Radiographical imaging of the normal anatomy and complications after gastric banding.

Laparoscopic adjustable gastric banding is a surgical procedure that is increasingly being performed for the treatment of morbid obesity. As with any intervention, gastric banding is not free from complications. Complications after gastric banding can be divided into early and late complications. Early complications include band malposition and perforation of the stomach. Late complications comprise pouch dilatation, intraluminal band penetration and oesophageal dilatation. Understanding the principles of the intervention is essential for both the interpretation of the resulting radiographical findings and the diagnosis of potential complications. We report on the normal anatomy and the most frequent complications seen after gastric banding.

Recurrent aspiration pneumonia after laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding is a popular therapeutic option for morbid obesity. Band slippage, pouch enlargement and esophageal dilatation are occasional late complications of this procedure. There are rare reports of recurrent aspiration after banding. We report a 44-year-old female suffering from dysphagia and aspiration pneumonia 2 years after adjustable banding. Her esophagus was dilated to 6 cm, and videocinematography showed a severe achalasia-like disorder. Withdrawal of fluid from the band should be immediate, and relieved the stomal obstruction in this patient. Aspiration pneumonia is a serious late complication, which is easily treated by deflation of the band.

Soluble CD40L in patients with morbid obesity: significant reduction after bariatric surgery.

BACKGROUND: Morbid obesity is associated with increased cardiovascular morbidity and mortality. Recent studies suggest that soluble CD40 Ligand (sCD40L) may play a pathogenetic role in atherothrombotic complications in cardiovascular disease as well as in inflammation and thrombosis. As morbid obesity is closely associated with chronic inflammation and insulin resistance (IR), it was of interest to study sCD40L in patients with morbid obesity before and after massive weight loss induced by bariatric surgery. PATIENTS AND METHODS: A total of 34 patients (mean age 40 +/- 12 years) with morbid obesity were studied before and 27.2 months after bariatric surgery. High sensitivity assays were used to measure concentrations of fasting sCD40L, monocyte-chemoattractant-protein-1 (MCP-1) and high-sensitive C-reactive protein (hsCRP). To investigate the associations of concentration changes of the parameters studied, differences between pre- and post-operative data were assessed and tested by univariate and multivariate linear regression analysis. RESULTS: After a mean weight loss of 33.1 +/- 18.4 kg, circulating sCD40L decreased significantly from (3.7 +/- 1.5) ng mL(-1) to (2.2 +/- 0.7) ng mL(-1), (P < 0.001). The decline in sCD40L after weight loss correlated significantly with the decrease in fasting insulin, 2-h insulin, HOMA insulin resistance (HOMA-IR), triglycerides, and the inflammatory biomarkers MCP-1 and hsCRP. CONCLUSIONS: We have shown a marked decrease in circulating sCD40L in association with an improvement of both insulin resistance and chronic inflammation in morbidly obese patients after bariatric surgery. As high sCD40L was shown to predict cardiovascular death and myocardial infarction in several prospective studies, the observed marked lowering of sCD40L might be of clinical relevance in morbidly obese patients.

Intra-abdominal sequestration of the lung and elevated serum levels of CA 19-9: a diagnostic pitfall.

BACKGROUND: Extralobar pulmonary sequestration is an uncommon congenital abnormality that is rarely diagnosed after the age of 40 years. We describe a 64-year-old woman with an intra-abdominal sequestration of the lung and elevated carbohydrate antigen (CA) 19-9 serum levels. CASE OUTLINE: On abdominal ultrasound a semi-solid cystic tumour was demonstrated that showed tight connection to the tail of the pancreas according to computed tomography. Cytological examination of the percutaneous biopsy did not lead to a definitive diagnosis. CA 19-9 serum levels were repeatedly elevated >250 IU/ml. With a tentative diagnosis of a tumour of the tail of pancreas the semi-solid cystic mass was resected. Frozen section histology suggested the diagnosis of pulmonary sequestration, which was confirmed by definitive histological examination. Immunohistochemical staining of the specimen with a specific monoclonal antibody against CA 19-9 showed strong immunoreactivity. Three months later the elevated CA 19-9 serum levels returned to normal. DISCUSSION: Elevated CA 19-9 serum levels have been described in benign pulmonary and mediastinal cystic lesions and in one case of extralobar intrathoracic lung sequestration. Although there is evidence that malignancies may arise in congenital lung cysts, CA 19-9 serum levels have not been investigated in such cases. Based on our results elevated serum values of CA 19-9 in combination with a cystic semi-solid mass in the left subphrenic space should include the differential diagnosis of extralobar pulmonary sequestration.

