[Thrombosis of an aorto-iliac stent graft used for treating an iliocaval arteriovenous fistula following lumbar disc surgery]. / Thrombose d'une endoprothèse couverte aorto-bi-iliaque posée en cure d'une fistule artério-veineuse après chirurgie discale lombaire.

OBJECTIVES: Major vessel injury is a rare complication of spinal surgery. Iliac artery injury is the most common. Frequently, a chronic arteriovenous fistula develops. METHODS: We describe the case of a 63-year-old woman who had developed a chronic arteriovenous fistula following lumbar disc hernia surgery. The patient was treated using an Anaconda™ stent graft (Vascutek Terumo). After 2years, the prothesis thrombosed and an aorto-iliac bypass was performed. RESULTS: A gel soft prosthesis 18/9 (Vascutek Terumo) was implanted by laparotomy. The postoperative period was uneventful. A month later, the patient had recovered good lower limb function. CONCLUSION: The choice between endovascular versus open surgery must take into account the patient's age, the risk of long-term complications, and the need for radiographic surveillance. Curative open surgery remains a valid option for young patients.

Right colectomy: value of the totally laparoscopic approach.

UNLABELLED: The role of laparoscopy for right colectomy remains controversial - largely because of a lack of standardization of the operative procedure, including a diversity of techniques including laparoscopy-assisted cases with extra-corporeal anastomosis and totally laparoscopic procedures with intra-corporeal anastomosis. METHODS: The charts of all patients who underwent right colectomy by a totally laparoscopic approach in our service since 2004 were reviewed and pre-, intra-, and postoperative data were collected. RESULTS: Eighty-two patients underwent totally laparoscopic right colectomy; of these, 32 had a BMI greater than 20 kg/m2 (39%). The mean operative duration was 113 minutes. In most cases, the operative specimen was extracted through a supra-pubic Pfannenstiel incision measuring 4-6 cm in length. Three cases were converted to a laparoscopy-assisted technique (in order to control the ileo-cecal vascular pedicle because of extensive nodal invasion in two cases, and to evaluate a hepatic flexure polyp in the third case). Overall morbidity was 29.3% and parietal morbidity was only 9.8%; there was no difference in morbidity between obese patients (BMI>30 kg/m2) and non-obese patients (BMI<30 kg/m2). The mean duration of hospitalization was 9 days and two patients developed ventral hernia in the extraction incision in long-term follow-up. CONCLUSION: These satisfactory results show that the totally laparoscopic approach to right colectomy is technically feasible and safe, even in obese patients. In addition, the very low rate of parietal complications is an argument in favor of this approach.

Management of acute diverticulitis in a tertiary care institution.

BACKGROUND: Diverticular disease of the left colon is a common disease, mainly in the population over 50 years of age. The surgical management of acute diverticulitis is remains controversial, especially in severe forms. OBJECTIVE: This study aimed to evaluate the results of laparoscopic surgery for diverticular disease in a tertiary care institution with a specialist interest in minimally invasive surgery. DESIGN: All patients who had elective laparoscopic sigmoidectomy for diverticulitis within eight years at University Hospital of Luxembourg were selected from a retrospective database to evaluate laparoscopic benefit in moderate and severe disease. RESULTS: A total of 155 patients were divided in two groups: Moderate Acute Diverticulitis (MAD) and Severe Acute Diverticulitis (SAD) respectively. The short-term outcomes, after laparoscopic sigmoidectomy, were evaluated. There were not important differences between two groups. CONCLUSIONS: The laparoscopic management of diverticular disease after moderate and severe crisis gives same benefits and short-term outcomes are similar. Elective Laparoscopic surgery is actually the standard of care for moderate and severe diverticular disease in our institution.

Transjugular Intrahepatic Portosystemic Shunt and Laparoscopic Colorectal Resection: the ideal minimally-invasive management for the treatment of colorectal cancer in severe cirrhotic patients. A case report and literature review.

