Postoperative day one systemic inflammatory response syndrome is a powerful early biomarker of clinically relevant pancreatic fistula

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most feared complication following pancreaticoduodenectomy (PD). There is increasing evidence that very early postoperative factors can be helpful to identify high-risk patients. The aim of this study is to analyze whether postoperative day one (POD1) systemic inflammatory response can be used as an early biomarker of CR-POPF development.

METHODS

All patients undergoing PD from 2014 to 2020 were considered. Variables were extracted from a prospectively held database. Clinical and perioperative variables, including POD1 systemic inflammatory response syndrome (SIRS) and C-reactive protein level were collected. To elucidate the independent role of early CR-POPF biomarkers, multivariate hierarchical logistic regression analyses were planned.

RESULTS

Out of 243, 213 patients were included in this analysis. CR-POPF occurred in 49 (23.0%) patients and 90-day mortality was 1.4%. POD1 SIRS was reported in 65 (30.5%) patients. Following hierarchical logistic regression analyses, CR-POPF was independently associated with body mass index (OR = 2.787, p = 0.003), soft pancreatic texture (OR = 4.258, p = 0.002) and POD1 SIRS (OR = 50.067, p = 0.001).

CONCLUSION

POD1 SIRS is powerfully associated with CR-POPF and therefore it could be used as a tool to optimize postoperative care of PD patients. Further prospective studies are needed to validate these findings.

Rotation thromboelastometry velocity curve predicts blood loss during liver transplantation

BACKGROUND

Patients undergoing liver transplantation (LT) have a high risk of bleeding. The goal of this study was to assess whether the first derivative of the velocity waveform (V-curve) generated by whole blood rotation thromboelastometry (ROTEM^®) can predict blood loss during LT.

METHODS

Preoperative V-curve parameters were retrospectively evaluated in 198 patients. Patients were divided into quartiles based on blood loss: low (LBL) in the first quartile and high (HBL) in the higher quartiles. A subgroup analysis was performed with patients stratified according to cirrhosis aetiology. A logistic regression model and receiver operator characteristics (ROC) curve were used to test the capacity of the V-curve, to discriminate between LBL and HBL.

RESULTS

In the HBL group, the V-curve showed a lower maximum velocity of clot generation (MaxVel), a lower area under maximum velocity curve (AUC), and a higher time-to-maximum velocity (t-MaxVel) than in the LBL group. t-MaxVel was the only parameter showing a capacity to discriminate between the two groups, with a ROC area of 0.69 (95% CI; 0.62-0.74). The ROC area was 0.78 (95% CI; 0.75-0.83) for the 148 patients with cirrhosis, 0.73 (0.60-0.82) for patients with viral hepatitis and 0.83 (0.78-0.96) for patients with alcoholic hepatitis, the group that showed the best discriminative capacity. Moderate but significant correlations were found between all parameters of V-curve and BL.

CONCLUSIONS

Pre-transplant V-curve obtained from ROTEM is a promising tool for predicting BL risk during LT, particularly in patients with cirrhosis.

How long should initiation of calcineurin inhibitors be delayed to protect renal function in liver transplantation?

BACKGROUND AND AIM

Delayed introduction of calcineurin inhibitors (CNI) in liver transplantation (OLT) seeks to protect renal function, although the optimal length of the delay is not well established. The aim of this study was to analyze the effects on renal function of CNI initiation on different days after OLT.

METHODS

We reviewed the charts of 260 OLT recipients. Group D1-a (n = 36) underwent the standard initial immunosuppression at our center: namely, CNI introduction on day 1 with further daily administration to achieve target levels of 8 to 15 ng/mL for tacrolimus or 150 to 300 ng/mL for cyclosporine. Due to renal concerns, 126 patients (group D1-b) had CNI introduced on day 1 either not daily or at doses to achieve less than the target on at least two occasions. In 43 patients (group D2), CNI were introduced on day 2 in 23 on day 3 (group D3), in 12 on day 4 (group D4), and at least at day 5 in 20 others (group D5). In periods without CNI treatment, patients received mycophenolate mofetil. Steroids were administered to all patients. The study period included the first 3 months post-OLT. Renal function was estimated as creatinine clearance (CrCl) using the Cockcroft-Gault equation.

