nodal involvement (p<0.05) and with metastasis (p<0.01). No relations between lymphocytopenia and alteration of cortisolemia and cortisol circadian rhythm were found, either at baseline or postoperatively (p<0.05).

CONCLUSION

Lymphocytopenia in cancer patients seems not to be associated with cortisol level and circadian rhythm alteration, either at baseline or after surgical stress. An impairment of circadian rhythm of cortisol was found at baseline in 19% of patients. It was significantly associated with the presence of metastatic disease.

Radical surgery does not recover immunodeficiency associated with gastric cancer

Cell-mediated immunodeficiency is known to occur in advanced cancer patients, but it is less characterized in earlier stages. Pre-existing immunodeficiency may impair the recovery of postoperative lymphocytopenia, occurring generally within 8-14 days after surgical stress. This study was aimed to verify whether immunodeficiency exists in patients with operable gastric adenocarcinoma and whether radical surgery may restore a count of peripheral blood T helper cells (CD4) and CD4/CD8 ratio within physiological normal values in the late postoperative period. Thirty-five consecutive patients (M/F 18/17; mean age 67 years, range 42-82) with histologically proven gastric adenocarcinoma, undergoing surgery with radical intent, were studied. Assessment of total lymphocyte count and lymphocyte subsets was performed by FAC scan at baseline, then postoperatively 14 and 50 days after surgery. Normal reference values were according to CDC criteria for HIV immunodeficiency (total lymphocyte > 1500/mmc; CD4 cells > 500/mmc; CD4/CD8 > 1.2). Surgical interventions, including D2 locoregional lymphadenectomy, were as follows: 19 Roux Y total gastrectomies; 3 Roux Y subtotal gastrectomies and 13 Billroth II subtotal gastrectomies. Pathological nodal staging was pN0 in 18 and pN+ in 17 cases. Hystotype was intestinal in 14 patients, diffuse in 14 and unclassifiable in 7. Grading was G1 n = 7; G2 n = 7; G3 n = 21. Lymphocyte immunodeficiency was found at baseline in 41% of patients and at 14 days after surgery in 67% of patients. Recovery of postoperative surgery-induced lymphocytopenia occurred on the 50th day only in those patients with normal values at baseline (59%). CD4 deficiency was significantly more frequent in pN+ vs. pN0 patients, either at baseline (p < 0.001 ), on the 14th day (p < 0.02) and on the 50th day (p < 0.007) postoperatively. Cancer-related CD4 deficiency was a frequent finding in our consecutive series of gastric cancer patients; this systemic immune impairment was not restored after complete tumor removal, even in late postoperative period (50th day ). Further studies on a larger number of cases may confirm the prognostic value of lymphocyte count in early gastric cancer stages, and to verify whether early and late postoperative immunodeficiency may be prevented by IL-2 administration.

Laparoscopic splenectomy using Ligasure. Preliminary experience

BACKGROUND

Intraoperative bleeding is the main complication and main cause of conversion during laparoscopic splenectomy (LS). We present the advantages of the use of the Ligasure Vessel Sealing System added to lateral approach for achieving a safe vascular control.

METHODS

Ligasure is an energy-based device which works applying a precise amount of bipolar energy and pressure to the tissue, achieving a permanent seal. We have performed a total of 35 LS in a 5-year period using different approaches and methods of dissection, including the anterior approach, monopolar coagulation, clips, endostaplers, and ultrasonic shears. In the last 10 patients (4 males and 6 females, mean age 24 yr) we employed a technique with 4 trocars, right semilateral position associated with the entire dissection of the spleen and vessels sealing (lower pole vessels, main vascular pedicles, short gastric vessels) performed with Ligasure. Six had thrombocytopenic idiopatic purpura (ITP), 2 hereditary spherocytosis and one each b-thalassemia and hemolytic anemia.

RESULTS

Nine LS were completed with one (10%) conversion because of hilar bleeding due to accidental injury with Ligasure. The average splenic weight was 485 g (range 265-1800), with an average diameter of 16 cm (range 12-25). In all but one patients (the converted one) the intraoperative blood loss was less than 100 mL (range 50-100 mL, average 80 mL). No blood transfusion were needed. The average operative time was 120 min (range 90-165), including 2 patients undergoing combined laparoscopic cholecystectomy. There was no mortality, with one (10%) postoperative complication (thrombosis of the spleno-portal axis), treated with a conservative approach. The average postoperative hospital stay was 3.5 days (range 3-6).