Surgical interventions on gastrointestinal tract are often not well tolerated by patients with cirrhosis and severe portal hypertension, impairing their prognosis if suffering from malignant disease. Combining the benefits of two minimally invasive techniques such as Transjugular intrahepatic portosystemic shunt (TIPS) and Laparoscopic Colorectal Resection (LCR), the complications related to surgical intervention might be reduced and thus, it allows patients with liver disease, to undergo a curative intervention. One patient with cirrhosis and portal hypertension diagnosed with a rectal cancer underwent a meticulous preoperative preparation through placement of TIPS before laparoscopic surgery. TIPS placement was performed without intraprocedure complications. The patient was successfully operated by laparoscopic technique 36 days after TIPS placement without intraoperative bleeding or postoperative complications. Our experience, despite being based on one case, allows us to conclude that decompression of portal system by TIPS, already used in open surgery, may be applicable as a preoperative laparoscopic procedure with equally satisfactory results.

Influence of obesity-susceptibility loci (MC4R and INSIG2) on the outcome of weight loss and amelioration of co-morbidity in obese patients treated by a gastric-bypass.

BACKGROUND: Genome-wide association and linkage studies have identified multiple susceptibility loci for obesity. OBJECTIVE: We hypothesized that such loci may affect weight loss and comorbidity amelioration outcomes following a gastric-bypass. DESIGN: A total of 200 obese patients who underwent a gastric bypass surgery were genotyped for single-nucleotide polymorphisms (SNPs) in insulin induced gene 2 (INSIG2) and melanocortin 4 receptor (MC4R) obesity genes. RESULTS: After a follow-up of 18 month, the patients (192) data of weight excess loss (72%) and co-morbidities (Hypertension -62- and Diabetes -39-) were analyzed and compared. 26 Patients with SNP were found (9 MC4R and 17 INSIG2). No significant differences in weight excess loss and amelioration of comorbidities were revealed. CONCLUSIONS: The data suggest no influence of weight excess loss and amelioration of co-morbidities after gastric-bypass by genetic susceptibility.

Breath test for differential diagnosis between small intestinal bacterial overgrowth and irritable bowel disease: an observation on non-absorbable antibiotics.

AIM: To estimate the prevalence of small intestine bacterial overgrowth (SIBO) among patients with an earlier diagnosis of irritable bowel disease (IBS) in our geographical area, and to collect information on the use of locally acting non-absorbable antibiotics in the management of SIBO. METHODS: A non-interventional study was conducted in 73 consecutive patients with a symptom-based diagnosis. RESULTS: When the patients underwent a "breath test", 33 (45.2%) showed the presence of a SIBO. After treatment with rifaximin 1,200 mg/d for seven days in 32 patients, 19 (59.4%) showed a negative "breath test" one week later as well as a significant reduction of symptoms, thus confirming the relationship between SIBO and many of the symptoms claimed by patients. In the other 13 patients, "breath test" remained positive, and a further cycle of treatment with ciprofloxacin 500 mg/d was given for 7 additional days, resulting in a negative "breath test" in one patient only. CONCLUSION: (1) about half of the patients with a symptomatic diagnosis of IBS have actually SIBO, which is responsible for most of the symptoms attributed to IBS; (2) only a "breath test" with lactulose (or with glucose in subjects with an intolerance to lactose) can provide a differential diagnosis between IBS and SIBO, with almost identical symptoms; and (3) the use of non-absorbable antibiotics may be useful to reduce the degree of SIBO and related symptoms; it must be accompanied, however, by the correction of the wrong alimentary habits underlying SIBO.

Intestinal permeability assessment before and after ileal pouch-anal anastomosis.

