A randomised controlled trial of roller versus centrifugal cardiopulmonary bypass pumps in patients undergoing pulmonary endarterectomy.

OBJECTIVES: There is some controversy as to whether there is a benefit from the use of a centrifugal pump compared with a roller pump during cardiopulmonary bypass to facilitate cardiac surgery. We compared the two pumps, with the primary aim of determining any difference in the effects on inflammation after pulmonary endarterectomy surgery which required prolonged cardiopulmonary bypass and deep hypothermic circulatory arrest. METHODS: Between September 2010 and July 2013, 58 elective patients undergoing pulmonary endarterectomy were included in this prospective, randomised, controlled study; 30 patients were randomly allocated to the control group, which used a roller pump, and 28 patients to the treatment group, which used a centrifugal pump. Interleukin-6, procalcitonin, C-reactive protein, thromboelastographic parameters, P-selectin, international normalised ratio, activated prothrombin time, free haemoglobin, haematocrit, red blood cell count, white blood cell count, platelet count and protein S100ß were recorded during and after the procedure. We also recorded the length of intensive care unit stay, blood loss and transfusion, neurological outcomes and respiratory and renal failure. RESULTS: There was a significant difference in the primary outcome measure: Interleukin-6 was significantly higher in the roller pump group (587 ± 38 ng · l(-1) vs. 327 ± 37 ng · l(-1); p<0.001) 24 hours after surgery, which we interpreted as an increased inflammatory response. This was confirmed by a significant rise in the procalcitonin level in the roller pump group 48 hours following surgery (0.79 (0.08-25.25) ng · ml(-1) vs. 0.36 (0.02-5.83) ng · ml(-1); p<0.05). There were, however, no significant differences in clinical outcome data. CONCLUSIONS: We have shown that the use of a centrifugal pump during prolonged cardiopulmonary bypass and deep hypothermic circulatory arrest is associated with a reduced inflammatory response compared to the standard roller pump. Larger multi-centre trials in this area of practice are required.

Aprotinin reduces the procalcitonin rise associated with complex cardiac surgery and cardiopulmonary bypass.

Aprotinin, a nonspecific serine protease inhibitor, has been primarily used as a haemostatic drug in cardiac surgery with cardio-pulmonary bypass (CPB). This study investigated the effect of aprotinin on the post-operative levels of procalcitonin (PCT) and a set of cytokines in patients undergoing pulmonary artery endarterectomy (PEA). We analyzed 60 patients with chronic thromboembolic pulmonary hypertension undergoing PEA. 30 patients (Group A) were treated with aprotinin (2,00,00 IU prior anesthesia, then 2,00,00 IU in CPB prime and 50,00 IU per hour continuously); a further 30 patients (Group B) received tranexamic Acid (1 g before anesthesia, 1 g after full heparin dose and 2 g in CPB prime). PCT, TNFalpha, IL-1beta, IL-6, and IL-8 arterial concentrations were measured from before until 72 hours after surgery. Aprotinin significantly affected early post-PEA plasma PCT. Patients treated with aprotinin (Group A) had lower peak PCT levels compared to patients in Group B (1.52 ng/ml versus 2.18, p=0.024). Postoperative peak values of PCT and IL-6 correlated closely in both groups (r=0.78, r=0.83 respectively). Aprotinin attenuates the post-PEA increase of PCT in the same manner as other pro-inflammatory cytokines. Significant correlation between PCT and IL-6 post-surgery may be indicative of an indirect IL-6-mediated pathway of PCT alteration.

Plasma hepcidin correlates positively with interleukin-6 in patients undergoing pulmonary endarterectomy.