RESULTS

Changes in CrCl from pre-OLT to month 3 were -19% ± 28% in group D1-a; -27% ± 19% in group D1-b; -29% ± 19% in group D2; -23% ± 26% in group D3; -4% ± 38% in group D4, and +4% ± 33% in group D5 (P < .05 vs groups D1-a, D1-b, D2, and D3). On multivariate analysis, CNI introduction at day ≥ 5 was protective for kidneys when adjusted for other variables that potentially influence renal function.

CONCLUSION

CNI should be introduced at day 5 after OLT to protect renal function.

Hepatitis C virus compartmentalization and infection recurrence after liver transplantation

Hepatitis C virus (HCV) compartmentalization may have important implications in the pathogenesis of HCV infection. The aim of this study was to investigate the presence and relevance of HCV compartmentalization in the setting of liver transplantation (LT). We collected samples of serum, peripheral blood mononuclear cells (PBMC), perihepatic lymph nodes (PLN) and liver explant at the time of LT, and serum and PBMC after transplantation from 57 HCV-infected cirrhotic patients undergoing LT: 38 individuals received antiviral treatment before LT and 19 were untreated controls. HCV-RNA levels were determined by real-time PCR and the hypervariable region 1 (HVR-1) was sequenced. HCV-RNA was detected in all samples from control patients. In virological responders, recurrence after LT was associated with residual HCV-RNA in the liver explant. Within the entire cohort, 47% of patients harbored differences in direct sequences from distinct compartments. Quasispecies analysis revealed that in most cases, HVR-1 sequences recovered after infection recurrence were identical or closely related to those isolated from the liver explant and serum at the time of LT. Our study shows that a significant proportion of HCV-infected cirrhotic patients exhibit compartmentalization. Viral variants originating within the liver appear to be the main cause of HCV recurrence after LT.

Impact of donor age and year of transplantation on graft and patient survival following liver transplantation for hepatitis C virus

BACKGROUND

Hepatitis C virus (HCV) infection has become the most common indication for liver transplantation (LT). Graft and patient survival are adversely affected by recurrent infection of the graft. Recent publications have described an inferior outcome for recently transplanted HCV patients and have highlighted the impact of advancing donor age on severity of recurrent HCV. The donor age at which a measurable impact on graft and patient outcome can be observed has not clearly been defined. In addition, the impact of donor age on graft and patient survival for non-HCV patients needs to be examined.

METHODS

We have examined a large European liver transplant database to define the impact of transplantation date and donor age on graft and patient survival for HCV patients (n = 4,736) and the impact for a comparison group of transplanted alcoholic liver disease patients (ALD, n = 5,406).

RESULTS

For the entire cohorts, graft and patient survival of HCV patients was inferior to ALD patients. Since 1987, there has been a steady and ongoing improvement in the outcome of transplanted ALD patients, an improvement not observed for HCV patients. Every year since 1989, there has been an increase in liver donor age. Graft and patient survival for both ALD and HCV cohorts was adversely affected by advancing donor age. Comparison of graft and patient survival for HCV and ALD cohorts was made according to donor age (donor age subgrouped <20, 20-30, 30-40, 40-50, 50-60 and >60 years of age). For donors younger than 40 years of age, HCV and ALD recipient graft and patient survival are not significantly different. For donors older than 40, HCV recipient graft survival is inferior to ALD graft survival, an inferiority that increases for each advancing decade of donor age. For donors older than 50 years, HCV recipient patient survival is inferior to ALD patient survival, an inferiority that increases when the donor age is greater than 60 years.

CONCLUSION

The results of liver transplantation for European HCV patients is inferior to a comparison group of ALD patients, and have not improved during the past 15 years. Liver donor age has increased significantly during that period. Advancing donor age has an adverse influence on graft and patient survival for ALD and HCV patients, but a significantly greater impact is observed for HCV patients when the donor is older than 40 years.

