Colorectal cancer surgery in octogenarians: real-world long-term results

AIMS

Colon cancer is the most common intra-abdominal cancer in older people. In the elderly with cancer, clinical decision making is often complicated by the effects of aging. However, as life expectancy continues to rise, more people aged 80 and older will present with colorectal cancer and may need major surgery.

METHODS

Between 2000 and 2020 we operated on 352 patients aged 80 and older for colorectal cancer. We reviewed the case-notes of these patients and made a survival analysis for those patients who had a surgical resection of the tumor.

RESULTS

In 20 patients a palliative procedure was performed. Three hundred and thirty-two (332) patients had a colorectal cancer resected. Of these, 57 patients died within 90 days postoperatively. Survival analysis was done for 275 patients who were alive longer than 90 days postoperatively. The overall 5-year survival in this group is 41.5%. There was no significant difference in postoperative survival between patients over the age of 85 and patients aged 80-84 at the time of operation. The survival of patients with stage IV colorectal adenocarcinoma is significantly worse than survival in stage I-III patients (Cox-Mantel log-rank test p < 0.001).

CONCLUSIONS

After exclusion of the patients in the 90-day mortality group the overall 5-year survival in octogenarians who had a resection of a colorectal cancer was 41.5%. The most difficult problem is to choose the right treatment for the right patient. Optimal surgical and adjuvant treatment should not be denied to these older patients.

Perineal bowel evisceration after extralevator abdominoperineal excision and vertical rectus abdominis myocutaneous flap closure

INTRODUCTION

Perineal bowel evisceration is a rare complication after extralevator abdominoperineal excision (ELAPE). This surgical technique is used to resect low rectal and anal cancer, with a lower likelihood of positive surgical margins, but resulting in a larger perineal defect. A vertical rectus abdominis myocutaneous (VRAM) flap allows filling of the empty pelvic space and closure of the defect in the pelvic floor.

CASE PRESENTATION

A 77-year-old woman, with a hysterectomy in her medical history, underwent an ELAPE followed by reconstruction of the perineal defect with a VRAM flap after neoadjuvant radiotherapy for a moderately differentiated invasive adenocarcinoma of the distal rectum. The postoperative course was complicated with a herniation of the perineal wound and evisceration of a bowel loop.

CONCLUSION

Closure of the perineal defect after ELAPE remains a challenge, especially in cases where several risk factors for delayed wound healing, flap failure and perineal herniation are present.

Atypical fundal perforation: a case report

Gastric perforations typically occur in the distal stomach, along the greater curvature or the antrum. The vast majority of upper gastrointestinal (GI) perforations are caused by peptic ulcer disease. We present a case of an atypical location of gastric perforation. A 31-year-old patient was experiencing nausea and severe abdominal pain. Explorative laparoscopy revealed a large fundal perforation. The patient underwent an abdominoplasty 5 days before with revisional surgery for hemorrhage. He had recently lost 42 kg after endoscopic sleeve gastroplasty (ESG) 8 months before. ESG is a minimally invasive alternative for bariatric surgery. Since its implementation, several studies have been published indicating the procedure as safe. However, some major adverse events, such as upper GI-bleeding, peri-gastric leak, and pneumoperitoneum, have been described. The atypical location of the perforation might be explained by a combination of events such as surgical stress, revisional surgery, major weight loss, and the history of ESG.

A large retroperitoneal Mullerian cyst: case report and review of the literature

BACKGROUND

Mullerian duct cysts are considered to be part of the urogenital cysts. Mullerian cysts, anatomically distant to the genitourinary organs or the pelvis, are extremely rare entities.

MATERIAL AND METHODS

Case report and review of the literature using key word "Mullerian cyst", "retroperitoneal" and "mediastinal".

RESULTS

A 48-year-old woman with abdominal discomfort and nausea was referred to our hospital. Further work-up with CT and MRI showed a large retrogastric, retropancreatic cyst, herniating through the diaphragm in the mediastinum. As etiology was unsure, a laparoscopic cystectomy was performed. Histological examination showed a benign cyst of Mullerian origin. A review of the literature confirmed that extrapelvic Mullerian cysts are rare, with only 28 mediastinal cysts and 12 extrapelvic retroperitoneal cysts being described.