Hepcidin, a recently discovered antimicrobial peptide synthesized in the liver, was identified to be the key mediator of iron metabolism and distribution. Despite our knowledge of hepcidin increased in recent years, there are only limited data on hepcidin regulation during systemic inflammatory response in human subjects. In a prospective study, the time course of plasma hepcidin was analyzed in relations to six inflammatory parameters - plasma cytokines and acute-phase proteins in patients undergoing uncomplicated pulmonary endarterectomy. Twenty-four patients (males, aged 52.6+/-10.2 years, treated with pulmonary endarterectomy in a deep hypothermic circulatory arrest) were enrolled into study. Hepcidin, interleukin (IL)-6, IL-8, tumor necrosis factor-alpha, C-reactive protein, alpha(1)-antitrypsin and ceruloplasmin arterial concentrations were measured before surgery and repeatedly within 120 h post-operatively. Hemodynamic parameters, hematocrit and markers of iron metabolism were followed up. In a postoperative period, hepcidin increased from preoperative level 8.9 ng/ml (6.2-10.7) (median and interquartile range) to maximum 16.4 ng/ml (14.1-18.7) measured 72 h after the end of surgery. Maximum post-operative concentrations of hepcidin correlated positively with maximum IL-6 levels. Both hepcidin and IL-6 maximum concentrations correlated positively with extracorporeal circulation time. In conclusions, the study demonstrated that plasma hepcidin is a positive acute-phase reactant in relation to an uncomplicated large cardiac surgery. Hepcidin increase was related to IL-6 concentrations and to the duration of surgical procedure. Our clinical findings are in conformity with recent experimental studies defining hepcidin as a type II acute-phase protein.

Disturbances of gastric electrical control activity after laparotomic cholecystectomy are related to interleukin-6 concentrations.

BACKGROUND: The aim of the present study was to characterize the disturbances of gastric electrical control activity after cholecystectomy and to correlate electrogastrographic (EGG) findings with inflammatory markers. PATIENTS AND METHODS: 52 adult patients were examined in conjunction with planned laparotomic or laparoscopic cholecystectomy. Gastric myoelectrical activity was recorded with a MicroDigitrapper device using three Ag-AgCl disposable skin electrodes. The dominant frequency was calculated using computerized algorithms. Repeated EGG records were correlated with inflammatory parameters - interleukin-6 (IL-6), tumor necrosis factor-alpha, procalcitonin, and C-reactive protein. RESULTS: Both basal and stimulated gastric electrical frequency decreased significantly in the postoperative phase measured 6 h after the start of surgery (p < 0.01). Postoperative bradygastria (electrical control activity frequency <2.4 cpm) was relatively more expressed after open cholecystectomy. Among the patients with a laparotomic cholecystectomy, IL-6 maximal postoperative concentrations correlated positively with a prolonged restitution of normal gastric activity. CONCLUSIONS: EGG examination showed a high sensitivity in the evaluation of gastric electrical activity after both laparotomic and laparoscopic cholecystectomy. A significant correlation of prolonged bradygastria and IL-6 plasma levels supports the role of the inflammatory milieu in the pathogenesis of impaired gastric electrical activity in the postoperative period.

Thrombophilia and pulmonary endarterectomy.

UNLABELLED: In the present study, we compared groups of patients with and without thrombophilia, who underwent pulmonary endarterectomy (PEA), definitive treatment for chronic pulmonary hypertension resulting from thromboembolic disease. METHODS AND PATIENTS: Between September 2004 and June 2007, we operated 54 patients with CTEPH. We divided our patients into three groups. Group I patients, had one or more signs of serious thrombophilia (15 patients), Group II patients, had no signs of thrombophilia (23 patients without thrombophilia and without Methylenetetrahydrofolate Reductase (MTHFR)), and Group III patients with MTHFR (16 patients with MTHFR only, without any serious thrombophilia). RESULTS: After the surgery, there was a statistically considerable improvement of hemodynamic parameters (mPA, CI, PVR) in all groups, without a statistical difference between the groups. Comparison of all these groups showed more complications in-group I (thrombophilia), in particular reperfusion oedema, pericardial effusion, and renal insufficiency. Within one month, there was a considerable improvement or normalisation of haemodynamic parameters, an increase in walking distance at the six-minute walking test, and NYHA classification with no significant difference between the three groups. CONCLUSIONS: Early hemodynamic results of patients with thrombophilia after PEA, were comparable to the results of patients without thrombophilia, when we looked at both clinical and hemodynamic improvements. We did not find any differences when we looked at the results between Group II and Group III (MTHF), when we considered the number and type of complications. Patients with thrombophilia in Group I had statistically higher morbidity, especially when it came to a higher number of reperfusion oedema, pericardial effusion, and renal insufficiency.