Liver transplantation in high-risk patients: hepatopulmonary syndrome and portopulmonary hypertension

Two pulmonary vascular disorders, considered mutually exclusive, may be present in candidates for orthotopic liver transplantation (OLT). On the one hand, hepatopulmonary syndrome (HPS), with a prevalence about 20% in end-stage liver disease, is characterized by pulmonary vascular dilatation and abnormal gas exchange. On the other hand, portopulmonary hypertension (POPH), a process defined by pulmonary hypertension associated with portal hypertension, is less common than HPS (4%). These entities have very distinct clinical implications; whereas HPS is clinically characterized by respiratory symptoms that evolve to severe hypoxemia, patients with POPH are commonly asymptomatic, frequently diagnosed in the setting of OLT, and the symptoms appear when there is hemodynamic compromise. The pathogenesis of both entities is a putative mechanism, the imbalance of vasoactive substances in pulmonary vessels. The role of OLT to reverse these vascular disorders is controversial, although complete resolution of HPS and, less frequently, POPH following OLT has been reported. The recognition that the presence of both HPS and POPH is an important cause of morbidity and mortality among recipients of OLT has resulted in a change in the policy to select OLT candidates. Accurate identification of patients with pulmonary vascular disorders associated with liver disease should be the first step in the management of OLT candidates. Because the determinants of the prognosis of OLT in the setting of these pulmonary vascular changes have not been well established, an accurate cardiopulmonary evaluation with careful assessment of pulmonary gas exchange (in HPS) and right ventricular function (in POPH) of potential OLT recipients is mandatory before the procedure.

Cost/efficacy clinical trial about the use of T-tube in cadaveric donor liver transplant: preliminary results

Biliary reconstruction is the most common cause of morbidity associated with orthotopic liver transplantation. Our objective was to assess the complications and hospital resources related to the use of a T-tube.

MATERIAL AND METHODS

Among 95 liver transplants performed from October 2002 to November 2003, 84 patients were randomized to receive a T-tube or no T-tube. We analyzed all patients with a follow-up of at least of 3 months.

RESULTS

Fifty-five transplants were analyzed with 8 months mean follow-up, including twenty eight with T-tube and twenty seven without a T-tube. No patient died during the follow-up. The overall rate of biliary complications was 45.4% (25/55) including 21/28 (75%) in the T-tube group and 4/27(14.8%) in the non-T-tube group (P < .0001). Complications related to T-tube extraction occurred in 48.2% (13/27), including 3 cholangitis and 10 leaks. The costs of hospital resources due to radiological studies were 5329 capital JE, Ukrainian for the T-tube group vs 5785 capital JE, Ukrainian for the non-T-tube group. The costs of hospital resources due to treatment were 28,280 capital JE, Ukrainian for the T-tube group vs 10,088 capital JE, Ukrainian for the non-T-tube group.

CONCLUSIONS

Use of a T-tube during orthotopic liver transplantation does not seem justified. Biliary anastomosis stenting is followed by an increased incidence of complications, most of which are related to its use. Hospital stay, radiological studies, and cost of hospital resources are higher among the T-tube patients. Therefore its systematic use is not advisable.

Role of dopamine in renal dysfunction during laparoscopic surgery

BACKGROUND

Sympathetic vascular insult and hemodynamic changes represent the most reliable explanation of renal impairment resulting from acute intraabdominal pressure. We evaluated the effects of low-dose dopamine administration during a long-lasting surgical laparoscopic procedure.

METHODS

For this study 40, patients submitted to a colorectal laparoscopic procedure with 15 mmHg of intraabdominal pressure were randomly allocated to two groups: 20 receiving 2 mg/kg/min of dopamine and 20 receiving the same perfusion of saline. Hemodynamic parameters, renal function, urinary output, and creatinine clearance, were studied.