CONCLUSIONS

The use of Ligasure, associated with the lateral position, results in a gain of time and safety. Furthermore, the average intraoperative bleeding of this series is very low.

Mesenteric cyst neoformation. A case report

Mesenteric cysts are rare lesions, with 1 case per 100,000 hospital admission reported. They have to be differentiated from ovarian cysts, gastrointestinal duplications and desmoid cysts. The symptoms are variable, ranging from asymptomatic cases with incidental discovery to chronic abdominal discomfort and acute abdomen. They are usually correlated to the location and the size of the lesion. Abdominal ultrasonography and computed tomography may lead to a correct diagnosis, which is regularly made at the time of abdominal exploration. Surgery is the treatment of choice, consisting with the removal of the cyst, eventually associated with bowel resection. It has to be radical in order to prevent the recurrence of the disease. A case of mesenteric cyst in a sixty-nine-years-old woman hospitalized for chronic abdominal pain is reported. In this case the cyst has been enucleated from the mesentery with open surgery without the need for bowel resection.

Phase IB study on prevention of surgery-induced immunodeficiency with preoperative administration of low-dose subcutaneous interleukin-2 in gastric cancer patients

BACKGROUND AND OBJECTIVES

Low count of total and T helper lymphocytes predicts a poor prognosis in cancer patients and surgical trauma can worsen cancer-related immunodeficiency. Aim of this phase IB study is to verify toxicity and biological effects of interleukin-2 (IL-2) at 9 million IU/day subcutaneously (sc.) administered one, two or three preoperative days in patients with gastric cancer undergoing radical surgery.

METHODS

Absolute value of total and T-helper (CD4) lymphocytes were measured at baseline and at 7th, 14th, and 50th postoperative days in 12 gastric cancer patients, who preoperatively received IL-2 at 9 million IU/day sc. as follows: group A (4 pts) 1-day; group B (4 pts) 2-days; group C (4 pts) 3-days administration. T and total lymphocytes count were recorded and retrospectively analyzed in a historical control-group of 22 consecutive patients, age and stage-matched.

RESULTS

Toxicity consisted of fever grade I. In group A (1 day) T helper lymphocytes count decreased at 7th and at 14th postoperative day; in group B (2 days) and group C (3 days) no decrease of neither total nor T helper lymphocyte count occurred postoperatively, whereas in the historical group these parameters decreased significantly postoperatively and recovered only at 50th day.

CONCLUSIONS

Two- and three-day schedules of sc. IL-2 preoperative administration at 9 million IU/daily prevented postoperative lymphocytopenia, whereas one-day administration did not. Since the IL-2 dose was so tolerable, that it could be given safely as outpatient, based on the previous results on survival observed in colorectal cancer patients with 3-days schedule we suggest that a 3-day schedule of Interleukin-2 as outpatient preoperative treatment seems advisable for further studies in gastric cancer patients.

[Stomach lymphoma]

BACKGROUND

Primitive gastric lymphoma (PGL) is a rare tumour, and although its incidence is rising it is difficult to state the role of the various therapeutic methods in treating this disease. Aim of this study is to point out what sequence of treatment is more effective trying to find out some guidelines which can be useful in clinical practice.

METHODS

Retrospective analysis of clinical data of 54 patients with PGL admitted at a University surgical department during 10 years. All the patients underwent neoadjuvant or adjuvant chemotherapy and D2 gastrectomy. Follow-up ranged from 6 to 120 months. Survival was related to: Mushoff's stage of disease, the grade according to the Working Formulation and the sequence of treatment. Statistical analysis was performed by Kaplan-Maier method and the difference between survival curves was compared by log-rank test.

RESULTS

Mean postoperative hospital stay was 12 days and morbidity was 18%. Five and 10 years overall survival rates were 70 and 85%. There was a significant difference in survival between patients with high grade PGL and those with intermediate grade (p=0.0188) as well as in those with low grade (p=0.0435). Patients in stages IE-II1E had a significantly longer survival than those in stages IIIE-IVE (p=0.0123). Patients in stages IE-II1E underwent neadjuvant chemotherapy and surgery and survived longer than those in whom surgery preceded chemotherapy (p=0.0293) instead for patients in stages IIIE-IVE neoadjuvant chemotherapy shortened survival (p=0.0403).