Hemodynamic instability after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension correlates with cytokine network hyperstimulation.

BACKGROUND: Pulmonary endarterectomy (PEA) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH). The present study tested the hypothesis that inflammation, as determined by circulating cytokine levels, may contribute to the difficulty in controlling arterial blood pressure after PEA. MATERIALS AND METHODS: Thirty-six patients with CTEPH (22 males and 14 females) underwent PEA using cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. Plasma concentrations of tumor necrosis factor alpha, interleukin (IL)-1beta, IL-6 and IL-8 were measured repeatedly in arterial blood samples. RESULTS: A significant correlation between norepinephrine support and IL-6 plasma concentrations was shown at the separation from CPB (k = 0.742) and 12 h after it (k = 0.801) as well as between norepinephrine support and IL-8 concentrations 12 h after the separation from CPB. Furthermore, a significant correlation was found between the cardiac index (CI) and both IL-6 and IL-8 at the separation from CPB. CONCLUSIONS: Hemodynamic instability after PEA has been associated with higher postoperative plasma concentrations of IL-6 and IL-8. The positive relation between inflammatory cytokines and CI, or cytokines and vasopressor support, is in accordance with the hypothesis that cytokine activation may be among the neurohumoral factors responsible for cardiodepression and systemic vasoplegia in CTEPH patients undergoing PEA.

Leptin and soluble leptin receptor changes after pulmonary endarterectomy: relations to cortisol and cytokine network.

Leptin is a hormone that regulates food intake. During inflammatory status, leptin may contribute to the anorexia and cachexia of infection. Pulmonary endarterectomy was used as a model of non-infectious cytokine network hyperstimulation. Leptin and soluble leptin receptor (SLR) were compared with evolution of cortisol and inflammatory cytokines in twenty-two patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy using cardiopulmonary bypass (CBP) and deep hypothermic circulatory arrest (DHCA). Leptin, SLR, cortisol, IL-beta, IL-6, IL-8, and TNFalpha concentrations in arterial blood were measured before/after sternotomy, last DHCA, separation from bypass, 12, 18, 24, 36, and 48 h after sternotomy. Mean duration of CPB was 338.2 min.; mean circulatory arrest time 39.9 min. The initial decline of leptin, SLR, TNFalpha, IL-6, and IL-8 was followed by an increase culminating 6-24 h after sternotomy. Leptin peak levels were detected 24 h after sternotomy (28.0 ng/ml, 21.9-37.6). IL-6 culminated after separation from CPB, IL-8 was highest 12 h after sternotomy. Leptin concentrations correlated with IL-6 (r=0.82), and TNFalpha (r=0.73). Large cardiovascular surgery caused a significant increase in serum leptin, indicating its acute regulation by stress factors. This effect may be secondary to the inflammatory response mediated via cytokine stimulation. Correlation between leptin and IL-6 indicates the role of IL-6 in leptin induction.

Plasma prohepcidin as a negative acute phase reactant after large cardiac surgery with a deep hypothermic circulatory arrest.