RESULTS

The hemodynamic parameters were similar in both groups. The urinary output decreased during the intraoperative period only the saline group (p = 0.4). Then 2 h postoperatively, it increased in both groups, and no statistically significant differences were found between the groups. The creatinine clearance decreased in both groups during the intraoperative time, but it was worse in the saline group (-28 +/- 120 vs -194 +/- 106; p = 0.022). During the postoperative period, both groups showed improvement, but in control group the values remained lower than at baseline (p = 0.04), and significantly lower than in the dopamine group (230 +/- 337 vs 100 +/- 192; p = 0.012).

CONCLUSIONS

An intrabdominal pressure of 15 mmHg induces a time-limited renal dysfunction, and low doses of dopamine could prevent this undesirable effect.

Ascites after liver transplantation

Massive ascites after liver transplantation, although uncommon, usually represents a serious adverse event. The pathogenesis of this complication has not been adequately investigated. To determine the incidence, characteristics, and pathogenic factors of massive ascites after liver transplantation (ascitic fluid > 500 mL/d for >10 days), the charts of 378 liver transplant recipients were reviewed. Massive ascites occurred in 25 patients (7%). Mean ascitic fluid production was 960 mL/d (range, 625 to 2,350 mL/d), and the duration of ascites was 77 days (range, 15 to 223 days). The ascitic fluid had a high protein content (36 +/- 7 g/L; range, 25 to 50 g/L). When patients who did and did not develop massive ascites were compared, significant differences were found in receptor sex (men, 88% v 60%, respectively; P <.01) and surgical technique (inferior vena cava preservation with piggyback technique, 72% v 41%; P <.01). Significantly increased wedged and free hepatic venous pressures and gradients between hepatic vein and right atrial pressures were found in patients who developed ascites, suggesting a difficulty in graft blood outflow. Massive ascites was associated with renal impairment, increased incidence of abdominal infection, prolonged hospitalization, and a tendency toward reduced survival. In conclusion, massive ascites after liver transplantation is relatively uncommon but associated with increased morbidity and mortality and is predominantly related to difficulties of hepatic venous drainage. Measurement of hepatic vein and atrial pressures to detect a significant gradient and correct possible alterations in hepatic vein outflow should be the first approach in the management of these patients.

Liver transplantation for small hepatocellular carcinoma: the tumor-node-metastasis classification does not have prognostic power

Tumoral recurrence rate and survival of patients with hepatocellular carcinoma (HCC) treated by orthotopic liver transplantation (OLT) depend on tumor stage. Thereby, from the beginning of our program, we selected only patients with solitary tumors < or = 5 cm without vascular invasion, thus avoiding the use of the tumor-node-metastasis (TNM) staging system as a selection tool. The present study reports the results obtained in 58 consecutive patients (52 +/- 8 years, 47 males) with HCC (7 incidentals) transplanted between 1989 and 1995. Transplantation was indicated because of tumor diagnosis in 40 cases and advanced liver failure in 18. Mean tumor size at staging was 28.2 +/- 12.1 mm. No adjuvant treatment was applied during the waiting period (58.9 +/- 45.1 days). The pathological tumor-node-metastasis (pTNM) classification allocated 15 patients to stage I, 19 to stage II, 11 to stage IIIA, and 13 to stage IVA showing preoperative understaging in 43% of the cases with known tumor. After a median follow up of 31 months, only two patients have shown tumor recurrence and fifteen have died, the 1-, 3-, and 5-year survival being 84%, 74%, and 74%. All HCV+ patients remain infected and 94% showed significant liver disease (6 cirrhosis). Six patients have had a second transplant. In conclusion, the application of restrictive criteria not following the TNM staging system prompts excellent results for liver transplantation in patients with HCC, both in terms of survival and disease recurrence, even without applying adjuvant treatment; however, the survival data should be tempered by the appearance of complications that may worsen the long-term prognosis.