CONCLUSIONS

In personal opinion, in patients in stages IE-II1E chemotherapy should be carried out before surgery, while in those in stages IIIE-IVE the reverse scheme is more effective in achieving longer survival rates.

[Serious complications of vertical banded gastroplasty. Case report]

Vertical banded gastroplasty, reported by Mason in 1982, is an effective method to control pathologic obesity (BMI>40 kg/m2). With the widespread of this procedure and the introduction of laparoscopic approach several complications are described in literature: gastroesophageal reflux, esophagitis, gastritis, gastric bleeding and perforations, prolonged vomit, dislocation of gastric ring, cholelithiasis, gastric fistulas, gastric stomal stenosis, dehiscence of vertical stomach staple line. From 2 to 10% of patients are reoperated because of inefficacy of treatment or short and long-term complications. Morbidity and mortality associated to reoperations are still high and it is difficult to identify criteria for an appropriate revision procedure. This can occur through endoscopy, laparotomy or laparoscopy, depending on clinical and radiologic feature. Dehiscence of vertical stomach staple line, observed in 10-20% of cases, even if asymptomatic, can lead to bad complications such as fistulas, peritonitis and sepsis. The case of a young woman, who underwent a vertical banded gastroplasty for pathologic obesity (117 kg, h 167 cm, BMI 42/m2) and subsequent laparotomies in the attempt to correct vertical staple line dehiscence, is reported. The patient came to our observation in a septic shock caused by peritonitis and ARDS and a total gastrectomy with Roux-en-Y esophago-jejunostomy was performed.

Mixed micelles containing lipophilic gadolinium complexes as MRA contrast agents

Mixed micelles for MRA are multicomponent systems containing a phospholipid, a biocompatible non-ionic surfactant (e.g. Synperonic(R) F-108) and a lipophilic gadolinium complex. A variety of lipophilic gadolinium complexes were designed taking into account features such as: (i) nature of ligand (cyclic versus acyclic); (ii) lipophilic moiety; (iii) global charge of the complex; and (iv) nature of bond connecting the complex to the lipophilic moiety. All the lipophilic gadolinium complexes after formulation as mixed micelles show high relaxivities in water and in blood (rat). Mixed micelles containing gadolinium complexes bearing only one aliphatic chain cannot be used as MRA contrast agents because they have a high haemolytic effect. Furthermore, in rats they are quickly eliminated from the blood stream. These drawbacks are completely circumvented using gadolinium complexes bearing two aliphatic chains. Mixed micelles containing such complexes show high relaxivities, no haemolytic effect and long blood permanence. This makes them promising candidates as MRA contrast agents. However, elimination, which occurs exclusively through the liver, is not complete, even after 7 days. Complexes containing labile (e.g. ester) bonds between the lipophilic moieties and the chelate subunit are eliminated through both the liver and the kidneys. However, elimination is still not complete after 7 days.

RETRACTED: Laparoscopic cholecystectomy and unsuspected gallbladder cancer

Gallbladder cancer is a relatively uncommon malignancy. Its presentation is similar to that of gallstone disease and sometimes with non-specific symptoms. Laparoscopic cholecystectomy has become the method of choice for removing the gallbladder in most benign conditions. Occasionally, unsuspected gallbladder carcinoma is encountered in association with laparoscopic cholecystectomy. Overall gallbladder cancers have a poor prognosis, despite surgery or adjuvant therapies. However, in selected cases, a favourable outcome can be expected and the less favourable predicted outcome can be improved. Management of patients with gallbladder cancer in different situations is discussed: gallbladder cancer noted post-operatively on final pathology, gallbladder cancer noted after removal of the gallbladder and opening of the specimen at the time of surgery, difficulty encountered at the time of dissection and resultant suspicion of gallbladder cancer, and diagnosis of extensive disease at initial placement of the laparoscope.

Abc protein transport of MRI contrast agents in canalicular rat liver plasma vesicles and yeast vacuoles

The mechanism of excretion into bile of hepatospecific magnetic resonance imaging (MRI) contrast media employed labeled Gd-reagents EOB.DTPA, BOPTA, B 20790 (iopanoate-linked), and B 21690 (glycocholate-linked) for measurement in rat liver canalicular plasma membrane vesicles and yeast vacuoles. The presence of ATP gave threefold greater transport of B 20790 and B 21690 than of EOB.DTPA and BOPTA. In yeast vacuoles the ATP stimulatory effect was eightfold with B 20790 and fivefold greater for B 21690, whereas in YCF1- or YLLO115w-deleted yeast cells the transport was significantly reduced and absent from double mutants, YCF1 and YLLO15w. The transport was similar in wild-type and deletant cells for B 21690; taurocholate gave 85% inhibition. These data suggest that bilary secretion of structurally related MRI agents depend on molecular structure. The findings are suggestive as of possible value for clinical diagnosis of inherited hyperbilirubinemias and other liver disorders.

