Tumour Necrosis Factor-α Inhibition Improves Stroke Outcome in a Mouse Model of Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammatory disorder where incidence and severity of myocardial infarction are increased. Data on the incidence and outcome of stroke are conflicting. Thus, we investigated outcome after Ischemia/Reperfusion (I/R) brain injury in a mouse model of RA and assessed for the role of the tumour necrosis factor-α (TNF-α) inhibitor Infliximab herein. We used a TNF-α reliant mouse model of RA. RA and wildtype (WT) animals were treated with vehicle (RA/WT) or Infliximab (RA Infliximab) for 4 weeks, before undergoing I/R brain injury. RA-animals displayed larger strokes and poorer neurological performance. Immunohistochemistry on brain sections revealed increased numbers of resident and peripheral innate immune cells (microglia and macrophages); increased Blood-Brain-Barrier (BBB)-disruption; decreased levels of the tight junction proteins (TJPs) claudin-5 and occludin; increased expression of matrix-metalloproteinases (MMP)-3 and -9 and enhanced lipid peroxidation. Treatment with Infliximab corrected these alterations. We show that RA associates to worse stroke-outcome via exacerbated BBB degradation by decrease of the TJPs claudin-5 and occludin. We identified MMPs-3 and -9 and increased oxidative stress as potential mediators thereof. Increased numbers of resident and peripheral innate immune cells (microglia and macrophages) may in turn contribute to all these effects. Infliximab-treatment restored the phenotype of RA-mice to baseline. Our data provide evidence clearly linking RA to adverse stroke-outcome in mice and indicate an approved TNF-α inhibitor as a potential strategy to reduce stroke-burden in this setting.

T-cell brain infiltration and immature antigen-presenting cells in transgenic models of Alzheimer's disease-like cerebral amyloidosis

Cerebral beta-amyloidosis, one of the pathological hallmarks of Alzheimer's disease (AD), elicits a well-characterised, microglia-mediated local innate immune response. In contrast, it is not clear whether cells of the adaptive immune system, in particular T-cells, react to cerebral amyloidosis in AD. Even though parenchymal T-cells have been described in post-mortem brains of AD patients, it is not known whether infiltrating T-cells are specifically recruited to the extracellular deposits of beta-amyloid, and whether they are locally activated into proliferating, effector cells upon interaction with antigen-presenting cells (APCs). To address these issues we have analysed by confocal microscopy and flow-cytometry the localisation and activation status of both T-cells and APCs in transgenic (tg) mice models of AD-like cerebral amyloidosis. Increased numbers of infiltrating T-cells were found in amyloid-burdened brain regions of tg mice, with concomitant up-regulation of endothelial adhesion molecules ICAM-1 and VCAM-1, compared to non-tg littermates. The infiltrating T-cells in tg brains did not co-localise with amyloid plaques, produced less interferon-gamma than those in controls and did not proliferate locally. Bona-fide dendritic cells were virtually absent from the brain parenchyma of both non-tg and tg mice, and APCs from tg brains showed an immature phenotype, with accumulation of MHC-II in intracellular compartments. These results indicate that cerebral amyloidosis promotes T-cell infiltration but interferes with local antigen presentation and T-cell activation. The inability of the brain immune surveillance to orchestrate a protective immune response to amyloid-beta peptide might contribute to the accumulation of amyloid in the progression of the disease.

Portable double-sided laser-heating system for Mössbauer spectroscopy and X-ray diffraction experiments at synchrotron facilities with diamond anvil cells

The diamond anvil cell (DAC) technique coupled with laser heating is a major method for studying materials statically at multimegabar pressures and at high temperatures. Recent progress in experimental techniques, especially in high-pressure single crystal X-ray diffraction, requires portable laser heating systems which are able to heat and move the DAC during data collection. We have developed a double-sided laser heating system for DACs which can be mounted within a rather small (~0.1 m(2)) area and has a weight of ~12 kg. The system is easily transferable between different in-house or synchrotron facilities and can be assembled and set up within a few hours. The system was successfully tested at the High Pressure Station of White Beam (ID09a) and Nuclear Resonance (ID18) beamlines of the European Synchrotron Radiation Facility. We demonstrate examples of application of the system to a single crystal X-ray diffraction investigation of (Mg(0.87),Fe(3+) (0.09),Fe(2+) (0.04))(Si(0.89),Al(0.11))O(3) perovskite (ID09a) and a Synchrotron Mössbauer Source (SMS) study of (Mg(0.8)Fe(0.2))O ferropericlase (ID18).