Prolonged pneumoperitoneum at 15 mmHg causes lactic acidosis

BACKGROUND

Acute increases in intraabdominal pressure (IAP) induce systemic and regional circulatory changes. Besides, mechanical compression on the capillary beds may decrease oxygen availability to the tissues. The purpose of this clinical study was to analyze the effects of increased IAP on acid-base disturbances and plasma lactate levels during prolonged carbon dioxide pneumoperitoneum.

METHODS

Twenty-eight patients undergoing laparoscopic sigmoidectomy were included in this study. Fourteen of them (group A) had IAP of 15 +/- 1 mmHg while the remaining 14 (group B) had IAP of 10 +/- 1 mmHg. The control group included six patients undergoing conventional sigmoidectomy.

RESULTS

A progressive significant increase in PaCO2 was observed in the laparoscopic groups (p < 0.01). Plasma lactate levels in group A significantly increased 90 min after insufflation (p < 0.05) and reached the highest value 1 h after deflation (9.9 +/- 1 vs 31.9 +/- 2.5 mg/dl, p < 0.005). Simultaneously, arterial pH decreased in all groups; however, at 1 h after surgery, it was significantly lower (p = 0.02) in group A. There was a significant correlation between acid concentration due to lactate and lactate concentration (GA: R2 = 0.717, p = 0.03; GB: R2 = 0.879, p = 0.006 and GC: R2 = 0.853, p = 0.008).

CONCLUSION

High IAP causes lactic acidic accumulation in patients undergoing prolonged laparoscopic procedures.

Moderate primary pulmonary hypertension in patients undergoing liver transplantation

Primary pulmonary hypertension (PPH) in patients with hepatic cirrhosis is often considered an unacceptable condition for liver transplantation because of increased morbidity and mortality during the procedure. We studied the incidence, characteristics, and final outcome of patients with PPH undergoing liver transplantation in our institution. Among the 226 patients undergoing 257 liver transplantations, eight (3.5%) fulfilled the conditions of PPH and responded to vasodilator therapy. Nitroglycerin 1.5 micrograms/kg produced a decrease in pulmonary vascular resistance index (PVRI) and mean pulmonary arterial pressure (MPAP) of 20% and 15%, respectively. Patients with PPH when compared with a matched group of patients without PPH had markedly increased hemodynamic changes in PVRI (P = 0.004) and MPAP (P = 0.0001) during and after the procedure. All patients with PPH required pulmonary vasodilator therapy after reperfusion of the new liver, while none in the group of patients without PPH required this therapy. Furthermore, after graft reperfusion, patients with PPH in which venovenous bypass was not used (n = 3), had a more compromised right ventricular function with a greater increase of central venous pressure (CVP) (90%) and MPAP (140%) when compared with patients with bypass or preservation of the recipient's vena cava (n = 5) in whom the increase of CVP and MPAP was 50% and 60%, respectively. Moderate PPH without a fixed level of pulmonary hypertension in patients undergoing liver transplantation is not related to an adverse outcome.

Predictive factors of early postoperative graft function in human liver transplantation

To identify factors predictive of early postoperative graft function, we analyzed 54 variables--including easily available clinical and laboratory data prospectively obtained from organ donors, transplant recipients and surgical procedures in 168 consecutive liver transplantations. Early postoperative graft function was classified into three groups according to a scoring system ranging from 3 to 9 based on peak serum ALT values, mean bile output and lowest prothrombin activity measured during the 72 hr after transplant: group 1 (score 3 to 4, good graft function; n = 73), group 2 (score 5 to 6, moderate dysfunction; n = 50) and group 3 (score, 7 to 9, severe dysfunction; n = 45). In univariate analyses, 8 of the 54 variables analyzed were statistically significant (p < 0.05) predictors of severe graft dysfunction: high serum sodium concentration and brain death caused by cranial trauma in organ donors, advanced age and low prothrombin activity in transplant recipients, prolonged total ischemia time and large transfusions of red blood cells, fresh frozen plasma and platelets during surgery. After introduction of these eight variables in a multivariate analysis, only four were found to independently predict early postoperative graft function: donor serum sodium concentration, total ischemia time, platelet transfusion during surgery and recipient prothrombin activity. In 52 liver transplantations, in which the predictive value of liver tissue adenine nucleotide concentration and several biochemical sensitive markers of donor nutritional status was also analyzed, only the ATP level in liver tissue obtained at the time of organ reperfusion was identified as an independent predictor of initial graft function.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictive factors of in-hospital CNS complications following liver transplantation

