Predicting Progression, Recurrence, and Survival in Pancreatic Neuroendocrine Tumors: A Single Center Analysis of 174 Patients

INTRODUCTION

The European Neuroendocrine Tumor Society, ENETS, reports variables of prognostic significance in pancreatic neuroendocrine tumors (PNET). However, studies have short follow-ups, and the optimal treatment remains controversial. We aimed to determine overall survival (OS), progression-free survival (PFS) after conservative treatment, and recurrence-free survival (RFS) after surgery and further to find predictors of aggressive PNET behavior to support treatment decisions.

METHODS

174 patients with PNET treated at Aarhus University Hospital from 2011 to 2021 were included in a retrospective cohort study. Patients were divided into surgically resected (SUR, n=91) and medically or conservatively treated (MED, n=83). Variables were tested in univariate and multivariate survival analysis. Median follow-up time was 3.4 years in the MED group and 4.5 years in the SUR group.

RESULTS

The 5-year OS was 95% and 65% for the SUR and MED groups, respectively. The 5-year RFS in the SUR group was 80% whereas the 5-year PFS in the MED group was 41%. Larger tumor size, Ki67 index, tumor grade, and stage were predictive of shorter OS, RFS, and PFS. Further, chromogranin A was a predictor of OS. Larger tumor size was associated with higher stage and grade. Only 1 of 28 patients with stage 1 disease and size ≤2 cm developed progression on a watch-and-wait strategy during a median follow-up of 36 months.

CONCLUSION

This study supported the ENETS staging and grading system to be useful to predict OS, PFS, and RFS in PNET. Further, our data support that small, localized, low-grade PNETS can be followed with active surveillance.

Non-operative management of blunt splenic injuries in a paediatric population: a 12-year experience

INTRODUCTION

Non-operative management (NOM) is now the primary treatment for blunt splenic injuries in children. Only one study has examined the use of NOM in a Scandinavian population. Thus, the purpose of this study is to report our experience in treating children with blunt splenic injuries with NOM at a Danish university hospital.

METHODS

We conducted a retrospective observational study of 34 consecutive children (aged 16 years or less) admitted to our level 1-trauma centre with blunt splenic injury in the 12-year period from 1 January 2001 to 31 December 2012. Data on patients and procedures were obtained by review of all medical records and re-evaluation of all initial computed tomographies (CT).

RESULTS

We included 34 children with a median age of 10.5 years (67.6% males) in this study. All patients were scheduled for NOM, and two (5.9%) patients underwent splenic artery embolisation (SAE). Two (5.9%) patients later needed surgical intervention. The NOM success rate was 88% (95% confidence interval (CI): 73-97%) without SAE and 94% (95% CI: 80-99%) with SAE. We found no difference in the American Association for the Surgery of Trauma grade when comparing the initial CT evaluation (mean 2.59 ± 1.1) with the CT re-evaluation (mean 2.71 ± 0.94); p = 0.226.

CONCLUSION

We demonstrated a high degree of success and safety of non-operative treatment in children with blunt splenic injury in a Scandinavian setting. Our results are comparable to international findings.

Combined ablation and resection (CARe) as an effective parenchymal sparing treatment for extensive colorectal liver metastases

BACKGROUND

Combined intra-operative ablation and resection (CARe) is proposed to treat extensive colorectal liver metastases (CLM). This multicenter study was conducted to evaluate overall survival (OS), local recurrence-free survival (LRFS), hepatic recurrence-free survival (HRFS) and progression-free survival (PFS), to identify factors associated with survival, and to report complications.

MATERIALS AND METHODS

Four centers combined retropectively their clinical experiences regarding CLM treated by CARe. CLM characteristics, pre- and post-operative chemotherapy regimens, surgical procedures, complications and survivals were analyzed.

RESULTS

Of the 288 patients who received CARe, 210 (73%) had synchronous and 255 (88%) had bilateral CLM. Twenty-two patients (8%) had extrahepatic disease. Median follow-up was 3.17 years (95%CI 2.83-4.08). Median OS was 3.33 years (95%CI 3.08-4.17) and 5-year OS was 37% (95%CI 29-45). One- and 5-year LRFS from ablated lesions were 87.9% (95%CI 83.3-91.2) and 78.0% (95%CI 71-83), respectively. Median HRFS and PFS were 14 months (95%CI 11-18) and 9 months (95%CI 8-11), respectively. One hundred patients experienced complications: 29 grade I, 68 grade II-III-IV, and three deaths. In the multivariate models adjusted for center, the occurrence of complications was confirmed as a major independent factor associated with 3-year OS (HR 1.80; P = 0.008). Five-year OS was 25.6% (95%CI 14.9-37.6) for patients with complications and 45% (95%CI 33.3-53.4) for patients without.