Bottom-up engineering of the surface roughness of nanostructured cubic zirconia to control cell adhesion

Nanostructured cubic zirconia is a strategic material for biomedical applications since it combines superior structural and optical properties with a nanoscale morphology able to control cell adhesion and proliferation. We produced nanostructured cubic zirconia thin films at room temperature by supersonic cluster beam deposition of nanoparticles produced in the gas phase. Precise control of film roughness at the nanoscale is obtained by operating in a ballistic deposition regime. This allows one to study the influence of nanoroughness on cell adhesion, while keeping the surface chemistry constant. We evaluated cell adhesion on nanostructured zirconia with an osteoblast-like cell line using confocal laser scanning microscopy for detailed morphological and cytoskeleton studies. We demonstrated that the organization of cytoskeleton and focal adhesion formation can be controlled by varying the evolution of surface nanoroughness.

Shwachman-Diamond syndrome

Shwachman-Diamond syndrome (SDS) is a rare autosomal recessive disorder with exocrine pancreatic insufficiency, bone marrow failure and skeletal abnormalities. Patients frequently present failure to thrive, susceptibility to infections and short stature. A persistent or intermittent neutropenia occurs in 88-100% of patients. Bone marrow biopsy usually reveals a hypoplastic specimen with varying degrees of hypoplasia and fat infiltration. Some patients may develop myeloblastic syndrome and acute myeloblastic leukemia. The genetic defect in SDS has been identified in 2002. The osteoporosis is increased in patients with SDS, and also, bone malformations are included among the primary characteristics of the syndrome. The severity and location change with age and sexes. The typical characteristics include the following: secondary ossification centers delayed appearance, metaphysis enlargement and irregularity (very common in childhood, particularly in coastal and femur), growth cartilage progressive thinning and irregularity (possibly asymmetric growth), generalized osteopenia with cortical thinning. We describe a clinical case regarding an SDS patient with severe bone abnormalities and treated surgically for corrective osteotomy. The persistent or intermittent neutropenia that characterized this disease and the consequent risk of infection is a contraindication for short stature correction and limbs lengthening.

Zum 150. Geburtstag von César Roux (1857–1918)

César Roux was one of the few universal surgeons at the end of the 19th century who dominated all fields of surgery and influenced current surgery with his innovative spirit. Pioneering spirit and the story of the success of modern surgery are linked with his name. On the occasion of his 150th birthday, we recall the memory of this great surgeon. The personality and the history of Professor César Roux form a part of our medical and surgical heritage.

Crystallization on heating and complex phase behavior of α-cyclodextrin solutions

Solutions composed of alpha-cyclodextrin (alpha-CD), water, and various methylpyridines, in particular, 4-methylpyridine (4MP), undergo reversible liquid-solid transitions upon heating, the crystalline solid phases undergoing further phase transformations at higher temperatures. This unusual behavior has been characterized by an ensemble of measurements, including solubility, differential scanning calorimetry, quasielastic neutron scattering, as well as x-ray powder diffraction. For the alpha-CD/4MP system five crystalline phases have been identified. The unit cell parameters and corresponding changes with temperature indicate a scenario for the crystallization process. A simple model is proposed that mimics the observed disorder-order transition.

Krukenberg's tumor, three years after a colic carcinoma

We report a case of left ovarian Krukenberg's tumor in a 65 year-old patient, three years after resection of a colonic carcinoma (pT3, G2, pN1, Stage 3, Dukes C). The case is briefly discussed with reference to the literature. Krukenberg's tumor usually occurs in younger patients, with a peak frequency before 40 years. Both ovaries are involved in 90% of cases. Pathogenetically the ovarian involvement arises either from hematogenous, lymphatic spreading or from contiguous extension from the primary colonic tumor. There may be some anatomic predispositions such as utero-ovarian vessel anastomosis in the ligamentum latum or by peritoneal adhesions.

[Quality of life of vascular disease patients following amputation]

STUDY AIM

The purpose of this study was to assess the quality of life following lower limb amputation for vascular disease.