Impact of weight loss on inflammatory proteins and their association with the insulin resistance syndrome in morbidly obese patients.

OBJECTIVE: Obesity is closely linked to the insulin resistance syndrome (IRS), type 2 diabetes, and cardiovascular disease, the primary cause of morbidity and mortality in these patients. Elevated levels of C-reactive protein (CRP) and interleukin-6 (IL-6), indicating chronic subclinical inflammation, have been associated with features of the IRS and incident cardiovascular disease. METHODS AND RESULTS: We studied the cross-sectional and longitudinal relation of CRP, IL-6, and tumor necrosis factor-alpha (TNF-alpha) with features of the IRS in 37 morbidly obese patients with different stages of glucose tolerance before and 14 months after gastric surgery. Weight loss after gastric surgery induced a significant shift from diabetes (37% vs 3%) to impaired glucose tolerance (40% vs 33%) and normal glucose tolerance (23% vs 64%). The baseline concentration of IL-6 was correlated with TNF-alpha (r=0.59, P<0.01) and CRP (r=0.44, P<0.05) levels. TNF-alpha, IL-6, and CRP were significantly correlated with insulin resistance estimated by the homeostatic model assessment (r=0.48, P<0.05; r=0.56, P<0.01; and r=0.35, P<0.05, respectively). Concentrations of CRP and IL-6 decreased after weight loss (median, 8.6 and interquartile range, 2.7/14.5 vs 2.5 and 1.2/4.1 mg/L; P<0.006, and 5.13 and 2.72/12.15 vs 3.95 and 1.97/5.64 pg/mL, P<0.02, respectively), whereas serum levels of TNF-alpha remained unchanged (8.6 and 6.3/18.8 vs 11.7 and 5.8/17.2 pg/mL; NS.). Multiple regression analysis revealed that the decrease in insulin resistance remained independently and significantly correlated with the decrease in IL-6 concentrations (P<0.01) and the decrease in body mass index with the decrease in CRP (P<0.05), respectively. CONCLUSIONS: Weight loss in morbidly obese patients induces a significant decrease of CRP and IL-6 concentrations in association with an improvement of the IRS.

Vitamin D receptor activity and prevention of colonic hyperproliferation and oxidative stress.

Unimpaired vitamin D action has been implicated in human cancer prevention. We have previously demonstrated the effectiveness of 1 alpha-dihydroxyvitamin D3 (1,25-D3) to reduce proliferation and increase differentiation in human colon cancer cells. The aim of this study was to investigate, on the one hand, expression of the vitamin D receptor (VDR) and of 25-hydroxyvitamin D(3)-1 alpha-hydroxylase (1 alpha-hydroxylase) in human normal and malignant colonic tissue and, on the other hand, to determine consequences of reduced or lacking VDR action in a VDR knockout mouse model. In low-grade malignancies of the human colon we found increased VDR and 1 alpha-hydroxylase mRNA expression. However, in late-stage high-grade tumors the vitamin D system is severely compromised. In the mouse colon we found an inverse relationship between VDR levels and proliferation in colon descendens, a tissue known to be specifically affected by nutrients during carcinogenesis. Expression of 8-hydroxy-2'-deoxyguanosine (8-OHdG), a marker of oxidative DNA damage, was significantly augmented with complete loss of VDR. These data suggest that genomic 1,25-D(3) action is necessary to protect against nutrition-linked hyperproliferation and oxidative DNA damage.

Functional impairment of the abdominal wall following laparoscopic and open cholecystectomy.

BACKGROUND: Subcostal incisions for open cholecystectomy (OC) denervate the right upper and middle abdomen. METHODS: Sensory and abdominal muscle function (Janda's muscle function test, Cybex 6000) was evaluated. Healthy volunteers (10 women, 12 men) were compared with 13 women and 12 men after OC and 11 women and 11 men after laparoscopic cholecystectomy (LC). For computed tomography (CT) studies, a spiral scanner was used. RESULTS: Of the OC patients, 21 (95.5%) complained of dys- and anesthesias below the incision. Of the LC patients, only nine (2.4%) reported anesthesias around the port sites. Normal subjects scored significantly higher in muscle strength (p <.01). LC patients scored higher than OC patients at 10 degrees and 20 degrees trunk flexion (p <.05). Depending on the flexion angles, the men in all groups developed 30-114% more muscle power than the women. Denervation of the abdominal muscles was confirmed by CT. CONCLUSION: OC reduced skin sensitivity and abdominal muscle function. Although the procedure is minimally invasive, LC also causes sensory and functional losses, albeit minor ones.