CONCLUSIONS

Recent strategies facing advanced CLM include non-anatomic resections, portal-induced hypertrophy of the future remnant liver and aggressive medical preoperative treatments. CARe has the qualities of an approach that allows effective tumor clearance while maintaining good tolerance for the patient.

Acceptable results using small radio frequency ablation needle for liver parenchyma transection

INTRODUCTION

The aim of this study was to investigate a single-electrode radio frequency ablation (RFA) needle as an instrument for liver resections with special emphasis on operation time, time of liver ischaemia, intra-operative blood loss and post-operative complications.

MATERIAL AND METHODS

A total of 40 consecutive patients having a liver transection performed by an RFA single electrode from 1 September 2011 to 28 February 2012 were included in the study. Data concerning type of liver resection, liver parenchyma transection time, intraoperative bleeding and transfusions were prospectively recorded and registered. Furthermore, complications were recorded with special emphasis on bile fistulas and abscesses.

RESULTS

In all, 20 females and 20 males had a liver resection performed by a single RFA electrode. The mean bleeding was 520 ml ± 469 ml, and the mean liver parenchyma transection time was 52 min. ± 22 min. Three patients, all of whom underwent major resections, received blood transfusions. Five patients developed bile fistulas and two abscesses. There were no re-operations for bleeding and no 30-day mortality.

CONCLUSION

A single electrode RFA needle is a suitable tool for liver parenchyma transection with regard to operation time and intraoperative bleeding, but the frequency of bile leakage seems to be unacceptably high in cases of hemi-hepatectomies.

FUNDING

The authors have no conflicts of interest or financial support to declare.

TRIAL REGISTRATION

not relevant.

Survival after resection plus intra-operative radiofrequency ablation (IRFA) to treat colorectal liver metastases (CLM): Results of an international collaborative study

3558

Background: Adding IRFA to parenchymal resection to treat CLM is gaining increasing acceptance in specialized HPB teams treating complex, bilobar disease. Objectives were to confirm the promising results of the prospective CLOCC and ARF2003 trials on a larger international scale. Methods: Four centers combined their clinical databases regarding IRFA for CLM. Demographics, treatments, CLM characteristics, complications (Clavien-Dindo), local recurrence, and survivals (liver progression-free, LPFS, relapse-free, RFS and overall, OS) were analyzed. Results: 280 patients (38% female, median age 61y) received resection plus IRFA over 2001-2011. 205 had synchronous CLM (73%) and 247 bilateral (88%). 227 patients received pre-operative chemotherapy (173 one line, 37 two lines, 10 three lines, 7 missing); 189 received post-operative chemotherapy (103 one line, 46 two lines, 40 three lines). Median number of tumors resected was 2 (range 1-19) and ablated 2 (1-12). Median size (mm) of largest CLM ablated per patient was 8.5(0.1-50). 96 patients experienced complications: 29 G1, 19 G2, 35 G3, 10 G4, and 3 deaths. 48 patients had local recurrence of ablated CLM. 155 patients developed new CLM, 165 extra-hepatic metastases, and 119 patients died during follow-up. One-year, 3-year and median (months) RFS, LPFS and OS were respectively: RFS 41%(95CI35-47), 14%(95CI9-19), 9m (95CI8-11); LPFS 53%(95CI47-59), 31%(95CI25-37), 15m (95CI11-19); OS 90%(95CI85-93), 58%(95CI51-65), 40m (95CI37-50). Median follow-up was 38m (95CI34-49). Conclusions: In this difficult-to-treat group, survival results were good and comparable with rates reported after resection only. IRFA complements resection, enabling to treat more patients, and offers the advantage of sparing healthy parenchyma.

[Laparoscopic liver surgery]

Laparoscopic liver surgery has evolved rapidly since it was introduced in the early 1990s. Today every kind of liver resection is carried out by the laparoscopic approach in selected centres. No randomized clinical trials have yet been performed to compare laparoscopic to open hepatic resection and the literature consists mainly of retrospective studies. Laparoscopic liver surgery seems to be superior to open liver surgery with regard to morbidity and mortality, as it also seems superior in cost benefit analysis. There are no data on long-term oncological results.

[Epidemiology of primary and secondary liver cancers]

Most primary liver cancers are hepatocellular carcinomas (HCC) or cholangiocarcinomas. In clinical practice, the majority of secondary liver cancers are metastases from colorectal cancer. The HCC incidence rate is constant in Denmark (2 per 100,000 per year), which is lower than in many other countries due to the low prevalence of viral hepatitis. The incidence rate of cholangiocarcinoma is slightly lower, and decreasing. The incidence rate of liver metastases is at least 40 per 100,000 per year. The prognosis for patients with liver cancer is poor, but seems to be improving.