PATIENTS AND METHODS

Thirty-six vascular patients operated on for 40 major amputations were reviewed to assess demographic and clinical characteristics, possibilities of prosthesis, perception of health problems and social adaptation. These data were correlated with general satisfaction and quality of life ratings, using the Nottingham Health Profile.

RESULTS

The average stay in hospital was 109 days. Thirteen patients (36%) died in hospital, 23 others (64%) were discharged, but only ten patients (28%) were able to go back home. The global mortality rate at 1 year was 44%. Eighteen patients (78%) were initially fitted but only seven (30%) were fully independent. Eight patients only (35%) were satisfied at the end of treatment. Patient's satisfaction was influenced by the level of his amputation, the presence of residual pain and by his mobility, but it was independent of prosthetic equipment.

CONCLUSION

Quality of life of vascular amputated patients is poor and marked by persistent pain and considerable handicaps in mobility, limiting social activities and relationship. The patients' satisfaction and quality of life appear to be related to their ability to manage social relations. Amputation should be considered as the first step towards rehabilitation and not the end of the treatment. It is only through a multidisciplinary approach that the quality of life of amputated patients can be improved.

[Chronic saphenous venous access: an interesting alternative in the case of vena cava superior syndrome]

An easy venous access improves the quality of life of patients who need prolonged intravenous therapy. In the case of vena cava superior syndrome the classic access in the jugular or subclavian vein can be difficult or even impossible. We report on seven implantations of Port-a-Cath in the inferior vena cava for patients presenting contra-indications to classic venous access to the vena cava superior (five cases of vena cava superior compression syndrome, one tracheostomy and one extended tumor of thoracic wall). We describe the operative technique and we analyze the indications, the results and the complications of this rarely used technique.

Analysis of 1930 bedridden patients in the internal medical sector of the emergency department of a large city hospital: appropriate and non-appropriate admission

This paper discusses criterion for the appropriateness of admission to the hospitalization ward in the internal medical sector of the emergency department, and analyses the bedridden patients in the emergency department of the major hospital in the city of Genoa. The analysis covers 1930 patients, for which considerations are made, globally and separately in two different age groups, as to the appropriateness of admission to the hospitalization ward of the emergency department, the occurrence of subjective urgencies and objective instabilities, and progression subsequent to hospitalization (discharge, transfer into other hospital wards, decease). The most significant results of the analysis were the following: (1) no significant difference was found between younger and older patients regarding appropriateness of admission; (2) in cases of appropriate admission subjective urgency was clearly prevalent in relation to objective instability, the latter being much more frequent in the older age group; (3) a lack of self-sufficiency and the absence of adequate family support were important factors regarding inappropriate admission of older patients; (4) the greater frequency of objective instability in the older patients-as well as a lack of self-sufficiency-was the major factor in their greater length of stay in the emergency department. These results challenge the misconceived but diffused conviction that there is widespread mishandling of the elderly regarding admission to the emergency department, while at the same time stresses the need for alternative services and structures concerning hospital admission of older patients.

[Outcome of nonspecific right iliac fossa pain syndromes]

One-third of all cases of abdominal pain and a quarter of cases of right iliac fossa pain urgently admitted to hospital leave hospital with no precise diagnosis. Based on a series of 400 patients hospitalised for right iliac fossa pain, comprising 107 cases with no identified aetiology, this prospective study was designed to assess the medium-term outcome of these patients, with or without surgical exploration. 67 cases were reviewed at five years. No major diagnosis was missed. Over this 5-year period, 30 patients (45%) experienced another episode of abdominal pain. Among the third of patients (21 cases, 31%) reviewed for another episode of right iliac fossa pain, 7 were readmitted to hospital, with 5 operations, for histologically confirmed acute appendicitis in 3 cases (5% of the series). The patient and his attending physician must be informed of the nonspecific diagnosis established during the first hospitalisation. There is no significant evidence to suggest a psychological component in the recurrent nature of the pain. Cancer must be formally excluded in patients over the age of 50. When surgical exploration is performed, nowadays by laparoscopy, appendicectomy is recommended. This procedure does not decrease the risk of recurrent pain, but confirms the real absence of histopathological abnormality and decreases the number of subsequent hospitalisations.