CONCLUSION

Retroperitoneal Mullerian cysts outside the pelvis have infrequently been described in the literature. As correct preoperative diagnosis is seldom possible, surgical resection is the gold standard of treatment.

Embolization of a large progressive symptomatic desmoid tumor in the rectus muscle of a female patient with multiple sclerosis: a case report

INTRODUCTION

Desmoid tumors are benign tumors, yet can lead to significant morbidity due to aggressive local expansions. Treatment starts with a wait-and-see policy, however, more aggressive treatments like broad margin resection surgery might be necessary in case of tumor progression.

PATIENTS AND METHODS

We report the case of a 26-year-old female with a symptomatic desmoid tumor in the left rectus muscle. The initial wait-and-see policy led to an increase in tumor size and progression of symptoms. Computed tomography (CT) angiography revealed a dominant arterial blood supply via a branch of the inferior epigastric artery. We then performed a super selective embolization of the dominant arterial blood supply, to avoid the need for broad margin resection.

RESULTS

At three months follow-up, the patient was asymptomatic and magnetic resonance imaging (MRI) showed no residual tumor. At nine months follow-up, MRI scan reconfirmed the successful outcome.

CONCLUSIONS

Embolization of a primary supplying vessel of a desmoid tumor is a viable treatment option. However, scientific evidence remains limited and further research is mandatory for inclusion in evidence based treatment algorithms.

A primary extraskeletal osteosarcoma of the mesentery: a case report

Extraskeletal osteosarcoma is a rare and invasive malignancy, typically located in the soft tissue without attachment to the skeleton. The present study reports a case of a primary mesenteric extraskeletal osteosarcoma of a 71-year-old woman. The patient complained of an incomplete defecation. Colonoscopy showed an ulcer with impression of external compression of the sigmoid. An additional abdominal computed tomography (CT) scan revealed a large, almost completely calcified, mass in the left lower abdomen causing hydronephrosis of the left kidney. The patient underwent surgery and the mass was resected completely. The histopathological diagnosis was a primary abdominal extraskeletal osteosarcoma arising from the mesocolon with local invasion of the sigmoid. She was in follow-up without adjuvant chemo- or radiotherapy. Five months after initial surgery the tumor recurred with widespread peritoneal metastasis.

High-dose lanreotide in the treatment of poorly differentiated pancreatic neuroendocrine carcinoma: a case report

Pancreatic neuroendocrine tumors (NETs), including poorly differentiated carcinomas (NECs), are rarely encountered. The majority of these tumors do not secrete excess hormones, but functioning NETs produce large amounts of vasoactive peptides and may cause carcinoid syndrome. Synthetic somatostatin analogs (SSAs) have been widely used in NETs for control of hormonal syndromes. Here, we present a case of poorly differentiated, grade 3 pancreatic NEC associated with carcinoid syndrome, for which adequate symptom control was achieved for 2 years and 4 months using the long-acting SSA lanreotide Autogel^®. In February 2009, a 55-year-old woman presented with episodes of flushing, diarrhea and epigastric pain. Imaging techniques revealed the presence of a metabolically active mass expressing somatostatin receptors in the hilar area of the liver. Histopathological examination confirmed the malignant nature of the mass, which was identified as a poorly differentiated grade 3 pancreatic NEC (TNM staging: T4NxM0). Therapeutic options were limited for the patient because of the extent of the primary mass involving the celiac axis, severe gastrointestinal toxicity experienced as a side effect of chemotherapy with cisplatin-etoposide and, later in the course of the disease, extensive liver metastases and carcinoid heart syndrome. Along with a palliative debulking surgery and right portal vein embolization, biotherapy with a high dose of lanreotide Autogel (120 mg/14 days) contributed to alleviation of symptoms caused by hormone overproduction, even after the development of liver metastases. These results suggest that patients with poorly differentiated NECs who exhibit signs of carcinoid syndrome can benefit from treatment with somatostatin analogs.

Is FNAC (fine needle aspiration cytology) a useful tool in detection of malignancy in thyroid surgery? A single institution experience

OBJECTIVE

To evaluate if FNAC (Fine Needle Aspiration Cytology) is a useful tool in the detection of malignancy in thyroid surgery. FNAC is used routinely as a preoperative diagnostic technique and surgical strategy is often adapted. But is FNAC such a good technique in defining surgical strategy?