[Gallbladder carcinoma and laparoscopic cholecystectomy. An emergent problem]

BACKGROUND

Gallbladder cancer (GC) is reported in 1.5-3% of cholecystectomies. Since the introduction of laparoscopic surgery, cholecystectomies have increased and occult GC may therefore be more frequent.

METHODS

Here we conduct a retrospective study on a series of 1200 LC performed between January 1991 and December 1998 at our Institution, to determine whether there was an increase in GC. We also evaluated the risk factors for this outcome and the possibilities of treatment, in case of unsuspected GC discovered after LC at histological examination. Seven cases of GC undiagnosed before surgery (0.6% of the study population) were submitted to LC (against 0.3% GC discovered after open surgery). The clinical course depended on the histopathologic stage of the cancer.

RESULTS

After a median follow-up of 18 months (range 12-48), 2 pT1 patients were alive and well, 2 pT2 patients were alive and disease free (in 1 case after a surgical removal of a trocar site metastasis appeared 6 months after LC). The other 3 patients died, 2 (1 pT2 and 1 pT3) after an additional resection of the liver bed with lymph node dissection, due to peritoneal dissemination of the disease. In 2 cases we found a gallbladder polyp pre and intraoperatively, which proved to be a carcinoma.

CONCLUSIONS

Undiagnosed GC is on the increase with the introduction of LC. Polypoid lesions of the gallbladder, age > 70 years: a long history of stones and a thickened gallbladder wall all represent significant risk factors. If one or more is present, examination of the gallbladder and a frozen section are recommended.

[Sequential endo-laparoscopic treatment in patients with common bile calculi]

BACKGROUND

Laparoscopic treatment of common bile duct (CBD) stones is gaining great acceptance worldwide, but actually it requires skills and technologies too expensive for a great part of general surgeons. So endoscopic removal of CBD stones before cholecystectomy is usually performed. Since 1991 in our department we started a policy of selective preoperative cholangiopancreatography (ERCP) in patients suspected for choledocholithiasis and waiting for laparoscopic cholecystectomy.

METHODS

A retrospective study has been made on a population of 1100 patients who underwent elective laparoscopic cholecystectomy in the period between January 1991 and December 1997. They were 391 male and 719 female with a mean age of 52 years, 126 of whom (11.5%) were selected to have ERCP preoperatively because they had clinical, biochemical and ultrasound signs of the presence of common bile duct stones (CBDS).

RESULTS

Successful cannulation of the CBD was achieved in 124 cases (98.4%), with failures due to ampullary diverticula. In 7 cases (5.5%) a precut was necessary to obtain cannulation. Sphincterotomy was performed in 113 patients (89.7%). In 93 patients (73.8%) stones were found (87 macrolithiasis and 6 microlithiasis); in 91 (97.8%) stones were removed in one (87) or two (4) endoscopic session. There were 2 major complications (one bleeding and one severe pancreatitis) due to ERCP or a sphincterotomy. Two patients developed symptoms from unsuspected common bile duct stones after LC and were removed endoscopically. No complications during LC were due to ERCP or ES.

CONCLUSIONS

Selective preoperative ERCP is an effective way of clearing the CBD stones before laparoscopic cholecystectomy, with low rate of complications related to endoscopic and laparoscopic procedures, and short mean hospital stay (5.5 days), according to the concept of minimally invasive treatment.