We prospectively evaluated 84 consecutive adult patients with chronic liver disease before and after liver transplantation to define the type and frequency of post-transplant neurologic complications, and to assess possible pretransplant and operative variables associated with in-hospital CNS complications. There were 25 patients (30%) who presented 23 neurologic complications of the central and six of the peripheral nervous system. Seventy-five percent of the complications occurred in the first month post-transplant. The most frequent CNS complications included anoxic (six patients) and septic (five) encephalopathy, as well as brain hemorrhage (five). Patients who presented CNS complications had a higher mortality rate than those who did not (55% versus 17%, p = 0.002). Multiple logistic regression analysis showed abnormal pretransplant neurologic examination suggestive of chronic hepatic encephalopathy (p = 0.007) and noncholestatic liver disease (p = 0.012) to be independently associated with in-hospital CNS complications. These data indicate that CNS neurologic complications following liver transplant are common in patients with noncholestatic liver disease and are associated with increased mortality. The pretransplant neurologic examination is an important predictor of CNS complications that occur in the immediate post-transplant period.

CEA as a prognostic factor in colorectal cancer

We have measured serum CEA levels in 207 patients with colorectal cancer. CEA sensitivity was related to tumor stage in tumors located in the right colon, but not in tumors located in the left colon or the rectum. CEA had prognostic value in patients with tumors located in the right colon (p < 0.001) but not in the left colon or the rectum. However, CEA did not have prognostic value independent of Dukes stage even in tumors in the right colon. Our results underline the different sensitivities and prognostic values for primary tumors in the left and right colorectal regions.

Use of CA 19-9 in the early detection of recurrences in colorectal cancer: comparison with CEA

The serum levels of CA 19-9 were determined in the follow-up of 370 patients with colorectal cancer and compared with CEA. An increase in CA 19-9 preceded clinical diagnosis of recurrence in 25% of 72 patients. The mean time between the rise in CA 19-9 and clinical diagnosis of relapse was 3.7 months (median 3). Sensitivity of CA 19-9 in the early diagnosis of recurrence was much lower than that obtained for CEA (75%). Only 1 patient had elevated CA 19-9 levels and normal CEA.

Prognostic value of CA 19.9 levels in colorectal cancer

Pretreatment serum levels of carbohydrate antigen 19.9 (CA 19.9) and carcinoembryonic antigen were measured in 293 patients with colorectal cancer. Carbohydrate antigen 19.9 was above the cut-off limit of 37 U/mL in 35% of patients. Carbohydrate antigen 19.9 sensitivity was related to tumor stage. Carcinoembryonic antigen was above the cut-off level of 3.5 ng/mL in 61% of patients, and the simultaneous use of two markers increased sensitivity to 66%. The main use of pretreatment levels of CA 19.9 in locoregional cancer is in prognosis. Carbohydrate antigen 19.9 provided more prognostic information than that obtained by conventional staging methods. In patients with Dukes' C tumors, additional information was obtained for allocation of these patients into groups at low or high risk of recurrence. Prognostic significance of carcinoembryonic antigen was not independent of Dukes' classification.