Hepcidin is a key regulator of iron metabolism and a mediator of anemia in inflammation. Recent in vitro studies recognized prohepcidin as a type II acute phase protein regulating via interleukin-6. The aim of the present study was to investigate the time course of plasma prohepcidin after a large cardiac surgery in relation to IL-6 and other inflammatory parameters. Patients with chronic thromboembolic hypertension (n=22, males/females 14/8, age 51.9+/-10.2 years) underwent pulmonary endarterectomy using cardiopulmonary bypass and deep hypothermic circulatory arrest were included into study. Arterial concentrations of prohepcidin, IL-1beta, IL-6, IL-8, tumor necrosis factor-alpha, and C-reactive protein were measured before/after sternotomy, after circulatory arrest, after separation from bypass, and then 12, 18, 24, 36, 48 h and 72 h after the separation from bypass. Hemodynamic parameters, hematocrit and markers of iron metabolism were followed up. Pulmonary endarterectomy induced a 48% fall in plasma prohepcidin; minimal concentrations were detected after separation from cardiopulmonary bypass. Prohepcidin decline correlated with an extracorporeal circulation time (p<0.01), while elevated IL-6 levels were inversely associated with duration of prohepcidin decline. Postoperative prohepcidin did not correlate with markers of iron metabolism or hemoglobin concentrations within a 72-h period after separation from CPB. Prohepcidin showed itself as a negative acute phase reactant during systemic inflammatory response syndrome associated with a cardiac surgery. Results indicate that the evolution of prohepcidin in postoperative period implies the antagonism of stimulatory effect of IL-6 and contraregulatory factors inhibiting prohepcidin synthesis or increasing prohepcidin clearance.

Transcutaneous electrogastrography in patients with ileus. Relations to interleukin-1beta, interleukin-6, procalcitonin and C-reactive protein.

BACKGROUND: The aim of the prospective study was to characterize the disturbance of gastric electrical control activity in different types of ileus and to correlate surface electrogastrography (EGG) findings with a set of inflammatory markers. PATIENTS AND METHODS: Fifty-four adult patients with mechanic, vascular and paralytic ileus proven on clinical and radiological exams and 14 age- and sex-matched controls were examined. Gastric myoelectrical activity was recorded using 3 Ag-AgCl disposable skin electrodes connected in pseudo-unipolar mode by Microdigitrapper device. The captured signal was amplified and digitalized. The dominant frequency was calculated using computerized algorithms (Fast Fourier transform and running spectrum analysis). The results were correlated with the known pathological diagnoses and 4 inflammatory parameters--interleukin (IL)-1beta, IL-6, procalcitonin (PCT) and C-reactive protein. RESULTS: Irregular EGG activity without a dominant frequency or bradygastria (electrical control activity frequency <2.4 cycles/min) was seen in all patients with both vascular and parayltic ileus and in 67.86% of the patients with obstructive ileus. Normogastria (2.4-3.7 cycles/min) was found in 32.14% of the patients with obstructive ileus. Among the patients with obstructive ileus and bradygastria, higher concentrations of IL-6 (642.0 +/- 214.7 ng/l) and PCT (0.93 +/- 0.22 microg/l) were observed compared with the patients with normogastria--IL-6 (354.5 +/- 109.2 ng/l), PCT (0.69 +/- 0.11 microg/l); p < 0.05 for both. The C-reactive protein concentration did not differ in both subgroups on p < 0.05. CONCLUSIONS: EGG examination confirmed a high sensitivity in the evaluation of gastric electrical control activity in both vascular and paralytic ileus. Significant correlation of EGG findings and both IL-6 and PCT plasma levels supports a role of the inflammatory milieu in the pathogenesis of impaired gastric electrical activity in patients with ileus.

Ghrelin as an acute-phase reactant during postoperative stress response.

Ghrelin is a growth hormone-releasing peptide, discovered in 1999 by Kojima et al. Its potential role in inflammation and stress response is not yet clear. The purpose of this study was to characterize perioperative levels of circulating ghrelin in relation to different surgical procedures. The authors compared plasma ghrelin changes with cortisol, cytokines, and acute-phase proteins. The prospective study was performed on 22 patients with resection for colon cancer (group 1). Group 2, functioning as a comparative group, consisted of 22 patients with elective laparotomic cholecystectomy. Plasma concentrations of ghrelin, cortisol, tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta, IL-6, IL-8, soluble IL-2 receptor, C reactive protein, and alpha1-antitrypsin were estimated repeatedly during a 72-hour postoperative period. Data revealed significant elevation of plasma ghrelin 24 hours after resection of coli (median 508.0 ng/l, interquartile range 398.2-633.7 ng/l) in relation to both preoperative levels (317.6 ng/l, 253.4-355.1 ng/l, p<0.01) and group 2 maximal postoperative levels (386.2 ng/l, 324-432 ng/l, p<0.05). Ghrelin levels returned to initial status 36-48 hours after surgery with subsequent decline to subnormal levels. The regression coefficient was the highest for ghrelin and TNF-alpha 24 hours after laparotomy (r=0.64, p<0.05) and for ghrelin and IL-6 24 hours after surgery (r=0.56, p<0.05). Maximal postoperative levels of all tested parameters except for cortisol and IL-1beta differed significantly between both patient groups at p<0.05. After large abdominal surgery, ghrelin shows itself as an acute-phase reactant. The significant correlation between ghrelin and inflammatory cytokines supposes their regulatory role in this period. Our comparison of more- and less-invasive surgical procedures with similar nutritional restrictions argues for a dominant role of inflammatory factors in postoperative ghrelin elevation.