METHODS

We retrospectively reviewed all files of 703 patients operated from 1997 till today. We obtained the results of the FNAC, the final pathological diagnosis and these data were analyzed.

RESULTS

There were 161 male and 542 female patients. 72 out 703 patients had a malignancy. 241 patients (34.3%) had a preoperative FNAC-procedure. Male patients had significantly more malignancies (p = 0.006). In 183 patients (75.9%) the FNAC was benign, 28 patients (11.6%) showed malignancy, in 15 patients (6.2%) only blood was found and 15 patients (6.2%) showed an inconclusive result. 70.1% of the patients were true negative, 5.8% were true positive, 5.8% false positive, 5.8% false negatives, 5.8% of inconclusive results were malignant on pathology. This gives a sensitivity of 50% and specificity of 92.4%.

CONCLUSIONS

The specificity of FNAC in malignancy is high (92.4%) but a sensitivity of 50% is low. With these results adaptation of surgical strategy (hemithyroidectomy or total thyroidectomy) secondary to the results of the FNAC is not recommended. Free hand FNAC might be a reason for the relatively high percentage of inconclusive results. Ultrasound guided FNAC can improve the yield of the puncture. On top of that pathological interpretation of the cytology is not always straight forward.

Polymerase chain reaction for Enterococcus faecalis in drain fluid: the first screening test for symptomatic colorectal anastomotic leakage. The Appeal-study: analysis of parameters predictive for evident anastomotic leakage

PURPOSE

With current diagnostic methods, the majority of patients with symptomatic colorectal anastomotic leakage(CAL) is identified approximately 1 week after operation.The aim of this study is to determine whether real-time polymerase chain reaction (RT-PCR) for detection of Escherichia coli and Enterococcus faecalis on drain fluid can serve as a screening test for CAL in the early postoperative phase.

METHODS

All patients included in this multicenter prospective observational study underwent left-sided colorectal resection for both malignant and benign diseases with construction of an anastomosis. In all patients, an intra-abdominal drain was placed during operation. During the first five postoperative days, drain fluid was processed for RT-PCR. The quantitative results of the RT-PCR on days 2 to 5 were compared to the results of day 1 in order to detect concentration changes.

RESULTS

In total, 243 patients, with both benign and malignant diseases, were included of whom 19 (7.8 %) developed symptomatic CAL. An increase in E. coli concentration was found insignificantly more patients with CAL on day 4 and 5 [p =0.0004; diagnostic odds ratio (DOR) 7.9]. For E. faecalis, this result was found for days 2, 3, and 4 (p <0.003) with highest DOR on day 3 (31.6). Sensitivity and negative predictive values were 92.9 and 98.7 %, respectively, virtually ruling out CAL in case of negative test results on the third postoperative day.

CONCLUSION

Quantitative PCR for E. faecalis performed on drain fluid may be an objective, affordable and fast screening tool for symptomatic colorectal anastomotic leakage.

Long-term and perioperative corticosteroids in anastomotic leakage: a prospective study of 259 left-sided colorectal anastomoses

OBJECTIVE

To determine the risk factors for symptomatic anastomotic leakage (AL) after colorectal resection.

DESIGN

Review of records of patients who participated in the Analysis of Predictive Parameters for Evident Anastomotic Leakage study.

SETTING

Eight health centers.

PATIENTS

Two hundred fifty-nine patients who underwent left-sided colorectal anastomoses.

INTERVENTION

Corticosteroids taken as long-term medication for underlying disease or perioperatively for the prevention of postoperative pulmonary complications.

MAIN OUTCOME MEASURES

Prospective evaluations for risk factors for symptomatic AL.

RESULTS

In 23% of patients, a defunctioning stoma was constructed. The incidence of AL was 7.3%. The clinical course of patients with AL showed that in 21% of leaks, the drain indicated leakage; in the remaining patients, computed tomography or laparotomy resulted equally often in the detection of AL. In 50% of patients with AL, a Hartmann operation was needed. The incidence of AL was significantly higher in patients with pulmonary comorbidity (22.6% leakage), patients taking corticosteroids as longterm medication (50% leakage), and patients taking corticosteroids perioperatively (19% leakage). Perioperative corticosteroids were prescribed in 8% of patients for the prevention of postoperative pulmonary complications.