Obstructing colorectal carcinomas. Prospective study

Intestinal obstruction owing to colonic carcinoma is a relatively frequent cause of acute abdominal pain. The aim of this prospective study is to evaluate the prognostic factors that may influence the final outcome of those patients operated upon for an intestinal obstruction (OG) as opposed to those electively operated upon (EG). From September 1984 to March 1988, a total of 188 patients with colorectal cancer have been included in the study. One hundred thirty-five were EG, while 53 (28.1 percent) were OG. The mean ages were similar in both groups. Sex, morbidity, and mortality rates were equally distributed. Curative resection rate was significantly higher in the EG group (P = 0.029). Tumor staging tended to be significantly more advanced in OG patients (chi-square = 9.054; df = 3; P = 0.026). Multivariate analysis (proportional hazards model) showed that the only independent prognostic factor was tumor staging (P = 0.0000). Obstruction itself disappears as a predictive variable when tumor staging is introduced in the model. We conclude that obstructing colon carcinomas tend to be more locally advanced, that probably being the only reason for a worse long-term prognosis.

Necrotising colitis with perforation in diarrhoic patients treated with loperamide

Two cases of necrotising enterocolitis with perforation occurred in patients with paralytic ileus after loperamide therapy. The possible role of loperamide in the pathogenesis of the complications is suggested.

Dysphagia and esophageal motor dysfunction in gastroesophageal reflux are corrected by fundoplication

Abnormalities in esophageal peristaltic function and acid clearance appear to be responsible for prolonged esophageal acid exposure, a major determinant of the reflux esophagitis and esophageal stricture. We evaluated esophageal motility by manometry in 50 healthy controls and in 35 symptomatic reflux patients before, within 6 months, and 1 year after Nissen fundoplication. Preoperative motility was analyzed in relation to the presence or absence of both nonobstructive dysphagia and erosive esophagitis. We found that (a) preoperative dysphagia was related more to peristaltic dysfunction than to esophagitis; (b) peristaltic wave amplitude and duration were significantly lower than control values in patients with reflux, without correlation to degree of esophagitis or lower esophageal sphincter hypotension; (c) dysphagia ceased in most patients after antireflux surgery at the same time that normal motility was restored independently of lower esophageal sphincter pressure increments. These results suggest that motility disturbances are an important cause of dysphagia in reflux disease, and that reflux is the cause of, rather than the consequence of, peristaltic dysfunction.

Obstructive jaundice and wound healing

Wound healing was studied in 95 jaundiced patients and 123 anicteric patients using skin prolylhydroxylase activity as an index of collagen synthesis. The mean (s.d.) value of skin prolylhydroxylase activity in jaundiced patients was significantly lower than that of controls in the preoperative period (40.1(19.2) versus 369.2(32.2) c.p.m./mg protein, respectively, P less than 0.001). Before operation there was a significant difference between patients with benign or malignant obstruction of the biliary tree (55.0(12.3) versus 25.2(10.4) c.p.m./mg protein, respectively, P less than 0.05). In patients with benign obstruction skin prolylhydroxylase activity returned to normal values (326.3(53.1) c.p.m./mg protein, P less than 0.001 versus preoperative values), while in patients with malignant lesions skin prolylhydroxylase activity increased significantly with respect to the preoperative period (25.2(10.4) versus 82.9(14.3) c.p.m./mg protein, P less than 0.01) but was still below normal values. Abdominal wound dehiscence was more common in jaundiced patients (six of 95) than in the anicteric group (two of 123). This complication appeared to be associated with a low skin prolylhydroxylase activity.

Peripheral blood lymphocyte changes after benign gastrointestinal surgery. Role of thymostimulin in reversing the postoperative immunodepression seen in humans

A generalized state of immunosuppression during surgery has been implicated in the development of septic complications postoperatively. We studied 18 patients operated upon for benign diseases, to examine the influence of surgical trauma on circulating lymphocyte subpopulations in man. Additionally, we evaluated the effect of thymostimulin on these changes, in another group of 10 patients. Our results suggest that the total number of lymphocytes, as well as lymphocyte subpopulations CD3+ and CD4+, fell significantly following surgery. This reduction in cell number is more pronounced on the helper/inducer lymphocytes. The CD4+/CD8+ ratio decreases significantly after operation. For patients with no complications, the immunosuppression in terms of peripheral lymphocyte population, seen in the postoperative period is usually reversible around the seventh day. On the other hand, peripheral blood lymphocyte changes in the postoperative period were less pronounced in patients treated with thymostimulin. Thymostimulin's action is predominantly on T lymphocytes, and within these, on the T helper/-inducer subpopulation. And finally, thymostimulin is capable of maintaining a normal relationship between helper/inducer and suppressor/cytotoxic cells (CD4+/CD8+ ratio) during the postoperative period, suggesting a better immune state.