Video-assisted resection of pulsative midesophagus diverticula.

BACKGROUND: Pulsative diverticula located in the midesophagus occur rarely. Surgical treatment is indicated for symptomatic diverticula. This study evaluated a new minimally invasive method of treatment. METHODS: Three women, ages 69 to 73 years, underwent resections of diverticula via a thoracoscopic access. No major complications were observed. Preoperative symptoms such as dysphagia, regurgitation, aspiration, loss of weight, and retrosternal pain were not reported at follow-up assessment 3 to 60 months after surgery. The patients were highly satisfied with the functional results. CONCLUSIONS: According to our results, minimally invasive treatment of midesophagus diverticula by thoracoscopic resections may be performed with excellent outcome.

[Spontaneous perforation of the large intestine. Resection with primary anastomosis or staged (Hartmann) procedure?]. / Spontane Dickdarmperforation. Resektion mit primärer Anastomose oder Diskontinuitätsresektion (Hartmann)?

Whereas primary resection to remove the septic focus stands undisputed in the therapy of spontaneous perforation of the colon, there is still no consensus as to whether to perform a primary anastomosis or a staged procedure (Hartmann). Prospective randomized studies comparing both concepts are lacking. Obviously these two competing therapies fit different groups of patients whose diseases differ concerning etiology, localisation and severity. Analysis of the literature of the past few years defined some criteria that help to decide when to omit primary anastomosis: MPI > 20, APACHE II score > 15, preoperative organ insufficiency, Hinchey grade III or IV and ASA score IV. In these cases a discontinuity resection is recommended. Primary resection with anastomosis and Hartmann procedure are not competing operations but situation-dependent therapeutic concepts in spontaneous colonic perforation.

Fecal excretion of calprotectin in colorectal cancer: relationship to tumor characteristics.

BACKGROUND: The aim of this study was to evaluate fecal calprotectin in patients treated for colorectal cancer. Furthermore, the changes in fecal calprotectin concentration from before to after surgery were investigated. METHODS: In 155 patients with newly diagnosed colorectal cancer, two spot samples were taken from the same feces on two consecutive days. RESULTS: Three ways of evaluating calprotectin excretion were compared, (1st spot 1st stool; maximum of 1st spot 1st stool and 2nd spot 1st stool; maximum of 1st spot 1st stool and 1st spot 2nd stool) and gave similar results with median fecal calprotectin values 47 mg/l, 52 mg/l and 54 mg/l, respectively. Median calprotectin concentration did not differ significantly between different tumor stages, although the levels were slightly lower in Dukes stage A tumor than in the rest of the stages. Neither were there any differences in the concentrations related to the localization, size or the histological grading of the carcinoma. As the currently used cut-off level for fecal calprotectin is 10 mg/l, 87% of all patients had elevated fecal calprotectin. Seventy-nine percent of the patients had levels above 15 mg/l and 74% had levels above 20 mg/l (1st spot 1st stool). In patients who delivered fecal samples after the operation the calprotectin value fell significantly from a preoperative median value of 45 mg/l to 14 mg/l after the resection. CONCLUSIONS: The majority of patients with colorectal cancer have increased fecal concentration of calprotectin. One single fecal spot seems to be sufficient for determination of the calprotectin level. Measurement of fecal calprotectin may possibly become of value as a marker for colorectal cancer, although calprotectin, similar to fecal occult blood (FOB) tests, is a non-specific test for colorectal pathology, also being elevated in inflammatory bowel diseases. Further investigation of its specificity is therefore needed.

25-Hydroxyvitamin D(3)-1alpha-hydroxylase and vitamin D receptor gene expression in human colonic mucosa is elevated during early cancerogenesis.

Human colorectal cancer cells not only express the nuclear vitamin D receptor (VDR) but are also endowed with 25-hydroxy-vitamin D(3)-1alpha-hydroxylase activity and therefore are able to produce the specific ligand for the VDR, the hormonally active steroid 1alpha,25-dihydroxyvitamin D(3) (1alpha,25(OH)(2)D(3)). In the present study we show by semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR) as well as by Western blotting and immunohistochemical methods, that in human large intestinal carcinomas expression of the genes encoding the 25-(OH)D(3)-1alpha-hydroxylase as well as the VDR increases in parallel with ongoing dedifferentiation in the early phase of cancerogenesis, whereas in poorly differentiated late stage carcinomas only low levels of the respective mRNAs can be detected. This indicates that, through up-regulation of this intrinsic 1alpha,25(OH)(2)D(3)/VDR system which mediates the anti-mitotic effects of the steroid hormone, colorectal cancer cells are apparently able to increase their potential for an autocrine counter-regulatory response to neoplastic cell growth, particularly in the early stages of malignancy.