CONCLUSIONS

We found a significantly increased incidence of AL in patients treated with long-term corticosteroids and perioperative corticosteroids for pulmonary comorbidity. Therefore, we recommend that in this patient category, anastomoses should be protected by a diverting stoma or a Hartmann procedure should be considered to avoid AL.

TRIAL REGISTRATION

trialregister.nl Identifier: NTR1258

Thoraco-abdominal wall reconstruction after surgical debulking of a giant retroperitoneal liposarcoma: a case report

A case of a patient with a recurrent dedifferentiated retroperitoneal liposarcoma with extensive invasion of the thoraco-abdominal wall including the skin, requiring reconstructive surgery after debulking of the tumor is reported.

Incarcerated vesico-inguinal hernia: a case report

In this paper we report a rare case of an incarcerated inguinoscrotal hernia of the urinary bladder in a 64-year-old male patient. He presented with a giant inguinal hernia and pollakisuria. The bladder was surgically repositioned intra-abdominally and resection of part of the bladder fundus was performed through laparotomy. Closure of the inguinal defect was performed through an inguinal approach. The patient's further recovery was uneventful. Herniation of the bladder is a very infrequent finding in inguinal hernias. We searched the literature and only found a few case reports describing this rare pathology. The literature and treatment options are discussed.

Splenic abscess complicating infective endocarditis: three case reports

We present three case-reports of splenic abscess in patients who were initially diagnosed with bacterial endocarditis. In all cases the diagnosis of splenic abscess was based on the findings of abdominal CT scan or MRI. All patients were treated by laparotomy and splenectomy. Two patients fully recovered and one patient, who suffered from splenic rupture and massive blood loss before surgery, died. Splenic abscess is a well-described but rare complication of infective endocarditis. Rapid diagnosis and treatment are essential as its course can prove fatal. Abdominal CT scan or MRI should be performed if there is clinical suspicion of splenic abscedation. Immediate splenectomy combined with appropriate antibiotics and valve replacement surgery is the treatment of choice. Splenic tissue is very fragile--especially if the abscess is located subcapsular--and a splenic rupture can result from minimal trauma. If the patient's general state allows it, it is best to perform splenectomy prior to valve replacement surgery to prevent re-infection of the valve prosthesis. A combined one-stage procedure is also an option.

Frozen section in thyroid surgery

OBJECTIVE

We studied the use of frozen section in the detection of malignancy in thyroid surgery in a large teaching hospital.

MATERIALS AND METHODS

We reviewed all case notes of patients operated on for thyroid disease between January 1st 1997 and December 31st 2004. We identified 420 operations in 408 patients. Data were available for 417 operations.

RESULTS

In patients with a solitary thyroid nodule, a frozen section is sometimes performed. Frozen section was done in 128 of 417 operations. The specificity for malignancy was 98.16%. The positive predictive value was 81.81% and the negative predictive value 93.85%. However the sensitivity was 56.25%. Frozen section is a time-consuming investigation. With follicular lesions it is very difficult to distinguish between benign disease and malignancy since the diagnosis of malignancy depends on capsular and/or blood vessel invasion. Also it costs about 100 Euro (approximately 125 dollars).

CONCLUSION

This study confirms that adequate histopathologic diagnosis of thyroid disease is based on extensive subsampling of the specimen which is not possible during a peroperatory frozen section procedure.

A defunctioning stoma in the treatment of lower third rectal carcinoma

INTRODUCTION

Total mesorectal excision (TME) is the accepted standard for rectal cancer treatment. However, there is an increased risk of symptomatic anastomotic leakage associated with TME as TME potentially endangers the blood supply of the remaining rectum. On top of this, many patients will receive neo-adjuvant radio-chemotherapy. A defunctioning stoma helps in avoiding severe complications of anastomotic failure.

MATERIAL AND METHODS

We prospectively collected data of all patients with a rectal carcinoma within reach of the palpating finger, operated on in our department between December 2000 and January 2005. There were 70 patients (42 men and 28 women, median age 70 (range 32-95)).