Laparoscopic versus open splenectomy: a comparative study

Laparoscopic splenectomy (LS) is gaining wide acceptance as a safe, effective alternative to open splenectomy (OS) in the treatment of hematologic disorders in adult and pediatric patients, with low conversion rates and complications. The aim of this retrospective case-control study was to compare two cohorts of patients, with similar characteristics, who underwent OS or LS in a single institution. The medical records of the initial 20 consecutive patients who underwent LS were reviewed and compared with a control group of 28 patients undergoing OS, matched for age, gender, diagnosis, splenic size and weight, and American Society of Anesthesiologists score. Data were collected regarding operative time, blood loss, blood transfusions, pathologic findings, accessory spleen detection, complications, ileus duration, and postoperative hospital stay. Nineteen patients underwent attempted LS. One procedure (5%) was converted to OS for uncontrolled hilar bleeding. Accessory spleens were detected in two cases in the LS group compared with four cases in the OS group (14%). Mean operative time was 165 minutes (range: 100-240 minutes) for LS and 114 minutes (75-180 minutes) for OS (P < 0.001). In the LS group a regular diet was tolerated 36 hours (range: 24-48 hours) after surgery compared with 72 hours (range: 48-96 hours) for the OS group (P < 0.001), and mean postoperative hospital stay was 4.1 days (range: 3-8 days) for LS, compared with 8.1 days (range: 5-12 days) for OS (P < 0.001). No differences were observed in blood loss, complication rates, or transfusion requirements. Compared with OS, LS requires more operative time (showing a learning curve), is comparable in blood loss, transfusion requirements, complication rates, and detection of accessory spleens and appears to be superior in terms of return of bowel function and hospital stay.

[Hernia repair with prolene mesh according to the Lichtenstein technique. Results of 692 cases]

BACKGROUND

Inguinal hernia repair with prolene mesh according to Lichtenstein "tension free" technique has gained great acceptance worldwide, showing efficacy to consolidate the posterior wall of the inguinal canal and to reduce recurrence risk because of tension on suture lines and postoperative pain. Personal experience of 692 hernias treated with this technique is reported.

METHODS

From January 1989 to December 1997, 692 patients were treated according to Lichtenstein at the General Surgery Department of the San Gerardo Hospital. Mean age was 60 years (range 18-88) with a male: female ratio of 13:1. Surgery was performed under local anesthesia in 185 cases, under epidural anesthesia in 317 and under general anesthesia in 190. Hernia was primitive in 647 cases (411 obliquo-external and 236 direct), while in 45 patients it was a recurrent hernia. In this series, 619 patients had monolateral inguinal hernia, while 73 had a bilateral one. In 40 cases hernia was incarcerated and in 8 strangulated.

RESULTS

Mean hospital stay was 2.3 days (range 1-8). Eleven (1.6%) early complications, were observed, with one periprosthetic infection which resolved after patch removal, 3 hematomas, 2 seromas and 2 wound infections. Furthermore, there were 32 (4.6%) late complications with only one recurrence (0.14%) in this series and 25 cases of persistent nerve irritation.

CONCLUSIONS

The results obtained with Lichtenstein "tension free" repairs of inguinal hernias confirmed this technique as easy to perform, also under local anesthesia, and associated with low rates of complications and without recurrences.

Abrogation of surgery-induced decline in circulating dendritic cells by subcutaneous preoperative administration of IL-2 in operable cancer patients

Surgery-induced immunosuppression is characterized by a decline in lymphocyte count, particularly T lymphocyte number. In addition, preliminary studies have shown that the postoperative period is also characterized by a decline in the number of circulating dendritic cells (DC), whose fundamental anticancer role has been recently demonstrated. Previous studies had already shown that the preoperative injection of IL-2 may completely abrogate surgery-induced lymphocytopenia, whereas its eventual influence on DC system during the perioperative period is still unknown. The present study was performed to evaluate the influence of IL-2 preoperative immunotherapy on the perioperative changes in circulating DC number in patients affected by colorectal cancer. The study included 14 consecutive patients, who were randomized to be treated with or without IL-2 presurgical immunotherapy (12 million IU/day for 3 days subcutaneously). Circulating immature and mature cells were evaluated before surgery and at days 3 and 7 of the postoperative period. The detection was made by FACS using monoclonal antibodies against CD123 and CD11c to recognize immature and mature DC, respectively. Surgery induced a significant decline in the mean number of both immature and mature DC. The pre-surgical administration of IL-2 completely abrogated surgery-induced decline in immature DC cell amount. Moreover, mature DC mean number was diminished only at day 3 of the postoperative period, since the value observed at day 7 was not significantly lower than that found before surgery. This preliminary study shows that surgery-induced immunosuppression is characterized also by a significant decline in the mean number of both immature and mature DC. Moreover, this study would suggest that the preoperative immunotherapy with IL-2 may counteract surgery-induced failure of DC system. Because of the fundamental antitumor role of DC, this evidence could have a prognostic impact on the clinical course of the neoplastic disease.