Growth hormone is a stimulating but not an essential factor in healing of colon. A study in GH-deficient dwarf rats

BACKGROUND

Growth hormone (GH) has been implicated as an important factor in the healing and previous studies showed significant strength acceleration of experimental intestinal anastomoses.

AIM

To study the healing of experimental colonic anastomoses in GH-deficient rats and to study the potential physiological effects of GH-substitution on healing parameters.

CONCLUSION

Exogenous rhGH treatment started 7 days prior to surgery and continued until day 4 postoperatively accelerates the strength development of the experimental colonic anastomoses in dwarf rats indicating a potent role of growth hormone in colonic healing. However, GH is not essential in the healing process, since anastomotic healing in GH-deficient dwarf rats is like rats with normal pituitary function.

[Endoclip on the cystic duct after laparoscopic cholecystectomy]

We report on a case that occurred after laparoscopic cholecystectomy in a 70-year-old man, where a polymer endoclip placed on the cystic duct migrated into the common bile duct. The clip migration was detected two months after surgery during endoscopic retrograde cholangiography, when a stone and the clip were removed. Based on this and other similar cases, we suggest the use of absorbable clips in laparascopic cholecystectomy.

Improved physical performance and increased lean tissue and fat mass in patients with ulcerative colitis four to six years after ileoanal anastomosis with a J-pouch

PURPOSE

This study was designed to examine the long-term changes in physical performance, body composition, and bone mineral density in patients with ulcerative colitis undergoing ileoanal anastomosis with J-pouch. Patients were also screened for abnormalities in blood biochemistry.

METHODS

Maximal isometric strength (sum of pinching, hand grip, arm flexion, and knee extension), work capacity (ergometer test at 1.5 W/kg), pulmonary function, body composition (dual-energy x-ray absorptiometry scan), and fatigue level were assessed before surgery and four to six years later.

RESULTS

Of 24 patients examined preoperatively, 12 females and 8 males were retested. At follow-up, their mean age +/- standard deviation was 38 +/- 9 years, weight was 76 +/- 14 kg, and height was 173 +/- 7 cm. Compared with preoperative assessments, muscular strength had increased 10.6 +/- 17.2 percent (P = 0.015), work capacity 10.4 +/- 13.3 percent (P = 0.003), total tissue mass 4.6 +/- 5.4 kg (P = 0.001), lean tissue mass 2.3 +/- 2.2 kg (P < 0.001), fat mass 2.2 +/- 3.7 kg (P = 0.014), and bone mineral density 1.6 +/- 2.4 percent (P = 0.008). Seventeen of 20 patients had biochemical abnormalities.

CONCLUSIONS

After ileoanal anastomosis with J-pouch, muscular strength and work capacity improved concomitant with an increase in total tissue mass, lean tissue mass, fat mass, and bone mineral density. Biochemical abnormalities were common.

[Cystic parathyroid adenoma. A rare cause of primary hyperparathyroidism]

Two cases of primary hyperparathyroidism associated with parathyroid cysts were identified by an elevated plasma Ca++ level. The diagnosis was established preoperatively by the presence of high quantities of PTH in the cyst fluid in one of the patients. Cysts in the neck or superior mediastinum should raise suspicion of primary hyperparathyroidism.

Time-dependent intestinal adaptation and GLP-2 alterations after small bowel resection in rats

Existing data on morphological adaptation after small bowel resection are obtained by potentially biased methods. Using stereological techniques, we examined segments of bowel on days 0, 4, 7, 14, and 28 after 80% jejunoileal resection or sham operation in rats and correlated intestinal growth with plasma levels of glucagon-like peptide-2 (GLP-2). In the jejunum and ileum of the resected rats, the mucosal weight increased by 120 and 115% during the first week, and the weight of muscular layer increased by 134 and 83%, compared with sham-operated controls. The luminal surface area increased by 190% in the jejunum and by 155% in the ileum after 28 days. The GLP-2 level was increased by 130% during the entire study period in the resected rats. Small bowel resection caused a pronounced and persistent transmural growth response in the remaining small bowel, with the most prominent growth occurring in the jejunal part. The significantly elevated GLP-2 level is consistent with an important role of GLP-2 in the adaptive response.