Gender-specific differences in the natural history, clinical features, and socioeconomic status of HIV-infected patients: experience of a treatment centre in Vienna.

BACKGROUND: In order to evaluate natural history, clinical features, and socioeconomic aspects in HIV-infected women, a prospective study comprising 695 HIV-infected patients was performed at our department. METHODS: Demographic data, CD4+ T-lymphocyte counts, human immunodeficiency virus-1 (HIV-1) plasma loads, AIDS indicator diseases and socioeconomic variables were recorded. Prognostic factors for survival were evaluated by univariate and multivariate analysis. Data of men and women were compared. RESULTS: The mean age of the 150 women (29.4 +/- 9.4 years) was significantly lower than that of men (32.6 +/- 9.7 years, p = 0.0002). CD4+ T-lymphocyte counts, HIV1-plasma loads, and AIDS indicator diseases did not significantly differ between men and women; the same was true for all socioeconomic variables (family status, education, professional training, employment status) except family status. No significant difference in median overall and AIDS-free survival was observed between females (2033 and 1593 days) and males (1554.5 and 1235 days, respectively, p = 0.36 and p = 0.098). Overall survival compared by age groups (< 30, 31-50, > 50 years), by risk categories (homosexuals, i.v. drug users, heterosexual contacts) and by CD4+ T-lymphocyte count (< 200, 200-500, > 500 cells/mm3), differed significantly (p < 0.001) as did AIDS-free survival. Lower age and a high CD4+ T-lymphocyte count were independently associated with the outcome in the multivariate analysis. (Overall survival/relative risk: 0.49 for age < 30 years and 2.3 for CD4+ T-lymphocyte count < 200 cells/mm3, AIDS-free survival/relative risk: 0.65 for age < 30 years and 3.3 for CD4+ T-lymphocyte count < 200 cells/mm3). HIV-1 plasma loads as a prognostic factor could not be evaluated due to the small number of patients who died or developed AIDS (2/375 and 10/375 patients, respectively). CONCLUSION: Our results showed no difference in the natural history and clinical features of HIV infection between men and women. However, pulmonary tuberculosis was associated with a significantly longer survival compared to other AIDS-defining diseases. Lower age and high CD4+ T-lymphocyte count are independent predictors for survival. With the exception of family status, socioeconomic variables showed no differences between male and female patients.

Dietary calcium and growth modulation of human colon cancer cells: role of the extracellular calcium-sensing receptor.

Using the human colon adenocarcinoma-derived cell line Caco-2, we investigated the possible role of the Ca2+-sensing receptor (CaR) in mediating effects of extracellular Ca2+ on cellular proliferation. Caco-2 cells respond to low ambient [Ca2+]o by activation of the protein kinase C-signaling pathway, leading to upregulation of c-myc mRNA expression and thereby, finally, to alleviation from the G1/S phase control of the cell cycle. This proliferative response can be reverted by activation of the CaR either through raising [Ca2+]o or, respectively, by using the CaR agonist Gd3+ as a substitute for Ca2+. The inhibitory effect of [Ca2+]o on cell replication exhibits saturation kinetics (IC50 = 0.045 mM), indicating the existence of a highly sensitive CaR operating at low ambient [Ca2+]o. Specific immunostaining revealed the presence of CaR-positive cells in the crypt epithelium of normal human colonic mucosa as well as in glandular (i.e., differentiated structures) of carcinomatous lesions. This could provide a rationale for use of calcium supplements for intervention in early phases of colon tumorigenesis.

Reconstructive intestinal surgery after open management of severe intraabdominal infection.

Open management (OM) of severe intraabdominal infection often is complicated by fistula formation and the need for complex reconstructive procedures. From 1988 to 1998 a series of 145 patients were treated by OM. Of these patients, 24 developed intestinal fistulas and 42 had to be treated by discontinuity resections prior to OM for intestinal perforations or anastomotic insufficiency. Of the patients with fistulas or enterostomies, 61% survived. Reconstructive surgery was performed after infections had completely subsided. Patients were examined on follow-up, and the quality of life was assessed by 36-item short-form health survey questionnaires. Restorative surgery was performed in 32 of 40 patients 102 days (median) after beginning OM. All patients survived. Anastomotic leakage developed in six patients (18%). Thirty patients (94%) were followed up; 70% indicated their quality of life to be good. Despite a higher rate of anastomotic problems than with elective visceral operations, reconstructive intestinal surgery after OM may be performed without mortality and satisfying long-term outcome.