[Use of the deep femoral artery as the anastomotic site in proximal or distal bypass. Indications, technique, results of a series of 19 cases]

Atherosclerosis predominantly affects the ilio-superficial femoral axis, and tends to spare the deep femoral artery which can offer excellent outflow for proximal reconstructions for occlusive vascular disease of the lower limbs. Often symptoms are relieved and ischemic lesions can heal. The deep femoral artery can also provide good, pulsatile inflow for distal reconstructions when it is desirable to avoid the groin (either because of multiple previous dissections or because of infection). Occasionally two-level sequential bypasses to and from the deep femoral artery are required for multilevel disease where the groin is to be avoided. Over the past 4 years we have performed 190 arterial reconstructions (41 central, 125 distal and 24 sequential two-level procedures). 19 times the proximal, distal or intermediate anastomosis was on the deep femoral artery. Short- and long-term results were good in these difficult patients, with relief of symptoms or significant improvement in most patients. Two major (and no minor) amputations were ultimately required. Arterial reconstructions using the deep femoral artery cannot only salvage many limbs, but offer good symptomatic relief in patients who are not suitable for usual reconstructive procedures.

[Transluminal dilatation by surgeons. Technique, results and advantages]

From January 1990 to December 1992, 25 balloon angioplasties were performed in the Department of Surgery, La Chaux-de-Fonds, Switzerland. The indications were claudication in 19, and limb salvage in 6 patients. In 4 patients, the stenosis was dilated in association with a femoropopliteal bypass (2 patients) or an intraluminal stent (2 patients). The follow-up period ranged from 3 to 36 months with a cumulated patency rate of 81%. Percutaneous transluminal angioplasty for atherosclerotic lesions of the lower extremity is associated with a good success rate. Important variables influencing patency include indications, site and extent of lesion and whether the responsible lesion is stenotic or occlusive. The advent of endovascular surgery has transformed the landscape of vascular disease management. In so doing it has confused the border between the various medical specialties. The decision to use transluminal angioplasty, should be a joint decision between surgeon and radiologist, but transluminal angioplasty should be part of the vascular surgeon's armamentarium.

[Laparoscopy: obstacle or revolution in the development of surgery?]

Laparoscopy is a new fascinating technique. However, after the first wave of enthusiasm, laparoscopy currently raises different problems related with surgical training. A national survey concerning laparoscopy and its teaching was sent to every surgeon-in-chief, chief resident and resident of all Swiss teaching hospitals. Surgical training is nowadays an important problem in Switzerland. Our survey revealed that laparoscopy intensifies this problem: a specific training in laparoscopy is desired by all surgeons and has to take place in the Swiss Board of Surgery (FMH). A preliminary experience of conventional surgery is desirable. Then a laparoscopic training should start on experimental certified models and be applied progressively on patients in attendance with a trained surgeon.

[How to reduce the number of negative appendectomies? A prospective two-center study of 120 patients]

A decisional protocol based on clinical findings and laboratory data was assessed prospectively in a consecutive series of 120 patients with suspected appendicitis over a 24-month period at 2 teaching hospitals. Using this protocol the high rate of negative appendectomy (31.5%) during the 2 years prior to the study was reduced to 22% without increasing morbidity or mortality. Ultrasound examination was poorly predictive in unclear cases. Laparoscopy was used to assess diagnosis in persistent symptoms.

[Surgical treatment of malignant tumors with mono- or multivisceral involvement]

Abdominal malignant tumors with a mono- or multivisceral involvement have a poor prognosis. Surgery is the only treatment with a hope to be curative. Between January 1989 and December 1992, 30 patients (12 men, 18 women, mean age 67.9) with abdominal malignancy involving one or more adjacent organs were operated on at the Department of Surgery, General Hospital, La Chaux-de-Fonds, Switzerland. The majority of the tumors originated from the colon and rectum. 64 organs were partially or totally resected. Every curative procedure consisted of an "en bloc" resection. 53% of the procedures were curative, 37% palliative and 10% explorative. Surgical morbidity reached 30% and hospital mortality 13% (one peroperative death). Surgery obtained a local control of the tumor in 75% of the cases. After curative procedures, local recurrence and secondary metastases appeared respectively in 25% and 19% of the cases. After a palliative operation, preoperative symptoms diminished or disappeared in 82% of the patients. Tumor curability essentially depends on invaded organs. Mobile organs can nearly always be excised. Non-mobile organs and retroperitoneum are resected much more difficultly. Surgical treatment of multiorgan malignancies is difficult. It involves a long and tenacious exploration before declaring the tumor non-resectable.