GH decreases hepatic amino acid degradation after small bowel resection in rats without enhancing bowel adaptation

Growth hormone (GH) treatment in short bowel syndrome is controversial, and the mechanisms of a possible positive effect remain to be elucidated. Rats were randomly subjected to either an 80% jejunoileal resection or sham operation and were given either placebo (NaCl) or biosynthetic rat GH (brGH). The in vivo capacity of urea nitrogen synthesis (CUNS) and the expression of urea cycle enzymes were measured and related to changes in body weight and adaptive growth in ileal segments on days 7 and 14. Ileal segments were examined by unbiased stereological techniques. brGH treatment decreased CUNS among the resected rats by 19% (P<0.05) and 36% (P<0.05) on days 7 and 14, respectively. The mRNA levels of urea cycle enzyme genes were not influenced by brGH treatment. brGH treatment did not increase the adaptive growth in the ileal segments. In conclusion, we found that GH treatment decreased the accelerated postoperative hepatic amino acid degradation in experimental short bowel syndrome without enhancing the morphological intestinal adaptation.

Growth hormone treatment increases transmural colonic growth in GH-deficient dwarf rats

Growth hormone (GH) has been implicated as an important factor in the growth regulation of several visceral organs including the gastrointestinal tract. Our aim was to study the effects of GH administration on colonic growth in dwarf rats with an isolated GH deficiency. Dwarf rats were treated with recombinant human growth hormone (rhGH; 2.0 mg/kg/day) for four weeks and compared with saline treated dwarf rats and rats with normal pituitary function. The colonic wall composition was measured by means of stereological techniques. RhGH treatment of the dwarf rats increased body weight by 80% and proximal and distal colon weight by 63% and 90%, when compared with placebo treated dwarf rats (P< 0.01). The weight of the proximal colonic mucosa increased by 83% (P< 0.01), submucosa by 78% (P< 0.05), and the muscularis propria by 51% (P< 0.001) in rhGH treated dwarf rats compared with dwarf controls. The weight of the distal colonic mucosa increased by 88% (P< 0.01), submucosa by 88% (P< 0.05) and the muscularis propria by 58% (P< 0.05) compared with dwarf controls. The growth of mucosa involved all mucosal layers, with a 73 and 92% increase in the proximal and distal colon luminal surface area respectively (P< 0.001, P< 0.01). The food consumption, expressed as g/day/100 g BW was 13% higher in dwarf rats receiving rhGH than in placebo treated rats (P< 0.05) and normal control rats (P< 0.05). When weights of the GI tract compartments are corrected for the increase in body weight the effects of GH treatment were small or non-significant. RhGH administration in GH deficient dwarf rats induces visceral growth with a pronounced increase in colonic luminal surface area and growth of all layers of the colonic wall. These findings confirm the important role of GH in the regulation of intestinal growth.

Time-dependent changes in the luminal surface and mass of the rat colon during prolonged systemic treatment with epidermal growth factor

BACKGROUND

Systemic treatment with epidermal growth factor (EGF) for 4 weeks increases the colonic mucosal weight and surface area. The present study was initiated to describe the time-dependent colonic changes during prolonged treatment with EGF.

METHODS

Forty-eight female Wistar rats were allocated into five groups receiving subcutaneous EGF treatment (150 microg/kg/day) for 0 (controls), 1, 2, 3, or 4 weeks. EGF was administered in the weeks before they were killed. By means of modern stereologic techniques (point counting and vertical sections), the weights of the colonic wall layers and the luminal surface area were measured on histologic sections. The colon was subdivided into proximal and distal parts.

RESULTS

The weight of the total colon increased relatively more than the total body weight. After 1 week of treatment with EGF the surface area and wet weight of the total colon increased by 47% and 10%, and after 4 weeks by 62% and 37%, respectively. After 4 weeks the weight increase was mainly due to increased mucosal weight (by 65%, P < 0.01) and less prominently the submucosa (by 45%, P < 0.01) and the muscularis propria (by 32%, P < 0.01). On the basis of the wet weight increase, the proximal colon was more responsive to EGF treatment than the distal colon.

CONCLUSIONS

Systemic treatment with EGF for 1 week increased the luminal surface area relatively more than the mass of the colon. Treatment with EGF for more than 1 week caused only a minor further surface area increase, whereas the colonic mass continued to increase in a time-dependent manner.

Perioperative growth hormone treatment and functional outcome after major abdominal surgery: a randomized, double-blind, controlled study

OBJECTIVE

To evaluate short- and long-term effects of perioperative human growth hormone (hGH) treatment on physical performance and fatigue in younger patients undergoing a major abdominal operation in a normal postoperative regimen with oral nutrition.

SUMMARY BACKGROUND DATA

Muscle wasting and functional impairment follow major abdominal surgery.

METHODS

Twenty-four patients with ulcerative colitis undergoing ileoanal J-pouch surgery were randomized to hGH (12 IU/day) or placebo treatment from 2 days before to 7 days after surgery. Measurements were performed 2 days before and 10, 30, and 90 days after surgery.