RESULTS

In 40 patients (40/70 = 57%) a sphincter-saving procedure was performed. Eleven patients were diagnosed with anastomotic leakage or failure. Seven patients had neo-adjuvant radio-chemotherapy, 4 had no neo-adjuvant therapy. In 4 patients signs of anastomotic leakage were seen on the barium-enema that is routinely performed before closing the defunctioning stoma. Seven patients (7/40 = 17,5%) had clinical signs of anastomotic leakage. Three of them could be treated conservatively with antibiotics and parenteral nutrition. Two of these patients did not have a defunctioning stoma. Four patients needed re-intervention and were treated in intensive care for several days. Three of these patients did not have a defunctioning stoma.

CONCLUSION

Neo-adjuvant radio-chemotherapy and TME resection are two factors in the treatment of rectal cancer that might interfere with anastomotic healing in the case of a sphincter-saving procedure. The construction of a defunctioning stoma helps in limiting the complications of anastomotic leakage or failure.

Skeletal muscle metastasis from a conventional renal cell carcinoma, two years after nephrectomy: a case report

In this paper, we describe a case of skeletal muscle metastasis from a conventional (clear cell) renal cell carcinoma, two years after nephrectomy. Our first clinical tentative diagnosis was soft tissue tumour, showing the mimicking capacity of renal cell carcinoma. A review of literature shows that skeletal muscle metastases from renal cell carcinoma are extremely rare: only 16 cases have been described. In 5/16, the muscle mass was the initial manifestation of the renal tumour. In the other 11/16, the muscle masses were metachronous (10 months-16 years). We conclude that, when confronted with a patient with a muscle mass and a history of renal cell carcinoma, one should always keep in mind the possibility of a (late) renal cell carcinoma metastasis.

Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature

An athletic 23 year old man presented with suprapubic tenderness, fever, and raised inflammatory blood variables. A diagnostic laparoscopy was performed, with a presumed diagnosis of retrocaecal appendicitis, but no abnormalities were found, apart from free fluid in the pouch of Douglas. Imaging of the pubic area suggested bony infection and inflammation. Biopsy and culture confirmed the presence of Staphylococcus aureus, a very common pathogen. The final diagnosis was osteomyelitis pubis, an infectious disease, and osteitis pubis, an inflammatory disease.

Laparoscopic management of acute small bowel obstruction

Laparosopy is now a well established tool in abdominal surgery. More often it is used in acute abominal situations. We present our experience with laparoscopy and laparoscopic treatment in patients with acute small bowel obstruction. Although it is technically challenging, in carefully selected patients laparoscopy and laparoscopic treatment is feasible and a valid option for treatment.

Characterization of the IGF system and analysis of the possible molecular mechanisms leading to IGF-II overexpression in a mesothelioma

The expression of members of the IGF system in a mesothelioma from a patient suffering from hypoglycemia, in term placenta and HT29 colon adenocarcinoma cells were compared. Very high levels of IGF-II mRNA and protein were detected in the mesothelioma. Moreover, half of the IGF-II protein took the high-molecular-weight form. We also analyzed the parental imprinting status and the promoter usage of the IGF-II gene. Our results showed loss of imprinting (LOI) in the mesothelioma while the imprinting was maintained in HT29 cells, expressing moderate levels of the transcript. Promoter P4 was active in the three tissues we analyzed, whereas IGF-II mRNA transcription from promoter P3 was only detected in the mesothelioma and the placenta, expressing comparably high levels of the transcript. IGF-II gene structure was identical in the analyzed tissues and cells. The type-I receptor mRNA expression was very low in the tumor. IGFBP-2, -4 and -5 mRNAs were detected in the mesothelioma, while IGFBP-2, -3 and -5 transcripts were detected in the placenta. IGFBP-1 and -6 transcripts were not detected.

Mycotic common carotid artery aneurysm in an immunosuppressed pediatric patient: case report

We report the case of a pediatric patient, treated for acute lymphoid leukemia, who developed a mycotic aneurysm (angioinvasive aspergillus infection) of the common carotid artery. In an emergency procedure we ligated the common carotid artery. The patient made a full recovery.