AIM: Intestinal permeability is considered an index of anatomic and functional integrity of the small intestine mucosa. Altered intestinal permeability has been suggested to be a possible cause of pouchitis. Aim of this paper was to assess variations in intestinal permeability during the first year of a pouch reconstruction. METHODS: Intestinal permeability (IP) was investigated in 8 ulcerative colitis patients before and after total proctocolectomy, with ileal pouch-anal anastomosis (IPAA), by means of the cellobiose/mannitol test. To each patient a basal test (before surgery) and 3 more tests during a 1 year follow-up were administered. RESULTS: Individual data were altered despite clinical findings in 9 of 30 IP measured values. An overall pattern of unaffected permeability was however shown and none of our patients, during the first year follow-up, has developed pouchitis. CONCLUSIONS: Six of the 8 investigated patients presented at least 1 altered IP value. A longer follow-up aimed to further investigate patients beyond the first year after IPAA confection as to the occurrence of pouchitis and its possible correlation with a previous permeability alteration of the pouch mucosa is in progress.

Effect of chemotherapy with 5-fluorouracil on intestinal permeability and absorption in patients with advanced colorectal cancer.

5-Fluorouracil (5-FU), in association with leucovorin (LV), is the most used chemotherapy agent in the treatment of colorectal cancer. Response rate, as well as side-effect incidence, increases with the dose intensity of regimens that are used. The most common dose-limiting toxicity for 5-FU/LV modulation is diarrhea. To assess the modification of small intestinal function, we investigated the changes in intestinal permeability (IP) and intestinal absorption (IA) in 41 chemo-naive patients (21 men and 22 women; mean age, 61 +/- 9 years) with advanced colorectal cancer after treatment with the association of folinic acid and 5-FU. After chemotherapy administration, we found a marked increase in IP and a reduction in IA, measured as cellobiose-mannitol (CE-MA) ratio (p < 0.0001) and D-xylose absorption (p = 0.0001), respectively. Patients who experienced diarrhea have an increase in CE-MA ratio and a reduction in D-xylose absorption values, both statistically significant. Cellobiose-mannitol ratio and D-xylose absorption tests can be used for the assessment of toxic effect of 5-FU on mature intestinal epithelium and also for evaluating the role of cytoprotective agents.

Intestinal permeability in Crohn's disease patients and their first degree relatives.

BACKGROUND: Family studies suggested that an altered intestinal permeability plays a role in the genesis of Crohn's disease. AIM: Aim of the present study was to investigate a possible genetic alteration of the mucosal barrier in Crohn's disease. SUBJECTS: 16 Crohn's disease patients and 26 of their cohabiting first degree relatives were studied. METHODS: To investigate intestinal permeability, Cellobiose/Mannitol test was administered to both groups. RESULTS: In the two groups, we found that the median intestinal permeability values were higher and statistically different from those obtained in 32 healthy control subjects as well as in five healthy control families. Six (37.5%) Crohn's disease patients and three (11.5%) of their first degree relatives showed increased individual intestinal permeability values. Intestinal permeability alteration in Crohn's disease patients was unrelated to sex, age, disease activity, localisation, duration, treatment schedule, as well as to serum anti-Saccharomyces cervisiae antibody positivity in a pilot study conducted in 7 Crohn's disease patients; anti-Saccharomyces cervisiae antibody values were negative in all 10 first degree relatives investigated. CONCLUSIONS: These findings demonstrate the increase in IP in 37% of the patients and in 11% of their relatives. More extensive investigation of the correlation between ASCA alterations and IP will be needed in both patients with Crohn's disease and their relatives.

Altered intestinal permeability to mannitol in diabetes mellitus type I.

BACKGROUND: Intestinal permeability has seldom been investigated in diabetes mellitus, even though patients frequently report gastrointestinal symptoms, and it has recently been shown that the prevalence of celiac disease associated with diabetes mellitus is higher than expected. METHODS: Intestinal permeability to cellobiose and mannitol was investigated in 31 patients affected by type I uncomplicated diabetes mellitus. Values were compared with those obtained in 32 normal subjects. RESULTS: The percentage of mannitol recovery was far higher than normal in two thirds of the investigated patients and correlated with the length of disease, even though the probes' ratio (cellobiose/mannitol) was in the normal range. CONCLUSIONS: A not previously reported increase of intestinal permeability to mannitol, clear-cut and not associated with that of the larger probe, is found in type I uncomplicated diabetes mellitus. These results may describe a primary feature of type I diabetes mellitus and the initial steps of evolution to celiac disease.