RESULTS

The total muscle strength of four limb muscle groups was reduced by 7.6% in the hGH group and by 17.1% in the placebo group at postoperative day 10 compared with baseline values. There was also a significant difference between treatment groups in total muscle strength at day 30, and at the 90-day follow-up total muscle strength was equal to baseline values in the hGH group, but still significantly 5.9% below in the placebo group. The work capacity decreased by approximately 20% at day 10 after surgery, with no significant difference between treatment groups. Both groups were equally fatigued at day 10 after surgery, but at day 30 and 90 the hGH patients were less fatigued than the placebo patients. During the treatment period, patients receiving hGH had reduced loss of limb lean tissue mass, and 3 months after surgery the hGH patients had regained more lean tissue mass than placebo patients.

CONCLUSIONS

Perioperative hGH treatment of younger patients undergoing major abdominal surgery preserved limb lean tissue mass, increased postoperative muscular strength, and reduced long-term postoperative fatigue.

Perioperative growth hormone treatment increases nitrogen and fluid balance and results in short-term and long-term conservation of lean tissue mass

The surgical procedure for forming an ileoanal anastomosis with a J pouch (IAA) usually involves a temporary ileostomy; patients undergoing IAA surgery thus need to recover quickly because they return for ileostomy closure 3 mo later. We evaluated the effects of perioperative biosynthetic growth hormone (GH) treatment on short- and long-term changes in body composition and on nutritional intake. Patients with ulcerative colitis undergoing IAA surgery were randomly assigned to double-blind treatment with placebo (n=12) or 6 IU GH twice daily (n=12) from 2 d before to 7 d after the operation. Examinations were from 2 d before to 9 d after the operation and on days 30 and 90. Body composition was assessed with a dual-energy X-ray absorptiometry scanner. The 2 groups had similar nutritional intakes. On postoperative day 7, placebo-treated patients had lost 4.2 kg (95% CI: 3.0, 5.4) total tissue mass, 3.6 kg (2.1, 5.1) lean tissue mass, and 0.5 kg (-0.1, 1.2) fat mass. These reductions persisted 3 mo later. Compared with placebo, GH improved nitrogen balance, changes in lean tissue mass [gain of 4.0 kg (1.9, 6.0), P=0.001], and changes in total tissue mass [gain of 3.2 kg (1.6, 4.9), P=0.001], but increased the loss of fat mass [loss of 0.7 kg (0.0, 1.5), P=0.049] on postoperative day 7. Three months later, the placebo-treated patients had lost 2.4 kg (0.7, 4.2) more lean tissue mass than GH-treated patients (P=0.009), whereas changes in total tissue and fat mass were not significantly different. Hence, GH treatment enhanced the long-term regain of lean tissue mass.

Differential changes in free and total insulin-like growth factor I after major, elective abdominal surgery: the possible role of insulin-like growth factor-binding protein-3 proteolysis

Major surgery is accompanied by extensive proteolysis of insulin-like growth factor (IGF)-binding protein-3 (IGFBP-3). Proteolysis of IGFBP-3 is generally believed to increase IGF bioavailability due to a diminished affinity of the IGFBP-3 fragments for IGFs. We have investigated 18 patients undergoing elective ileo-anal J-pouch surgery. Patients were randomized to treatment with GH (12 IU/day; n = 9) or placebo (n = 9) from 2 days before to 7 days after operation. Free IGF-I and IGF-II were measured by ultrafiltration of serum, and IGFBP-3 proteolytic activity was determined by a [125I]recombinant human IGFBP-3 degradation assay. In the GH-treated group, total IGF-I increased preoperatively by 99%. Postoperatively, total IGF-I decreased by 48% (placebo) and 52% (GH). Immunoassayable IGFBP-3 decreased by 27% (placebo) and 26% (GH). In the placebo-treated group, free IGF-I was unchanged throughout the study. In the GH-treated group, free IGF-I increased by 277% preoperatively and remained elevated after operation. IGFBP-3 proteolytic activity increased by 63-73% after operation. The relative elevations of free IGF-I levels despite decreased total IGF-I levels could thus relate to augmented IGFBP-3 proteolysis.

[Injury pattern in a sports club with its own sports physician]

As the first Danish athletic association, TST-79 in 1995 appointed a permanent sports doctor for use by all its members. We publish the results of the first year. Seventeen percent of all handball players and 11% of all football players were seen in the consultation. The athletes were between 10 and 69 years old. Seventy-eight percent of the injured athletes could be diagnosed, instructed and, if necessary, treated after one consultation. Eight percent were sent for further examination at a hospital. Ultrasound examinations were necessary for establishing the diagnosis in 10% of the injured athletes. Some of the injuries were serious, and would probably not have been seen if the athletes did not have the possibility of consulting a sports doctor. This would increase the risk of chronic injury. It is suggested that a permanent arrangement with a sports doctor is an economically reasonable investment.