Quantitative analysis of procalcitonin after pulmonary endarterectomy in relation to cytokines and C-reactive protein.

BACKGROUND: Endarterectomy of the pulmonary artery (PEA) is a potential curative treatment method for selected patients with chronic thromboembolic pulmonary hypertension (CTEPH). The postoperative course after PEA is associated with high rate of early postoperative mortality, which ranges from 5 to 23%. The aim of this prospective clinical study was to assess the time course of procalcitonin (PCT) after uncomplicated PEA in relation to other inflammatory parameters. PATIENTS AND METHODS: 32 patients with CTEPH treated with PEA using cardiopulmonary bypass and deep hypothermic circulatory arrest were included into study. PCT, C-reactive protein (CRP), interleukin (IL)-1beta, IL-6, IL-8, and sTNFRI arterial concentrations were measured before/after sternotomy, last DHCA, separation from bypass, and repeatedly to 48 h after sternotomy. RESULTS: Mean duration of CPB was 338.2 min.; mean circulatory arrest time 39.9 min. The initial decline of PCT, IL-6, and IL-8 was followed by an increase culminated 6-24 h after sternotomy. PCT peak was detected +24 h (1.97 ng/ml, 1.70-2.54). IL-6 culminated after separation from CPB, IL-8 was highest 12h after sternotomy. PCT levels correlated with IL-6 (r = 0.81), CRP (r = 0.72), and sTNFRI (r = 0.58). CONCLUSION: Postoperative PCT culmination was delayed in alignment to pro-inflammatory mediators as IL-6 and IL-8. Positive correlation between PCT and IL-6 corresponded with the role of IL-6 in PCT induction in perioperative phase. Plasma PCT estimation extended to a measurement of CRP and IL-6 may become a useful complementary examination in early postoperative period after PEA.

Plasma procalcitonin in patients with ileus. Relations to other inflammatory parameters.

Plasma procalcitonin (PCT) is a highly specific marker for the diagnosis of bacterial infections and sepsis. PCT levels are usually low in viral infections, chronic inflammation or postsurgical states. The purpose of this study was to characterize PCT plasma levels in patients with various types of ileus at preoperative stage, where the other inducing factors such as a surgical stress are excluded. The prospective study was performed on 54 patients admitted to in-patient surgical department with a proven diagnosis of ileus. Patients were divided to three groups--obstructive, vascular and paralytic ileus. Plasma levels of PCT (Kryptor analysis), TNFalpha, IL-1beta, IL-6, cortisol (ELISA) and CRP (Kryptor ultrasensitive analysis) were estimated before any invasive procedure was realized. We demonstrated significant elevation of PCT in both obstructive ileus in adhesions and vascular ileus compared with healthy subjects (p 0.01). PCT levels were not elevated in paralytic ileus. The regression coefficient was the highest for PCT and CRP (r=0.78, p 0.01), for TNFalpha and IL-8 (r=0.76, p 0.01) in vascular ileus. There was no significant correlation between PCT and other inflammatory parameters. The different types of ileus induce an elevation of plasma PCT levels and PCT shows itself as an acute phase reactant. The highest PCT concentrations were presented in patients with vascular ileus, whereas paralytic ileus revealed similar cytokine and PCT pattern as in healthy subjects. Plasma PCT estimation extended to a measurement of CRP and IL-6 may become a useful complementary examination for diagnostics of acute abdomen in patients.