[Videolaparoscopic cholecystectomy. Experience and results in 1019 cases]

BACKGROUND

Laparoscopic cholecystectomy is now worldwide considered the elective therapy for biliary lithiasis. Morbidity, mortality and conversion rates reported in the literature are assessed between 1 and 6%, 0 and 0.9%, 3.6 and 7.2% respectively. Data on personal experience with 1019 attempted laparoscopic cholecystectomy are reported.

METHODS

In the period between 1991 and 1997 1019 laparoscopic cholecystectomy were performed. Patients were 361 males and 658 females (ratio M:F 1:2), with an average age of 51 years (range 5-85). Indications were: 647 symptomatic cholelithiasis, 28 hydrops, 121 empyemas, 76 cholecystocholedocolithiasis and 13 alithiasic cholecystopathy.

RESULTS

Conversion was necessary in 61 cases, with a conversion rate of 6%. Mean duration of surgery was 65 minutes (range 30-240) with a mean hospital stay of 2.1 days (range 1-10). No deaths occurred in our series, with a morbidity rate of 1.8% (18 cases, 7 major and 11 minor). Only 1 case of bile duct injury (0.1%) is reported.

CONCLUSIONS

In consideration of low conversion rate, low early and late morbidity, absence of bile duct injury, advantages for the patient and the opportunity of evolution of this surgery, laparoscopic cholecystectomy can be considered the standard treatment for biliary lithiasis.

[The use of the biofragmentable ring (BAR-Valtrac) in colon surgery]

BACKGROUND

Clinical results of colic anastomosis using biofragmentable anastomosis ring (BAR-Valtrac) are presented. Such a method showed to be a real alternative technique to the usual ones.

METHODS

Eighty-six colic anastomosis using BAR are collected, 76 of which performed as elective surgery and 10 in emergency. The patients were 47 males and 39 females, with a mean age of 64 years. In 63 cases the patients were affected by colic neoplastic disease, in 16 by complicated diverticular disease (stenosis or perforation) and 7 patients had neoplastic disease of other organs involving the colon BAR device was used in 48 colic reconstructions after segmentary resection and in 38 colic reconstructions after left hemicolectomy. In each case 31-34 mm BAR were used.

RESULTS

No perioperative death occurred in our series. Only one case (2%) of anastomotic leak was observed, while in 3 cases (4%) intestinal canalization disorders occurred. No problems for ring expulsion occurred in any patient. Three late complications were observed, as three cases of asymptomatic substenosis discovered during instrumental follow-up and spontaneously cleared up.

CONCLUSIONS

On the basis of clinical results, and according to those reported in literature BAR anastomosis is considered a safe, feasible and easy technique to perform colic anastomosis, even in emergency, limited to the intraperitoneal tract of the colon.

Pre-operative IL-2 immunoprophylaxis of cancer recurrence: long-term clinical results of a phase II study in radically operable colorectal cancer

This study evaluates retrospectively the outcome of 20 colorectal cancer patients radically operated (M/F 13/7; primary/recurrent 15/5; Dukes B=11; C=6; D=3) who received pre-operative IL-2 (18,000, 000 IU/daily s.c. for 3 days) and the outcome of 40 colorectal cancer (primary/recurrent 40/0) patients age, sex and stage-matched radically operated, as control group. After a median follow-up of 72 months, in the IL-2 pre-operative group we observed 6/20 recurrences (30%) vs. 19/40 (47.5%) in controls. Mean and median disease-free period in patients who relapsed were respectively 21 months and 20.5 months (range 6-36) in IL-2 group vs. 14.1 and 12 months in the control group (range 3-34). After a 5-year follow-up, 4/20 (20%) IL-2 treated patients were dead vs. 19/40 control patients (47.5%) (log-rank chi2=3.7, p=0.05). Pre-operative IL-2 administration is safe, active in preventing post-operative lymphocytopenia and seems to improve the clinical outcome in radically operated colorectal cancer patients.

Combined laparoscopic splenectomy and cholecystectomy for the treatment of hereditary spherocytosis: is it safe and effective?