An intermittently volvulating paraoesophageal hernia mimicking angina pectoris. A case report

Paraoesophageal hernia is a type of hiatal hernia. The clinical signs are specific, different from those of the axial hernia. The diagnosis is often delayed. Once the diagnosis is made, surgical correction is mandatory. We present a new case of a patient with chest pain episodes who proved to have an intermittently volvulating paraoesophageal hernia.

Purification and properties of an enzyme involved in the ATP-dependent activation of the methanol:2-mercaptoethanesulfonic acid methyltransferase reaction in Methanosarcina barkeri

In Methanosarcina barkeri the transfer of the methyl group from methanol to 2-mercaptoethanesulfonic acid is catalyzed by the concerted action of two methyltransferases. The first one is the corrinoid-containing methanol:5-hydroxybenzimidazolylcobamide methyltransferase (MT1), which binds the methyl group of methanol to its corrinoid prosthetic group. MT1 is only catalytically active when the cobalt atom of the corrinoid is present in the highly reduced Co(I) state. In the course of its purification and even during catalysis, MT1 becomes oxidatively inactivated. The enzyme, however, may be reductively reactivated by a suitable reducing system (hydrogen and hydrogenase), ATP, and an enzyme called methyltransferase activation protein (MAP). In order to elucidate its role in the reactivation process, MAP was purified to apparent homogeneity. The protein had an Mr = 60,000. Preincubation of the enzymic components involved with 8-azido-ATP or with ATP demonstrated MAP to be the primary site of action of ATP. In agreement herewith, the protein was autophosphorylated by [gamma-32P]ATP in a 1:1 stoichiometry. Phosphorylated MAP substituted for ATP in the activation of MT1, and the addition of increasing amounts of MAP phosphate resulted in a corresponding increase of active MT1. However, in the presence of limiting amounts of MAP, maximal activation of MT1 could be achieved during a lag phase provided ATP was present, indicating that MAP acts as a catalyst. This paper is the first to report on the presence, isolation, and function of a phosphorylated protein in a methanogenic archaeon.

Dysrhythymia from an intrapericardial air gun pellet: a case report

We report a case of penetrating intrapericardial injury caused by an air gun pellet in which the onset of dysrhythmia suggested that the pericardium had been breached. Electrocardiographic changes appeared to be more useful in diagnosing pericardial penetration than transthoracic echocardiogram in this case.

Changes in myocardial high-energy phosphate stores and carbohydrate metabolism during intermittent aortic crossclamping in dogs on cardiopulmonary bypass at 34 degrees and 25 degrees C

The effect of cooling to 25 degrees C on myocardial metabolism was studied during four periods of global ischemia (10 minutes each) followed by 15 minutes of reperfusion in dogs on cardiopulmonary bypass. Systemic and heart temperature at normothermia (group N, 34 degrees C; n = 15) was compared with general hypothermia (group H, 25 degrees C; n = 16). Before and at the end of each aortic crossclamp period in small myocardial biopsy specimens the adenosine triphosphate, creatine phosphate, inorganic phosphate, glycogen, and lactate content was analyzed. Also, lactate and inorganic phosphate were measured in the coronary effluents during the repetitive periods of reperfusion. Hemodynamic function was not different at 60 minutes after cardiopulmonary bypass compared with pre-cardiopulmonary bypass values, and was not different between the groups N and H. The tissue content of adenosine triphosphate and glycogen decreased progressively during the experimental period, resulting in slightly depressed values in both groups at the end of cardiopulmonary bypass. Pronounced effects of ischemia and reperfusion on tissue content of creatine phosphate, inorganic phosphate, and lactate were observed after each period of ischemia. The net decrease in tissue creatine phosphate content was not different between groups N and H (41 +/- 4 versus 38 +/- 4 mumol.gm-1 dry weight; mean +/- standard error of the mean) after 10 minutes of ischemia. However, during ischemia the net inorganic phosphate increase in myocardial tissue was significantly higher in group H (70 +/- 7 mumol.gm-1) than in group N (44 +/- 3 mumol.gm-1). These findings do not support the notion that myocardial protection is improved during hypothermia. Moreover, quantitatively the release of inorganic phosphate and lactate did not correlate with the amount accumulated in the myocardial tissue during the preceding periods of ischemia. The release appeared to be temperature dependent, that is, significantly reduced at 25 degrees C. The present data demonstrate why clinical outcome is satisfactory in both surgical procedures, when in general the periods of aortic crossclamping do not exceed 10 minutes each and the reperfusion periods in between the ischemic episodes last about 15 minutes. Besides, the findings indicate that hypothermia is not strictly necessary under these circumstances.