[Genetic variability of cytokines in relation to the risk of post-surgical complications]. / Genetická variabilita cytokinu ve vztahu k riziku pooperacních komplikací.

Gene polymorphysm of the principal pro- and anti-inflammatory cytokines, namely that of tumor necrosis factor-alpha, interleukin (IL)-1beta, IL-6, IL-8 a IL-10, can influence the course of the physiological tissue reaction to operation trauma. Recent clinical studies try to confirm that the patient's phenotype significantly determines both the intensity of post-surgical tissue response and the incidence of post-surgical complications and therefore it represents an independent prognostic factor of the postsurgical development. It appears that the impact of individual genetic variants can differ in the relation to the seriousness of the posttraumatic SIRS and in the relation to the danger and prognosis of the sepsis. For clinicians, such findings can be soon transformed into the estimation of perisurgical risks--including genome profile of markers critical for the inflammatory, thrombotic, vascular and neurological response to post-surgical stress.

[Gynecological aspects of thyroid disorders. A review]. / Gynekologické aspekty poruch stítné zlázy. Prehled.

OBJECTIVE: The most frequent thyroid syndromes--hypothyroidism and thyrotoxicosis--are often accompanied with menstrual disturbances. The aim of this study was to summarize knowledge of physiology, pathology and clinical aspects of both thyroidal and gonadal axis interactions. SUBJECT: A review. SETTING: Department of Pathological Physiology, 1st Faculty of Medicine, Charles University, Prague. CONCLUSION: About 25% female infertility and 15% menstrual cycle disorders result from thyroid dysfunction. Particularly, the subclinical hypothyroidism has a high prevalence in the population; therefore, thyroid function must be examined in female with unclear infertility or menstrual disturbances. The next overlap of thyroid disorders and gynaecology represents iodine-131 use for differentiated thyroid carcinoma in fertile age with aspects to ovarian failure and gestational risk.

[Prediction and monitoring of severe acute pancreatitis]. / Predikce a monitorace tezké akutní pankreatitidy.

Twenty to thirty percent patients with acute pancreatitis develop severe acute pancreatitis with high mortality and morbidity rate. Markers of severity of acute pancreatitis are clinically important for the early diagnosis of complications. We reviewed the literature for markers of acute pancreatitis. On their relevance for prediction of severe pancreatitis are given. Several markers can predict severe cases of acute pancreatitis with a different positive and negative predictive value. Useful predictors of severity may include serum procalcitonin and urinary trypsinogen activation peptide at the admission, serum interleukins-6 and -8 at 24 h, and serum C-reactive protein (CRP) in 48 hours interval. The valuable marker for daily monitoring appears to be serum procalcitonin.

[The risk of malignancy after organ transplantation]. / Riziko vzniku malignity po orgáinové transplantaci.

Improvements in immunosuppressive therapy during the past decade brought about improvements of the long term tolerance of organ allografts. However, the long-term immunosuppressive therapy has an important limitation, because it can increase the risk of cardivascular diseases, infections and tumors. As compared with age-matched healthy population, organ-transplant recipients have an increased incidence of tumors.

[Pathophysiology of postoperative dysfunctions of the intestinal motility. A review]. / Patofyziologie pooperacních poruch strevní motility. Review.

The postoperative motility dysfunction (POI) is a frequent secondary complication of surgical procedures. The POI results from a number of simultaneous factors of both local and systemic nature. Activation of inhibitory neural reflexes and a mediator response to the surgical procedure are among the main ones. Neurohumoral response of the organism to painful stimuli and the effect of the opioid medication used during the perioperative period, are the modulating factors. The intraabdominal procedure with manipulation with the intestine results in activation of the mediator response, followed by increased levels of cytokines and other mediators, inhibiting the smooth intestinal musculature contractility. The extent of the traumatization of the tissue is a principal factor affecting the extent and duration of the POI.

