Botulinum toxin infusion into the mesenteric artery has selective action on peristalsis in a rat model: experimental research.

OBJECTIVE: Botulinum toxin type A (BoNT/A) reversibly blocks neurotransmission at voluntary and autonomic cholinergic nerve terminals, inducing paralysis. The aim of this study was to block panenteric peristalsis in rats through BoNT/A administration into the superior mesenteric artery (SMA) and to understand whether the toxin's action is selectively restricted to the perfused territory. MATERIALS AND METHODS: Rats were infused through a 0.25-mm surgically inserted SMA catheter with different doses of BoNT/A (10 U, 20 U, 40 U BOTOX®, Allergan Inc.) or with saline for 24 h. Animals were free to move on an unrestricted diet. As a sign of bowel peristalsis impairment, body weight and oral/water intake were collected for 15 days. Statistical analysis was conducted with nonlinear mixed effects models to study the variation over time of the response variables. In three 40 U-treated rats, the selectivity of the intra-arterial delivered toxin action was studied by examining bowel and voluntary muscle samples and checking the presence of BoNT/A-cleaved SNAP-25 (the smoking gun of the toxin action) using the Immunofluorescence (IF) method through a specific antibody recognition. RESULTS: While control rats exhibited an increasing body weight, treated rats showed an initial dose-dependent weight reduction (p<0.001 control vs. treated) with recovery after Day 11 for 10 and 20 U-treated rats. Food and water intake over time showed significantly different half-saturation constants with rats treated with higher doses who reached half of the maximum achievable in a greater number of days (p<0.0001 control vs. treated rats). BoNT/A-cleaved SNAP-25 was identified in bowel wall NMJs and not in voluntary muscles, demonstrating the remarkable selectivity of arterially infused BoNT/A. CONCLUSIONS: Blockade of intestinal peristalsis, can be induced in rats by slow infusion of BoNT/A into the SMA. The effect is long-lasting, dose-dependent and selective. BoNT/A delivery into the SMA through a percutaneous catheter could prove clinically useful in the treatment of entero-atmospheric fistula by temporarily reducing fistula output.

Closed incision Negative Pressure Therapy (ciNPT): does depression affect underlying tissues?

OBJECTIVE: Closed incision Negative Pressure Therapy (ciNPT) has become a widespread practice in recent years. Described benefits concern the rate of wound infection, based on the assumption that negative pressure spreads inside the wound removing collections and edema. The study aims to clarify this technical point, on which experimental scientific evidence is lacking in literature. MATERIALS AND METHODS: In the experimental animal (newly sacrificed pig), the pressure was measured for hours at the bottom of three surgical abdominal wounds sutured by planes and dressed in negative pressure therapy commercial sets. RESULTS: The depression applied to the surface of the sutured wounds (ciNPT) is not transmitted to the underlying tissues. The blue dye deposited in the deep layer of the wounds didn't surface as an effect of ciNPT. CONCLUSIONS: The possible benefits deriving from the application of negative pressure on sutured wounds must depend on a different mechanism from the diffusion of depression in the wound planes and in the underlying tissues.

[The "damage control" in severe hepatic injuries: our experience]. / Il "damage control" nel trattamento di gravi lesioni epatiche: nostra esperienza.

PURPOSE: To evaluate our 12-year experience in the treatment of complex hepatic injuries with periepatic packing and damage control priciples. METHOD: A retrospective review was conducted of 21 Patients with grade IV-V injuries of the liver and severe haemorrage induced hypothermia and acidosis admitted to the Ospedale Maggiore Trauma Center in Bologna from 1989 to 2001 RESULTS: All the Patients had major blunt trauma. Mean age was 39.6; mean ISS 41.5; mean RTS 4.13; extimated loss of blood was greater than 5300 ml. Packing provide definitive control of bleeding in 16 Patients but 10 had recurrent bleeding or bleeding from different injuries such as bone fractures and required further surgery or arterial embolization. 12 Patients died (57.2%). Survival was strongly associated with the ISS, GCS, the loss of blood and acidosis. CONCLUSION: The authors concluded that in selected circumstances the traditional approach to hepatic injuries is not appropiate. In this situation, alternative and aggressive treatment--damage control--has been recommended as the procedure of choice.

[Surgery associated with intraoperative hyperthermia-chemotherapy in the treatment of malignant tumors of the digestive system with peritoneal carcinosis]. / Chirurgia associata ad ipertermochemioterapia intraoperatoria nel trattamento dei tumori maligni dell'apparato digerente con carcinosi peritoneale.

In the last two years the authors have treated 4 patients affected with malignant tumors of large bowel with very poor prognosis. In every cases they found large spreading to peritoneal cavity. These patients underwent to intraperitoneal hyperthermia-chemotherapy using a special device conceived by authors. This treatment produced promising results as related to life quality in these cases.

Postoperative combined radiohyperthermia in Astler-Coller stages B2 and C distal rectal cancer.

Pelvic perineal recurrence rate is the major therapeutic problem after curative surgery of extraperithoneal rectal cancer, after lower anterior resection as well as abdomino-perineal resection: local failure rate is high, particularly for stages B2-C. Radiotherapy alone or in combination with chemotherapy proved to be an useful adjunct to surgery. Postoperative radiotherapy, with 40 to 50 Gy doses, has shown local improvement, but causing intestinal damaging. There is now evidence that hyperthermia enthances radiation effects, by killing radioresistant acid tumor cells. In order to give high postoperative radiation doses, without intestinal damage, and to kill acid tumor cells by hyperthermia, we developed a device, able both to displace intestinal loops and to produce combined hyperthermia. From 1993 to 1995, four patients with Astler-Coller stages B2 (2 patients), C1 (1 patient) and C2 (1 patient) distal cancer, were operated by Hartmann's procedure and treated with postoperative radio-hyperthermia with our device. Overall radiation dose delivered in the pelvic area was of 65 Gy, associated with three heating sessions at 43 degrees C for 30 minutes. Pelvic infection occurred in one patient; all pelvic byopsies were negative and no bowel damage was found. Three patients underwent recanalization, one had anasthomotic leackage. The C1 and C2 stage patients died from hepatic metastasis, 18 and 11 months after recanalization; one B2 stage patient is still under treatment and the other is alive and disease free 13 months after recanalization. Our technique allows to give high postoperative radiation doses, without small intestine damage, and to give a good hyperthermia for better control of local failure.

[Surgical strategy in gastric cancer in aged patients]. / Strategia chirurgica del cancro gastrico nel paziente anziano.

The trend of the National mortality rate for gastric cancer in the general population and in the old people between 1955 and 1990 was studied. A decreased incidence of mortality in the general population whereas an increased mortality rate in elderly was found. Between 1990 and 1994, 17 patients over 70 years of age were operated on for gastric cancer. The influence of the ASA classification on postoperative complications was then evaluated registering a significant statistical difference between patients included in ASA III group and or > and major complications and mortality (P = 0.044). The surgical strategy in the management of elderly patients with gastric cancer is also discussed.

[A modified Thal cardioplasty in the management of advanced esophageal achalasia]. / Modifica dell'intervento di cardioplastica secondo Thal nel trattamento dell'acalasia esofagea avanzata.

A modified esophagocardioplasty with gastric patch in the treatment of advanced achalasia is presented. The technique was employed in 4 patients from 1977 through 1993 and satisfactory results were obtained in follow up studies up to 16 years. This procedure provides better passage through the esophagogastric junction with preservation of the antireflux mechanism.