[Standardized hepatectomy. 18 cases operated in a peripheral hospital]

Hepatectomy has long been a formidable surgical procedure because the risk of hemorrhage it can involve. With a better understanding of hepatic anatomy, left hepatectomy, right hepatectomy and segmental hepatic resections have been standardized. Between January 1989 and December 1992, 18 hepatectomies were performed on 16 patients in the Department of Surgery, General Hospital, La Chaux-de-Fonds, Switzerland. The mean age of the patients was 65. The surgical indications were: hepatic metastases 11 (61%); gallbladder or biliary duct neoplasm 4 (22%); hydatic cyst 3 (17%). 11 segmental resection, 3 left hepatectomies, 2 right hepatectomies, 2 pericystectomies were performed. Blood loss during these operations averaged 2800 ml. Surgical complications appeared in 6 cases (hemorrhage 1, postoperative effusion 4, sepsis 1). One patient died within 30 days (mortality 5%). Hepatectomy is nowadays a safe procedure. It can be performed in a general hospital with a trained surgical team and an efficient intensive care unit.

[Treatment of irreducible hiatal hernia with reflux esophagitis by Collis-Niessen gastroplasty-fundoplication. Indications, technique, results of a series of 17 cases]

Hiatus hernia with reflux can be asymptomatic or can lead to severe, complicated esophagitis or even to metaplasia, dysplasia and carcinoma. Ideally all refluxing patients with esophagitis who are not easily and completely controlled with medical therapy should undergo anti-reflux surgery before complications such as ulcers, stricture or columnar metaplasia (Barrett's esophagus) occur. When esophagitis is long-lasting or severe, shortening of the esophagus is common. In such cases the esophagus must be "lengthened" before an anti-reflux procedure can be performed safely. This is the Collis gastroplasty. We have performed 17 Collis-Nissen procedures over 5 years for complicated gastroesophageal reflux disease (GERD). Results were good to excellent in 8 cases, satisfactory in 6 and poor in 3. We conclude that a complete preoperative workup with esophagoscopy (and biopsies), 24-hour pH monitoring and esophageal manometry must be performed in all patients with complicated GERD to allow the best operative procedure to be chosen (gastroplasty-fundoplication, resection or total duodenal diversion). The role of alkaline reflux is also discussed.

[Pain syndrome in the right iliac fossa and laparoscopy: routine appendectomy or not?]

Diagnostic laparoscopy is useful in the evaluation of patients with lower right quadrant pain when the diagnosis is uncertain. The object of this study was to determine whether a normal appendix should be routinely removed at laparoscopy. We have decided to do this in children, men under the age of 30 and women of childbearing age. However we do not perform appendectomy in men over the age of 30, women over 50 and in immunodeficient patients. This is a working hypothesis and is the basis of an on-going prospective study in our unit.

[Flexible choledochoscopy: two years experience]

This study is a retrospective review of 258 procedures on the gallbladder and bile ducts (115 without and 143 with flexible choledochoscope). There were 14 bile duct explorations for stone removal without choledochoscopy and 16 with a flexible choledochoscope. Residual stones were found in 2/14 (14.2%) cases without and 1/16 (6.3%) case with choledochoscope. A review of the literature confirms that there are fewer residual bile duct stones following flexible choledochoscopy. There were no complications attributable to the procedure.

[Simultaneous proximal and distal revascularization for arterial obstruction of the leg at two sites. Indications, techniques and results]

In chronic aortoiliac occlusive disease, 50 to 75% of the patients have further femoropopliteal lesions. The surgical treatment of these multilevel obstructions is sometimes controversial: the distal reconstruction can be performed at the time of the proximal one or deferred to a later date. It can be difficult to determine the hemodynamic importance of an iliac stenosis. Angiography is not a perfect predictor of the iliac segment hemodynamics because as it underestimates the severity of aorto-iliac stenoses when single plane views are taken. Direct measurement of the femoral pressure at angiography disclosing a gradient between brachial and femoral arteries indicates significant iliac stenosis. Intraarterial papaverine administration can also be of importance to determine critical stenoses. Despite proximal reconstruction, distal ischemia can persist if peripheral resistance is high. Distal revascularization can relieve ischemic symptoms, providing an adequate outflow bed. However some patients do not benefit from this two-level procedure because of a steal phenomenon in the intermediate vascular bed.