Randomised comparison of leucocyte-depleted versus buffy-coat-poor blood transfusion and complications after colorectal surgery

BACKGROUND

Allogeneic blood transfusion is associated with an increased frequency of postoperative infection. We studied whether such events can be avoided by the intraoperative and postoperative use of leucocyte-depleted blood.

METHODS

589 consecutive patients scheduled for elective colorectal surgery were randomised to receive buffy-coat poor (n = 299) or filtered leucocyte-depleted red-cells (n = 290) when transfusion was indicated. 260 patients actually received blood transfusion. Three patients were excluded from analysis.

FINDINGS

The 142 patients randomised to and transfused with buffy-coat-poor blood had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 155 patients who were allocated to this group but who were not transfused. (12 vs 1%, p < 0.0001) and (5 vs 0%, p = 0.005), respectively. Those receiving buffy-coat-poor blood also had a significantly higher frequency of wound infections and intra-abdominal abscesses than the 118 randomised to and receiving leucocyte-depleted blood (12 vs 0%, p < 0.0001) and (5 vs 0%, p = 0.017), respectively. Postoperative pneumonia occurred at a significantly higher rate in patients receiving buffy-coat-poor blood: 23 versus 3% in non-transfused patients (p < 0.0001), and 23 versus 3% in patients transfused with leucocyte-depleted blood (p < 0.001). The mortality rate between the groups was not statistically different.

INTERPRETATION

Our data suggests that the association between allogeneic blood transfusion and postoperative infection is limited to allogeneic blood products that are not adequately depleted of immunosuppressive leucocytes. This undesirable effect can be reduced by leucocyte depletion with high-efficiency filters.

The sportsman's hernia--fact or fiction?

This review is based on the results of 308 operations for unexplained, chronic groin pain suspected to be caused by an imminent, but not demonstrable, inguinal hernia: the 'sportsman's hernia' (SH). No differences in perioperative findings between cured and non-cured athletes were found. However, there was a remarkable difference between the various perioperative findings in the studies. It was characteristic that further clinical investigation of the noncured, operated athletes gave an alternative and treatable diagnosis in more than 80% of cases. Herniography was used consistently in the diagnostic process in all the studies on SH. However, in 49% of cases hernias were also demonstrated on the opposite, asymptomatic groin side. In conclusion, the final diagnosis (and treatment) often reflects the speciality of the doctor and the present literature does not supply proper evidence to the theory that SH constitutes a credible explanation for chronic groin pain.

Effects of longterm epidermal growth factor treatment on the normal rat colon

BACKGROUND

Epidermal growth factor (EGF) exerts trophic effects on the mucosa of damaged and defunctioned colon, but the effects on the normal large bowel wall are not known.

AIMS

To investigate the effect of systemic EGF treatment on growth and morphology of normal rat colon.

METHODS

Rats were treated with subcutaneous biosynthetic EGF injections of 150 micrograms/kg/day for 28 days. The weight of the histological colonic wall layers and the luminal surface area were measured using quantitative morphometric analysis (stereology). The colon was subdivided into proximal and distal parts.

RESULTS

EGF treatment increased the total colon wet weight by 23% compared with controls (p < 0.005). The weight increase occurred in the mucosal (33%) and the submucosal layers of the bowel wall (36%) and there was a 69% increase of the total luminal surface area (p = 0.001). In the proximal part of colon of EGF rats there was a 68% increase in mucosal weight (p < 0.005) accompanied by a 79% increase in the mucosal surface area compared with controls (p < 0.005), whereas submucosal and muscularis propria weights were identical. In distal colon, the mucosal weight increased 28% in the EGF group (p < 0.005), the mucosal surface area increased by 72% after treatment (p < 0.01). Furthermore there was a 34% increase in the weight of submucosa (p < 0.001) in the distal colon among EGF rats.

CONCLUSIONS

Treatment of rats with EGF has a stimulating role on the mucosa and luminal surface area of the entire functioning colon and a trophic effect on the submucosa of the distal colon.

Effect of insulin-like growth factor I (IGF-I) administration on the healing of colonic anastomoses in rats

BACKGROUND

The gastrointestinal tract is highly responsive to the tropic effect of growth hormone (GH). GH stimulates the healing of colonic anastomoses either directly or through insulin-like growth factor I (IGF-I) since specific GH receptor as well as IGF-I receptor have been demonstrated in colon.

AIM

To determine whether exogenous treatment with IGF-I could stimulate the healing of left colonic anastomoses in rats.

METHODS

After colonic anastomotic operations adult rats were randomised to treatment with either IGF-I (500 mu g per day) or vehicle (controls). Anastomotic breaking strength and collagen deposition were determined at day after surgery.