Intraesophageal pH monitoring after breakfast + lunch in gastroesophageal reflux

To evaluate intraesophageal pH monitoring during two consecutive 3-h postprandial periods (breakfast + lunch) in the diagnosis of pathological gastroesophageal reflux, we studied 40 patients with documented gastroesophageal reflux and 15 healthy controls. Reflux events were analyzed in the two separate postprandial periods, their sum (double postprandial pHmetry), and a standard 24-h period. Data from all pH-recording periods were compared and correlation coefficients were obtained between postprandial and 24-h reflux events. While pH recordings from the two separate postprandial periods provided good separation between patients and controls, double postprandial pHmetry was most accurate in the diagnosis of gastroesophageal reflux. In the latter procedure, mean percent reflux time was 2.5 +/- 1.8% in controls and 19.4% +/- 10.3% in patients (p less than 0.001), with a specificity of 100% and a sensitivity of 97%. A high degree of correlation existed for all reflux events between postprandial and 24-h pHmetries. We believe that double postprandial intraesophageal pH monitoring accurately distinguishes between normal persons and patients with pathological reflux. The technique considerably shortens the examination time in relation to 24-h pH monitoring and may prove the esophageal test of choice for objective evidence of gastroesophageal reflux.

Management of penetrating abdominal stab wounds

The authors present the results of a therapeutic trial of the conservative or surgical management of penetrating abdominal stab wounds (PASW) based on clinical criteria. In a prospective series of 100 patients, 70 were treated non-operatively. Thirty patients were operated upon, twenty-one immediately and nine during the 48 h observation period. In five laparotomies no significant injuries were found. Morbidity was similar in both immediate and delayed laparotomy groups (3/21 versus 1/9). Acute alcoholic intoxication identifies a subgroup of patients that are difficult to evaluate and hence are more likely to be managed by laparotomy (chi 2 = 4.056, P less than 0.05). The authors conclude that selective surgical management of PASW based on clinical criteria is an accurate and safe procedure.

Sclerotherapy vs. distal splenorenal shunt in the elective treatment of variceal hemorrhage: a randomized controlled trial

One hundred and twelve consecutive Child Class A and B cirrhotic patients were included in a prospective controlled trial aimed at investigating the efficacy and safety of endoscopic sclerotherapy vs. distal splenorenal shunt in the elective treatment of hemorrhage from esophagogastric varices. Fifty-seven patients were randomly allocated to splenorenal shunt and 55 to endoscopic sclerotherapy. Since only 4 of the 55 patients assigned to endoscopic sclerotherapy had to be excluded after randomization and before treatment as compared to 14 of the 57 patients assigned to splenorenal shunt, it is suggested that the applicability of endoscopic sclerotherapy is greater than that of splenorenal shunt. One patient in each group died within 30 days of the procedure and two in the endoscopic sclerotherapy group were lost to follow-up just after discharge. Variceal rebleeding during follow-up occurred in 37.5% (18/48) of patients in the endoscopic sclerotherapy group and in 14.3% of those in the splenorenal shunt group (6/42) (p less than 0.02), whereas hepatic encephalopathy was more frequent in patients submitted to splenorenal shunt (10/42, 24%) than in those treated by endoscopic sclerotherapy (4/48, 8%) (p less than 0.05). The therapeutic modality was the only variable with independent predictive value for rebleeding during follow-up, whereas for hepatic encephalopathy, the therapeutic modality, and the presence of encephalopathy related to the bleeding episode each showed independent predictive value. Early and long-term mortality, did not differ between the two therapeutic groups, being the 2-year survival was 71% for splenorenal shunt and 68% for endoscopic sclerotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)