Intestinal permeability and diabetes mellitus type 2.

BACKGROUND: Intestinal permeability can be investigated by means of molecular probes which are able to cross the intestinal wall through tight junctions of villi (smaller probes) and/or of crypts (larger probes). Intestinal permeability is altered in the majority of uncomplicated diabetes mellitus type 1 patients, due to the augmented absorption of the smaller probe. The aim of this work was to investigate if any similar alteration of intestinal permeability is present in diabetes mellitus type 2. METHODS: Intestinal permeability was studied by means of the Cellobiose/Mannitol test (CE/MA). The first and larger probe (Cellobiose) crosses tight junctions of crypts, the smaller (Mannitol) crosses those of villi. The CE/MA test was administered to 18 patients affected by diabetes mellitus type 2, with length of disease = 4.5+/-1.9 years (mean+/-SD) with no relevant intestinal pathologies. Results obtained in these 18 patients were compared with those of 25 healthy volunteers. RESULTS: Intestinal permeability to the CE/MA test was normal in all patients. All the investigated permeability parameters (%CE, %MA, CE/MA) overlapped, as a mean, with those of control subjects and were not statistically different. CONCLUSIONS: The present data confirm that diabetes mellitus type 2 has not pathophysiological components at intestinal level. This is different from what was demonstrated in diabetes mellitus type 1, the last being very well known to be associated with autoimmune diseases and celiac disease.

Assessment of small intestinal damage in patients treated with pelvic radiotherapy.

Pelvic radiotherapy almost always induces intestinal symptoms. We investigated the radiation-induced damage to the small intestinal mucosa and evaluated its relationship with symptoms, using cellobiose/mannitol permeability test (CE/MA) and plasma postheparin diamine oxidase test (PHD) in 20 patients treated with pelvic radiotherapy. The symptoms developed during radiotherapy were noted. Intestinal permeability significantly (p=0.013) increased from 0.021 +/- 0.026 to 0.047 +/- 0.055 (mean +/- SD) after 15 days of radiotherapy, while it returned to normal values (0.010 0.015) at the end of radiotherapy. PHD values did not change. All patients developed intestinal symptoms. These findings indicate that pelvic radiotherapy induces an early small bowel mucosa damage followed by mucosal adaptation. Acute intestinal symptoms during pelvic radiotherapy may not depend only on small intestinal mucosal damage.

[Physical training of patients with ischemic heart disease. Effects on diastolic time]. / L'allenamento fisico in pazienti affetti da cardiopatia ischemica. Effetti sul tempo diastolico.

In patients (pt) with coronary artery disease diastolic duration is an important determinant of myocardial oxygen supply. To assess the effects of physical training on diastolic duration, twelve male pt with previous infarction were studied. During 12 month training program the physical exercise was of progressively increasing intensity, duration and frequency. Training induced a significant reduction in heart rate. Both systolic and diastolic blood pressure were unchanged. The mean values of electromechanical systole were lower after training. On the contrary, the training induced a lengthening of diastolic duration expressed as percentage of cardiac cycle (% diastole) from 51.4 +/- 2.6 to 57.5 +/- 3.8% (p < 0.001). Thus, this results validate the hypothesis that physical exercise training can improve myocardial perfusion through an increase in diastolic duration, partially independent of bradycardia.

Zollinger-Ellison syndrome and antral G-cell hyperfunction in patients with resistant duodenal ulcer disease.