Hereditary spherocytosis is the most common red blood cell membrane disorder and often is associated with hemolytic crisis and premature cholelithiasis. Splenectomy is the only effective therapy for this disorder and often it is performed in combination with cholecystectomy. Conventional surgery requires a wide upper abdominal incision for correct exposure of the gallbladder and spleen. Laparoscopic cholecystectomy and splenectomy have been performed safely worldwide. We report our experience with seven patients (one male and six female, average age 12 years) who underwent combined laparoscopic splenectomy and cholecystectomy for hereditary spherocytosis. The patient was placed in supine position and the procedure performed with a five-trocar technique. Cholecystectomy was performed first, then splenectomy was achieved and the spleen removed by morcellation into a retrieval bag (five cases) or via a 4- to 5-cm left subcostal incision (two cases). No patient required conversion to open technique or blood transfusion. The mean blood loss was 162 mL, mean operative time 207 minutes, mean spleen size 14.5 cm, and median postoperative hospital stay 4 days. No perioperative mortality or major complications occurred in our series. After a median follow-up of 18 months all patients showed sharp hematologic improvement. Despite the small number of cases, we consider the combined laparoscopic approach safe and effective for the treatment of hereditary spherocytosis.

Molecular mechanisms for the hepatic uptake of magnetic resonance imaging contrast agents

The mechanisms were investigated for the hepatic transport of 4 different gadolinium complexes used as contrast agents for magnetic resonance imaging (MRI). In basolateral rat hepatocyte plasma membrane vesicles, Gd-DTPA uptake was indistinguishable from non-specific binding to vesicles; Gd-BOPTA and Gd-EOB-DTPA entered plasma membrane vesicles following a linear, concentration-dependent mechanism up to 1.5 mM of substrate. By contrast, Gd-B 20790 uptake followed a saturative kinetic with an apparent Km of 92 +/- 15 microM and a Vmax of 143 +/- 42 pmol/mg prot/15 sec, and it occurred into an osmotic-sensitive space. Sulfobromophthalein ant taurocholate, but not unconjugated bilirubin inhibited the uptake rate of Gd-B 20790 but not that of the other three compounds. Injection into Xenopus laevis oocytes of 5 ng of human OATP cRNA resulted, after 3 days, in a >/=2-fold stimulation (p < 0.001) of transport of Gd-B 20790 but not of Gd-BOPTA or Gd-EOB-DTPA. Collectively, these data indicate that the hepatic uptake of the MRI contrast agent Gd-B 20790 is a carrier-mediated mechanism operated by OATP while MRI compounds with other chemical structures enter the hepatocyte by other mechanisms.

Laparoscopic splenectomy for hematological disorders. Our experience in adult and pediatric patients

Laparoscopic splenectomy has gained increasing acceptance in the surgical management of a variety of splenic disorders, in particular hematological diseases. In this series, we report our experience with 20 patients (male:female ratio of 4:16 with median age of 16 years, range 5-49 years) who underwent this procedure because of ITP in 9 cases, spherocytosis in 7 and Cooley disease, sickle cell anemia, dyserythropoietic and hemolytic anemia in one case each. The patient was placed in a supine position using a fourtrocars technique. We did not perform pre-operative splenic artery embolization in any case. Spleen lower pole and its posterolateral attachments were dissected first, using electrocautery and endoclips. Vascular hilar isolation was achieved with an EndoGIA stapler and the spleen was removed by morcelation within a retrieval bag (16 cases) or via a 4-5 cm left subcostal incision (4 cases). One patient required conversion to open technique (conversion rate 5 %), because of uncontrolled bleeding from splenic hilum. Mean operative time was 165 min (range 100-240 min), mean splenic size was 13.5 cm (range 11-20 cm), with weight ranging between 140 and 1060 g and estimated blood loss was 151 ml (75-280 ml). No patient required a blood transfusion. Median postoperative hospital stay was 4 days (range 3-8 days). Postoperative complications occurred in 2 patients (10%), with no mortality rate in this series. Regarding the low complication rate and the advantages of a small abdominal trauma in the postoperative period, such as less postoperative pain, faster hospital discharge and better cosmetic results, the laparoscopic approach for elective splenectomy in hematological disorders has a substantial benefit for the patient.

[Hernioplasty using a Lichtenstein polypropylene mesh]

"Tension free" technique with prosthetic mesh for inguinal hernia repair was introduced since 1988 in Authors' Institution. In a review of 98 hernioplasties performed, only one relapse was observed (around 1%), while prosthetic infection cases were never observed. The disorder most frequently complained by the patients is a pain in the pubic area, persisting even months after the operation. Therefore this technique seems to be reliable, safe, and easy. While waiting for a long-term follow up to confirm these results, the Authors however suggest to limit the indications for this technique avoiding the use of prosthetic material in young patients since Shouldice's hernioplasty assures a low percentage of relapse for them.