[In situ venous grafts. Indications, technique and results. Prospective study of 26 consecutive cases]

The in situ saphenous vein bypass has been introduced in our department since 1989. A total of 26 bypasses in 22 patients have been followed prospectively. Indications for revascularisation have been severe arterial insufficiency in 73% of the cases (stage III or IV). With the exception of one postoperative death (myocardial infarction), all the patients have recovered uneventfully, with a regression to stage I. No amputation has been necessary. Morbidity has been 30%, with mainly minor local complications. The primary patency rate is 83% at one year and 78% after 2 and 3 years, whereas the secondary patency rate is 91% at one year, and remains constant thereafter up to 3 years. Considering our results and those from the literature, we believe that the in situ technique is very valuable, especially for below-knee vascular reconstruction. Technical difficulties of the method are analysed.

[The 60 hour week in surgery: possible or impossible?]

The number of hours of work per week by doctors is the subject of great controversy in many countries. This has led to restrictive legislation in several states or countries (New York and Great Britain, for example) which is both cumbersome and restrictive. We have polled the Swiss surgeons (both trained and in training) in teaching hospitals on this subject with a questionnaire which also covered some other aspects of training. A majority wishes that the working week be limited (to 60 h/week). However a real limit of 60 h per 7 day week (including call duty) is not reasonable. Furthermore the other problems are considered to be more important by 84% of respondents. Thus the overall opinion is that there are too many surgeons training in a poorly structured system, both on a personal and institutional basis.

[Storage of reports in endoscopic surgery]

A computer system, based on multimedia technology allowing informatic storing of endoscopic pictures, written summary of the case and personal oral commentary by the operating surgeon is presented. This system is time-sparing and does not require special training owing to a highly developed interface between the computer and the operator. The system is currently in clinical practice.

High-sensitivity electrophoretic method for the detection of Bence Jones protein and for the study of proteinuria in unconcentrated urines

The study of proteinuria, and especially the search for Bence Jones proteins (BJP), has almost always required urine concentration. We evaluated a high-sensitivity electrophoretic method using unconcentrated urine based on colloidal gold staining. The sensitivity for the detection of BJP is further enhanced by immunofixation. Sensitivity to BJP is better than 1 mg/L and, apart from the alpha-1 microglobulin, all the proteins relevant to the classification of proteinuria can be visualized with a sensitivity of approximatively 3 mg/L.

[Value of antral mucosectomy, selective proximal vagotomy and a combination of the 2 procedures in serum gastrin production and inhibition of stomach acid. An experimental study]

This experimental study was aimed at determining the volume and acidity produced by the normal stomach, following antral mucosectomy (MA), proximal selective vagotomy (VSP) and combination of both procedures. In 10 mongrel dogs, a double-lumen tube was placed in the stomach under general anesthesia. One of the lumen was rinsed with a constant flow and the other retrieved the gastric secretion. Gastric secretion and acidity were calculated every 10 minutes for 120 minutes. At 60 minutes, pentagastrin was injected. After these controls, a MA was carried out in half the animals and a VSP in the other half. 6 and 12 weeks postoperatively, the same controls were repeated. The dogs were then submitted to the operation of the other group. Following MA and pentagastrin stimulation, the gastric secretion (volume) is not modified with regard to the preoperative levels. On the other hand, after VSP, pentagastrin stimulation induces only a small volume response. The vagus thus seems to be involved in liquid secretion of the stomach. Following MA, pentagastrin stimulation lowers gastric pH at 6 weeks but not at 12 weeks postoperatively. Gastrin is known to have a trophic effect on the oxyntic mucosa. This effect disappears in a few weeks and explains these different figures. Following VSP, gastric acidity decreases and plasmatic gastrin increases. In this situation, pentagastrin directly acts on a trophic mucosa and produces the important lowering of the gastric pH. Finally, after MA, pentagastrin induces an increase in plasmatic gastrin. This effect seems to be mediated by central stimulation of the nuclei of the vagus nerve.