We measured basal and pentagastrin-stimulated acid secretion, as well as basal and meal-stimulated plasma gastrin concentration to determine, in 67 patients affected by resistant duodenal ulcer, whether their condition could be related to gastric acid secretion and/or gastrin-related syndromes. We then compared them to 46 duodenal ulcer control patients. The outpatients were investigated consecutively. The resistant duodenal ulcer patients differed from the controls only in their higher complication rates (bleeding or perforation, P < 0.05). We identified five patients in the resistant duodenal ulcer group with Zollinger-Ellison syndrome and 12 with antral G cell hyperfunction, whereas in the control group only one patient was affected by antral G cell hyperfunction. IgG anti-Helicobacter pylori antibodies were positive for the presence of infection in 7 of the hypergastrinaemic patients. When Zollinger-Ellison syndrome or antral G cell hyperfunction were excluded, no differences could be found in gastric acid secretion, or basal and meal-stimulated plasma gastrin levels, between the resistant and control duodenal ulcer patients, except for basal acid hypersecretion (resistant duodenal ulcer 16% vs duodenal ulcer 2% P = 0.0144). In the presence of duodenal ulcer disease resistant to H2-blockers, it is mandatory to measure basal plasma gastrin concentration since it was possible to diagnose the gastrin-related syndromes, Zollinger-Ellison syndrome and antral G cell hyperfunction, in 26% of this group of patients.

LFB1 and LFB3 homeoproteins are sequentially expressed during kidney development.

LFB1 (HNF-1/HNF-1 alpha/APF) and LFB3 (vHNF-1/HNF-1 beta) are two homeoproteins involved in the transcriptional regulation of several liver-specific genes. Both genes are expressed in the polarized epithelia of a wide range of tissues, including liver, the digestive tract and kidney. We have analyzed the expression pattern of LFB1 and LFB3 in the developing rat kidney by in situ hybridization. Our results show that LFB3 transcripts can be detected in mesoderm-derived cells as soon as they are induced to differentiate into a polarized epithelium, while LFB1 transcripts appear only at a later stage when the three different segments of the nephron become apparent. LFB1 transcripts are restricted to the proximal and distal tubules, whereas LFB3 is also detected in the collecting ducts. Neither LFB1 nor LFB3 are expressed in the glomeruli or in the transition epithelia of the ureters and of the urinary bladder, none of which are involved in active transport mechanisms. The sequential activation of these two genes is also observed in transfilter organ cultures of nephrogenic mesenchyme at different stages after induction. This expression pattern suggests that LFB3 and LFB1 play a role in two critical stages of the developmentally regulated conversion of the nephric mesenchyme into a polarized epithelium: the early inductory phase (LFB3) and the postinductory phase (LFB1+LFB3).

Biologically active recombinant prothrombin and antithrombin III expressed in a human hepatoma/vaccinia virus system.

Several systems have been devised that are based on viral promoters suitable for gene expression in eukaryotic cells. One such system, vaccinia virus, has been successfully used to express a variety of heterologous proteins following the construction of a recombinant virus. Indeed, because of the ability of vaccinia virus to infect a wide range of host cells, the expression system can be custom-designed so that a cell line can be instrumental in ensuring the correct processing of the recombinant polypeptide. We show that recombinant vaccinia virus and human hepatoma cells in culture are an efficient expression system with which to produce correctly modified and biologically active human prothrombin (15 micrograms/10(7) cells) and antithrombin III (40 micrograms/10(7) cells).

LFB3, a heterodimer-forming homeoprotein of the LFB1 family, is expressed in specialized epithelia.

We have cloned and characterized a mouse cDNA coding for LFB3, a DNA binding protein containing an extra-large homeodomain. The first 315 amino acids of LFB3 are highly homologous to the DNA binding domain of LFB1, a regulatory protein involved in the expression of several liver-specific genes. LFB3 is a transcriptional activator which binds to DNA as a dimer and forms heterodimers with LFB1 both in vitro and in vivo. However, LFB3 expression seems not to be directly correlated with the liver-specific phenotype, since it is detected in dedifferentiated hepatoma cell lines which express neither LFB1 nor several liver-specific genes. LFB3 expression starts before that of LFB1 during mouse and rat development, and is strongly increased upon retinoic acid induced differentiation of F9 embryonic carcinoma cells. LFB3 and LFB1 are expressed in the epithelial component of many organs of endodermal and mesodermal origin, suggesting that they may play a more general role associated with the differentiation of specialized epithelia.