RESULTS

IGF-I treatment increased the anastomotic collagen content by 23% compared with controls. This resulted in a lower extensibility of the anastomosis (P < 0.05), whereas the anastomotic breaking strength did not differ between groups. The treatment resulted in a 3 fold increase in serum IGF-I of IGF-I treated rats, compared to controls. The postoperative body weight increased by 5% in the IGF-I rats from day 0 to day 3, while the control group had a weight loss of 2% in the same period (P < 0.001).

CONCLUSION

Treatment of colon-operated rats with IGF-I increased the postoperative body weight and stimulates the collagen deposition of left colonic anastomoses, whereas the anastomotic strength may be unaffected by IGF-I treatment.

Chronic systemic treatment with epidermal growth factor in the rat increases the mucosal surface of the small intestine

We examined the effects of treatment with human recombinant epidermal growth factor (EGF) on the functioning small intestine in the rat. Male Wistar rats, 7-8 weeks old, were treated with EGF administered subcutaneously in doses of 0 (n = 7) or 150 micrograms/kg/day (n = 8) for 4 weeks. The histological composition and mucosal surface area of the perfusion-fixed small intestine was quantified with stereological principles. The length of the gut remained unchanged. The amount of tissue and surface area per length of gut (median (ranges)) were increased from 117 (101-131) mg/cm and 2.6 (2.1-3.5) cm2/cm in the controls to 146 (138-152) mg/cm and 3.5 (2.5-3.8) cm2/cm for the complete small intestine (both comparisons P < 0.02). The weight increase was due to mucosal growth in all parts of the intestine, whereas the surface area was only increased in proximal and middle parts. It is concluded that EGF treatment in rats increases the mucosal weight and surface area of the functioning small intestine.

Transmural trophic effect of short chain fatty acid infusions on atrophic, defunctioned rat colon

PURPOSE

This study was designed to investigate and quantify trophic alterations in the defunctioned, atrophic rat colon after short chain fatty acid (SCFA) treatment was administered in a clinically relevant way.

METHODS

Diverting colostomy with exclusion of distal colon was performed on adult female rats (58), and treatment was started four weeks later. Enemas of either a SCFA solution of sodium-acetate, sodium-propionate and sodium-butyrate (concentration, 780 mM), or isotonic saline (placebo) were instilled through the anus into the defunctioned colon. This was done twice daily for 7 or 14 days before death.

RESULTS

After SCFA instillation for 14 days, the colonic wet weight was 18 percent higher compared with placebo (P < 0.01), and there was a similarly significant difference in dry weight (P < 0.05). Using stereologic assessment to determine the histologic composition of defunctioned colon, we found significant increases among SCFA-treated rats in the weight of the mucose (P < 0.05), the submucosa (P < 0.05), and the muscularis propria (P < 0.05) and a 30 percent increase in the mucosal surface area compared with placebo-treated in the mucosal surface area compared with placebo-treated rats (P < 0.05). Measurements of breaking strength and hydroxyproline content showed no differences between treatment groups.

CONCLUSIONS

SCFA enemas have a transmural trophic effect and preserve mucosal surface area of defunctioned and atrophic colon in rats.

[Iliopsoas tendinitis in athletes. Diagnosis and treatment]

Iliopsoas tendinitis is a common injury in sport. Despite of this there are only a few articles in the literature that deal with these injuries. The changes in the inflamed tendons and muscles have been difficult to determine objectively. The modernization of ultrasound devices has improved the methods of examination and made it possible to diagnose objective changes in the tendons and muscles. Recommendations for the treatment of acute and chronic iliopsoas tendinitis are given.

Trophic effects of biosynthetic growth hormone on normal and defunctioned left colon in rats

BACKGROUND

In rats with diverting colostomies the effects of growth hormone can be differentiated from the actions of fecal passage.

METHODS

After sham operation or diverting colostomy rats were treated with biosynthetic growth hormone (b-hGH) for 4 weeks.

RESULTS

In defunctioned colon of b-hGH-treated rats there were increases in mucosal surface area and the weight of mucosa and muscularis propria compared with the atrophic colon of saline-treated rats. The breaking strength of defunctioned colon rings was greater and the defatted dry weight and hydroxyproline content of these specimens were also increased. In intact colon b-hGH stimulated luminal surface area, the weight of mucosal and submucosal layers, and the hydroxyproline content compared with controls. The breaking strength was highest in specimens from saline-treated rats.

CONCLUSIONS

B-hGH has a growth-promoting role throughout the whole thickness of the colonic wall in rats also in the absence of fecal passage.