Immunocytochemical localization of the extracellular calcium-sensing receptor in normal and malignant human large intestinal mucosa.

We identified the parathyroid type Ca(2+)-sensing receptor (CaR) in normal human colon mucosa and in cancerous lesions at the mRNA and protein level. Polymerase chain reaction produced an amplification product from reverse-transcribed large intestinal RNA which corresponded in size and length to a 537-bp sequence from exon 7 of the CaR gene. With a specific antiserum against its extracellular domain, the CaR could be detected by immunostaining in normal human colon mucosa in cells preferentially located at the crypt base. The CaR protein was also expressed in tumors of the large bowel in all 20 patients examined. However, the great majority of CaR-positive cells in the adenocarcinomas inspected were confined to more differentiated areas exhibiting glandular-tubular structures. Poorly or undifferentiated regions were either devoid of specific immunoreactivity or contained only isolated CaR-positive cells. In the normal mucosa and in glandular-tubular structures of cancerous lesions, the CaR was exclusively expressed in chromogranin A-positive enteroendocrine cells and in only a small fraction of PCNA-positive cells.

Dietary changes after vertical banded gastroplasty.

BACKGROUND: Gastric restriction surgery relies on obstruction to oral intake by formation of a gastric pouch. Therefore, the therapeutic effect is closely related to intolerance for different types of food, and an ingestion of an unbalanced diet. We investigated dietary changes after VBG and their associations with therapeutic success. METHODS: 70 patients (4 men, 66 women, median age 32) with a median preoperative BMI of 44.6 were examined > or =3 years after VBG. Weight reduction, nutritional changes (type of diet, number of daily meals, amount of food that could be ingested, intolerance for different types of food, frequency of vomiting), satisfaction with results, and willingness to undergo the operation once again were investigated. RESULTS: The average reduction of the BMI was 13, with sufficient weight loss in 80%. 36% were eating a solid, 43% a soft, and 21% a liquid diet. Weight reduction did not depend on the type of diet eaten but on the ingestion of sweets. 93% indicated they could take only small amounts of food. The average number of daily meals was 3.76% reported an intolerance for some type of food (most often meat, fruit, or vegetable). Vomiting was the most common problem and occurred in 71%. 71% indicated a high level of satisfaction with the results of the operation, and 96% said they would undergo the operation again. CONCLUSIONS: The investigation demonstrated successful weight reduction despite dietary changes in 80% of patients after VBG. Weight reduction was not influenced by type of, diet but depended on consumption of sweets.

Therapy of cervical esophageal carcinoma.

Surgical treatment of cervical esophageal cancer is influenced by special problems arising from the anatomical characteristics of this organ. The cervical and thoracic extension of these tumors makes an extensive lymphadenectomy necessary, and radical resections often may only be achieved by laryngectomy. The extent of the resections performed determines the type of intestinal restoration by gastric or colonic interposition and small bowel transplantation. The patient's voice may be preserved by means of tracheopharyngeal shunts with intestinal interposition. The advances of radiation therapy and chemotherapy will enable less extended resections with greater rates of laryngeal preservation.

In situ mRNA hybridization analysis and immunolocalization of the vitamin D receptor in normal and carcinomatous human colonic mucosa: relation to epidermal growth factor receptor expression.

There is evidence that vitamin D receptor (VDR)-mediated action of 1 alpha,25-dihydroxyvitamin D3 (1 alpha,25-(OH)2D3) could limit colon cancer cell growth particularly when induced by activation of the epidermal growth factor receptor (EGFR). We therefore wanted to ascertain the relevance of this observation for human colon cancerogenesis. Utilizing in situ mRNA hybridization and immunocytochemical techniques, we analyzed cell-specific expression of VDR and EGFR in normal and malignant human colonic mucosa. In normal mucosa, VDR positivity is weak and observed only in a small number of luminal surface colonocytes. In contrast, EGFR expression at a relatively high level is also found in cells at the crypt base. The number of VDR-positive colonocytes increases remarkably during tumor progression. It reaches its maximum in low grade adenocarcinomas and returns to lower levels in highly malignant cancers. In both low- and high grade carcinomas, the great majority of tumor cells contain the EGFR message. The relative abundance of EGFR over VDR in normal mucosa and in high grade carcinomas would create a situation in which mitogenic effects from EGFR activation are only ineffectively counteracted by signaling from 1 alpha,25-(OH)2D3/VDR. In contrast, in well to moderately differentiated tumors, upregulation of VDR could retard further tumor progression.