[Laparoscopic diagnosis and treatment of organic hyperinsulinism--our first experience]. / Laparoskopická diagnostika a lécba organického hyperinzulinismu--nase první zkusenosti.

Laparoscopic pancreatic procedures are still at the stage of evaluation with regard to their indications and the technical variation used. Laparoscopic pancreatic surgery is currently used for staging malignant pancreatic tumours, for the resection of benign pancreatic tumours and for the occasional management of inflammatory disorders of the pancreas. Insulinomas are rare tumours with incidence per year of 0.1-0.4 per 100,000. Ist Surgical clinic, IIIrd Internal clinic and Radiological clinic are cooperating since 1971. On the list of IIIrd Internal clinic are 80 patients with insulinoma. Since 1971 at Ist Surgical Clinic 66 patients have been operated. In our article are diagnostic and therapeutic problems discussed. Laparoscopic pancreatic procedures are still at an evaluation stage regard to their indications and techniques. Authors give report about first experience with successful laparoscopic enucleation of insulinoma in case 83 year old woman (Fig. 3, 4). The operative time was 90 min. Drainage is necessary. CT guided drain in cavity of seroma is shown (Fig. 5).

Ghrelin and leptin elevation in postoperative intra-abdominal sepsis.

BACKGROUND: Both ghrelin and leptin are important signals in the regulation of food intake and energy balance. Leptin concentrations are elevated in the majority of obese individuals, and its levels usually correlate with adiposity and body mass index. Ghrelin as a new growth hormone (GH)-releasing peptide was discovered in 1999. Ghrelin stimulates food intake and exhibits gastroprotective properties. Many other regulatory effects of both ghrelin and leptin involving cardiovascular, gastrointestinal, renal, and endocrine systems were revealed. New experimental studies show both hormones as new acute phase reactants in animal models of inflammatory reaction. The aim of this study was to characterize the levels of circulating ghrelin and leptin in relation to systemic inflammatory response. We used a postoperative bacterial sepsis after large abdominal surgery as a model of cytokine network hyperstimulation. PATIENTS AND METHODS: The prospective study was performed on 25 surgical patients with proven postoperative intra-abdominal sepsis after large abdominal surgery. Plasma levels of ghrelin (RIA), leptin, TNF-alpha, IL-1beta, sIL-2R, IL-6 (ELISA analysis), CRP and alpha1-antitrypsin (nephelometric analysis) were analyzed. RESULTS: Authors demonstrate statistically significant elevation of plasma ghrelin (492.3+/-70.6 ng/l) and leptin (31.6+/-12.2 microg/l) compared with the control group (336.5+/-46,1, p<0.01 for ghrelin, 3.5+/-1.2 microg/l, p<0.001 for leptin). The regression coefficient was the highest for ghrelin and IL-6 (r=0,44, p<0.05), and for ghrelin and TNF (r=0.43, p<0.05) in the sepsis group. In regard to leptin, the regression coefficient was the highest for IL-6 and leptin (r=0.53, p<0.05) and for leptin and CRP (r=0.51, p<0.05). There was no significant correlation between ghrelin and IL-1beta, ghrelin and sIL-2R, and leptin and IL-1beta. CONCLUSIONS: During postoperative intra-abdominal sepsis, both ghrelin and leptin plasma levels are elevated and positively correlate with both inflammatory cytokines (TNF-alpha, IL-6) and main APP member (CRP). It supports experimental finding that TNF-alpha and IL-6 can be important regulatory factors of their synthesis. This hormonal reaction is not specific to sepsis--the significant increase of both ghrelin and leptin occurs during an uncomplicated postoperative response, although in a lesser extent than was shown in sepsis.

Gonococcal infection as a cause of acute abdomen.

Gonococcal infection in the postantibiotic era continues to cause disseminated and severe disease in some patients. The differential diagnosis of pain in the lower abdomen in young women is difficult. Our case report described a 19-year-old patient who presented with acute abdomen as a result of Gonococcal infection, assessed as a local complication, pelveoperitonitis: pelvic inflammatory disease. The message of our case report is sexually transmitted infections should invariably be considered in young women and searched for accordingly.