Impaired wound healing but unaltered colonic healing with increasing age: an experimental study in rats

Age-related differences in the healing of left colonic anastomoses and abdominal incisional wounds were compared between young and old rats. Immediately after surgery the anastomotic strength (suture-binding capacity) was 67% higher in old rats corresponding to a 107% higher collagen content per unit length of left colon compared to young rats. After 2 and 4 days of healing there was no difference in the breaking strength of the anastomoses between young and old rats, although the increase in collagen content of the anastomosed segment was 100% in the young rats and only 35% in the old rats from day 2 to day 4. The healing of the abdominal incisional wounds was, however, impaired in old rats compared to young rats, since the tensile strength and the energy absorption on the 4th postoperative day was 67 and 57% lower, respectively. In conclusion, old rats have impaired skin healing, whereas colonic healing is not affected by age.

Diverting colostomy induces mucosal and muscular atrophy in rat distal colon

The progress of adaptive changes in the left colon after diverting colostomy was studied in rats using stereological techniques. Standardised segments of left colon proximal and distal to the colostomy was examined after 0, 1, 2, 4, or 12 weeks. In excluded colon the mucosal weight was reduced by 37% (p < 0.01) and the luminal surface area by 47% (p < 0.01) after four weeks and reached a steady state at this point of time, as no further reduction was seen from 4 to 12 weeks. The number of proliferating crypt cells was determined immunohistochemically after in vivo labelling with bromodeoxyuridine and was compared with the total number of colonocytes. Total bowel rest leads to a reduction in the number of proliferating epithelial cells and not to a reduced average life span. The weight of the muscularis propria decreased by 32% after four weeks (p < 0.01) and by 48% after 12 weeks (p < 0.001), whereas the weight of the submucosa was unchanged. No adaptive changes were found in segments proximal to the colostomy. These results show that the wall composition of defunctioned colon in rats is radically changed resulting from a mucosal and muscular atrophy, and from a reduction in luminal surface area.

Growth hormone treatment of rats with chronic diverting colostomy. Differential response on proximal functioning and distal atrophic colon

Diversion of colon from the fecal stream leads to profound intestinal atrophy. After diverting colostomy for 4 weeks, female rats were treated with biosynthetic human growth hormone (b-hGH; 2.0 mg.kg-1 body wt.day-1) in order to investigate whether b-hGH could reverse atrophic changes in distal colon, with special reference to changes in morphometric composition, collagen content and biomechanical properties. Biosynthetic hGH treatment for 28 days stimulated growth of the muscularis propria of the defunctioned, atrophic colon (p < 0.05), whereas the mucosal atrophy was unaffected by the treatment. In colon proximal to the colostomy, however, b-hGH increased the colonic wet weight (p < 0.01), defatted dry weight (p < 0.005) and the collagen content (p < 0.05). Morphometric analysis showed that the growth increase was localized to the mucosa and the muscularis propria. In conclusion, fecal diversion alters the response of b-hGH treatment and indicates that the trophic effect of growth hormone on colonic mucosa is dependent on fecal bulk passage, whereas the trophic effect on muscularis propria is fully retained when colon is deprived of luminal nutrients.

Decrease in collagenous proteins and mechanical strength of distal colon after diverting colostomy in rats

The effects of a diverting colostomy on weight, collagen content, and biomechanical strength of the left colon was investigated in rats. Female rats received either a diverting colostomy or a sham-operation and were killed randomly 1, 2, 4, or 12 weeks after surgery. The dry weight and hydroxyproline content of excluded colon decreased by 37% (P < 0.001, confidence limits (CL) = 21-53%) and 25% (P < 0.001, CL = 18-31%), respectively, after 4 weeks, and by 52% (P < 0.001, CL = 38-66%) and 40% (P < 0.001, CL = 27-53%), respectively, after 12 weeks compared to sham-operated rats. The breaking strength of the defunctioned colon decreased by 21% (P < 0.05, CL = 2-40%) after 4 weeks and by 25% after 12 weeks (P < 0.05, CL = 4-46%). The tensile strength of defunctioned colon (load per unit collagen) was reduced by 19% after 4 weeks (P < 0.05, CL = 6-32%). Proximal to the colostomy site we found no differences in the hydroxyproline content or biomechanical strength. In conclusion, defunctioning of the left colon in rats leads to deterioration in the biomechanical properties caused by a lesser content and a decreased quality in the collagen of the left colon.

[Lateral ligament ruptures of the ankle joint in young athletes]

Treatment of lateral ligament rupture of the ankle has previously been primarily surgical. Immobilisation in a plaster cast has recently become more usual, and gradually this treatment is partially being replaced by immobilisation in adhesive elastic bandage. Operation of younger, athletic patients with large ruptures is, however, still recommended. It is inexpedient to operate these patients. They will be delayed for several weeks in their return to sport.