Hepatocyte-directed MR contrast agents. Can we take advantage of bile acids?

A series of gadolinium complexes conjugated to bile acids was prepared and investigated as possible hepatospecific MR imaging contrast agents. In the design of such compounds, features such as the nature of the bile acid, the site of conjugation on the bile acid skeleton, and the global charge of the conjugate were taken into account. Relaxivity measurements carried out in human serum indicate interaction of the conjugates with human serum proteins; even small structural variations significantly affect relaxivity in human serum. Pharmacokinetic data (biliary elimination in the range of 18.4-45.6%) show that bile acids can be used as address moieties to transport gadolinium complexes through hepatocytes. For a homogeneous series of compounds, differing only in the bile acid residue conjugated, it was unexpectedly found that cholic acid is twice as efficient an address moiety as cholylglycine or cholyltaurine. Preliminary results show that none of the conjugates is transported through the basolateral membrane of hepatocytes by the Na+/taurocholate carrier.

Pre-operative interleukin-2 immunotherapy induces eosinophilic infiltration in colorectal neoplastic stroma

Interleukin-2 (IL-2) may induce peripheral eosinophilia and this phenomenon is related with response to IL-2 immunotherapy in patients with metastatic renal cell carcinoma. In previous experiences is reported that preoperative course with IL-2 may reverse the surgery-induced immunosuppression. This study's objective is to evaluate the histological changes of inflammatory infiltration in tumour stroma, in patients pretreated with IL-2 immunotherapy. 7 patients admitted to our surgical department with resectable recurrent colorectal cancer were treated with pre-operative course of IL-2; the tissue samples were analyzed for eosinophilic and inflammatory infiltration and compared with the samples obtained in the primary operation, performed without immunotherapy. In all patients were observed an increase of eosinophilic infiltration in tumour tissue. The mean increase were 200%, with high statistical significance (p < 0.0001). IL-2 pre-operative immunotherapy is able to change the interaction between host and tumour, by modifying the histological inflammatory infiltration in colorectal cancer tissue.

The chemistry of iomeprol and physico-chemical properties of its aqueous solutions and pharmaceutical formulations

The synthesis and the chemical characterization of iomeprol, a new triiodinated nonionic radiographic contrast agent, are reported. The physico-chemical properties both of aqueous solutions of the pure compound and of its pharmaceutical formulations are presented and these last data are compared with those of other contrast media. The pharmaceutical development of the product is described. Iomeprol is obtained via a synthesis which is particularly friendly to the environment. The compound shows an unusually high solubility which allows the formulation of contrast media with the lowest osmolalities and viscosities as compared with corresponding contrast media of the same category. In view of these favourable characteristics and of the remarkably high stability of its solutions, iomeprol for injection is formulated also at 400 mgI/ml, the highest concentration so far available on the market for non-ionic contrast media.

Gd(DOTP)5-outer-sphere relaxation enhancement promoted by nitrogen bases

The relaxation properties of Gd(DOTP)5- (1, 4, 7, 10-tetra-azacyclododecane- N,N',N'',N'''-tetrakis(methylenephosphonic acid)) have been investigated as a function of pH, temperature, concentration, and magnetic field strength. We have found that the complex has one exchangeable water molecule in its inner coordination sphere, at a distance of 3.26 A from the metal ion, and it does not form oligomers in solution in the concentration range 0.2 to 10 mM. The possible presence of two species in solution with an average fractional hydration number is also taken into accounts. The NMRD profiles were recorded at 5 degrees C, 25 degrees C, and 35 degrees C and quantitatively analyzed in terms of the paramagnetic relaxation equations. Interestingly the addition to a solution of the Gd(III)-complex of nitrogen bases results in a marked relaxation enhancement, which shows a strong pH dependence with a maximum around pH = 9. The relaxivity gain has been shown to depend on outer-sphere effects originating from multiple electrostatic interactions between the anionic complex and the organic cations that bring the exchangeable protons of the substrate molecules in to close proximity with the paramagnetic center. High resolution NMR relaxation data for N-methyl-D(-)-glucamine suggest that the hydroxyl group on the beta-carbon plays a role in stabilizing the interaction, presumably through a hydrogen bond with an uncoordinated oxygen atom of the complex.