[Definitive surgery in complicated gastroduodenal ulcers]

Indications for surgical therapy in uncomplicated peptic ulcer disease have decreased considerably since the introduction of H2-receptor blocking drugs and more recently omeprazole. On the other side, the number of acute complications such as perforation or hemorrhage has remained nearly constant. The recent literature seems to indicate that the pattern of patients presenting with complications has changed and that the number of acute ulcers has increased. In a review of 283 patients, we found 150 perforated ulcers (PU) and 133 bleeding ulcers (BU). Almost all the patients with PU and 70% of the patients with BU have been treated operatively. The mortality is 14.3% and 12.5%, respectively. The vast majority of our patients have chronic ulcers, and only 7% have acute or subacute lesions confirmed by histologic examination. Based on our experience and the literature, we propose a therapeutic algorythm for these two conditions.

[Development of a gastroplasty with variable diameter. Experimental study using artificial sphincters]

The vertical banded gastroplasty is currently the most popular technique in the surgical treatment of morbid obesity. This experimental study was aimed to create a gastroplasty with a variable stoma. The Marlex band was replaced by the cuff of an artificial sphincter to allow selective variation of the diameter of the stoma. The study was carried out on four mongrel dogs. The artificial sphincter was connected to a subcutaneous port. Injection of sterile fluid into the port inflates the cuff and decreases the surface of the stoma. The study was followed up for one year. Under gastroscopic control the system was regularly activated, the diameter and the surface of the stoma was measured and calculated. The sphincter allowed the surface of the stoma to decrease from 103 +/- 2.0 mm2 to 61 +/- 2.1 mm2. There was no significant variation of the surface for each volume unit injected into the system. After one year, the systems and stomachs were harvested and examined. It is possible to create a gastroplasty with a variable stoma. This system works without any technical problem. Microscopic examination of the stoma shows no peri-sphincteric fibrosis.

[Esophagogastroduodenoscpy by the surgeon]

In 1990, 123 gastroscopies were performed by surgeons in the Department of Surgery, General Hospital, La Chaux-de-Fonds, Switzerland. Seventy-five percent of these procedures were done on a diagnostic basis and twenty-five percent were controls. Endoscopy includes diagnostic, therapeutic and control procedures of numerous surgical diseases. It is thus important for the general surgeon to be committed in the endoscopic management of these pathologies. Furthermore, preoperative gastroscopy can influence or modify the operative technique. By his nearly inborn knowledge of anatomy, tissue consistency and texture, the surgeon has a priceless advantage to learn, practice and teach endoscopy. Therefore, teaching programs in surgical endoscopy should be widely created and developed in university and teaching hospitals to allow young surgeons a systematic and progressive training during their residency.

[Epidermoid carcinoma of the esophagus: preliminary results of combined treatment]

In 1986, a prospective study was started in CHUV on the squamous-cell carcinoma of the esophagus treated with a multimodality protocol associating preoperative chemotherapy and surgery. Nineteen patients are currently followed-up. Dysphagia is the main symptom and was found in 16 patients (84%). After chemotherapy, dysphagia disappeared completely in 7 cases (44%), regressed in 7 other cases and worsened in 1 case. Twelve patients were operated on, without operative mortality. Histologically, no tumor was found in one case (5%) after the preoperative treatment. Follow-up is currently too short to draw statistical conclusions. The rationale, advantages and perspectives of the multimodality treatment are presented and compared with different recent series.

Acetaldehyde activation of poly(ADP-ribose)polymerase in hepatocytes of mice treated in vivo

The activities of poly(ADP-ribose) polymerase and of DNA polymerases alpha and beta and the level of cytochrome P450 were determined in mouse parenchymal liver cells 5 h after treatment with 0.1, 0.3, 1.0, and 3.0 mumole of acetaldehyde. Injection with 1.0 and 3.0 mumole of acetaldehyde induced an increase in poly(ADP-ribose) polymerase activity and in the P450 level, but had no effect on DNA polymerases. The stimulation of poly(ADP-ribose) polymerase activity can be used as an index of induced DNA damage. The possibility of using this experimental approach with other cells derived from mice treated in vivo with different xenobiotics is discussed.