Receptor-active glycolipids of epithelial cells of the small intestine of young and adult pigs in relation to susceptibility to infection with Escherichia coli K99

Glycolipids from mucosa scrapings of small intestine of neonatal and adult pigs were tested by the thin-layer chromatogram overlay assay for the binding of Escherichia coli K99. There was practically no binding to acid or non-acid glycolipids of adult pig, known to be resistant to infection with this bacterium. However, piglets, which are susceptible to infection, showed a clear binding to a doublet band in the acid glycolipid fraction. The receptor-active glycolipid was isolated and shown by mass spectrometry, NMR spectroscopy and degradation methods to be NeuGc alpha-3Gal beta 4Glc beta Cer (NeuGc-GM3), the two bands being due to heterogeneity of the ceramide. When tested against various reference glycolipids, NeuAc-GM3 was shown to be inactive. This ganglioside was dominating in adult pig. The apparent developmental disappearance of N-glycolyl groups in glycolipids of intestinal mucosa may have a correspondence in protein-linked sequences as well as thus explain the resistance of adult pigs to infection with E. coli K99.

Metabolic and haemodynamic changes in the heart during the early phase of cardiopulmonary bypass: II. Animal experiments

A significant release of lactate instead of uptake was observed during the first 10 min of cardiopulmonary bypass preceding aorto-coronary bypass surgery in human patients. To clarify these findings in more detail, myocardial lactate and oxygen metabolism was studied in healthy dog hearts subjected to a protocol similar to the clinical situation. In one group (n = 11) normothermia at 34 degrees C was used with an empty beating heart, and in the other group (n = 11) hypothermia with ventricular fibrillation was applied. Within the first 10 min of bypass no significant changes in high energy phosphates were observed in myocardial biopsies. However, a marked decrease in mean aortic blood pressure and a simultaneous lowering in oxygen consumption was observed in both groups after instalment of bypass. An initial shift from lactate uptake to lactate release occurred while on bypass in the normothermia group. After 10 min of bypass, lactate uptake was restored in hearts of both groups. Therefore, the lactate release during the initial phase of bypass in patients originates both from the instalment of the bypass and from (local) inadequate perfusion, which is most likely to be due to stenosed coronary arteries.

[Paraduodenal hernia: an unusual cause of intestinal obstruction]

Paraduodenal hernia. The paraduodenal hernia is the most common type of intraabdominal hernia. There exists a right and left variety, both of them with their own specific pathogenesis. The clinical manifestations range from intermittent and mild digestive problems to acute intestinal obstruction. An exact preoperative diagnosis is seldom made. The knowledge of their pathogenesis and the anatomical characteristics is very important for a successful surgical treatment.

The myocardial content of fatty acids and phospholipids during the calcium paradox

Readmission of Ca2+ after a short period of Ca2+-free perfusion results in a rapid and massive release of cytoplasmic proteins from the heart (calcium paradox). Maximal release rates of proteins are already reached within 2 min after Ca2+ repletion. The precise mechanism underlying the loss of cellular membrane integrity, resulting in the loss of intracellular proteins, has not been clearly defined. The present study indicates that neither substantial degradation of phospholipids, being important constituents of myocardial membranes, nor accumulation of fatty acids occur during the early phase (within 1.5 min) of Ca2+ readmission. Thereafter significant amounts of such fatty acids as arachidonic acid accumulate in the Ca2+ repleted hearts. The late onset of arachidonic acid accumulation, most likely reflecting phospholipid degradation, is considered to be an epiphenomenon occurring in myocardial cells which became heavily damaged, as indicated by the substantial loss of lactate dehydrogenase, during the early phase of Ca2+ repletion. Interestingly, tissue fatty acid levels increased already significantly during the Ca2+-free perfusion period (by about 240%). The significance of this finding is not completely understood. A possible causal relationship with disturbed ion homeostasis during the induction of calcium paradox remains to be established.