Preliminary Results of the Influence of Duodenojejunal Bypass in a Porcine Model of Streptozotocin-Induced Diabetes Mellitus.

BACKGROUND: Type 2 diabetic obese patients present with a normalization of plasma glucose levels shortly after most bariatric procedures, before any significant weight loss takes place. There is only scarce literature in the new field of metabolic surgery, with most experiments being performed on small animal models. AIM: Our aim is to develop a reliable large animal model for assessment of surgical correction of diabetes. METHOD: Titrated doses of streptozotocin (STZ) were used for induction of diabetes mellitus. After standardization of the surgical technique to avoid any restrictive component, three groups were created, a duodenojejunal bypass (DJB; n = 4), a gastroileal conduit (GIC; n = 3) near the ileocecal valve, and a sham (control; n = 5) group. Preoperative and postoperative glycemic curves were recorded by means of intravenous glucose tolerance tests. Body weight fluctuations were recorded as well. RESULTS: Diabetes was successfully induced with the use of STZ in all cases. Animals in the sham group remained diabetic for 3 weeks after operation. There was normalization of blood glucose levels in the operative groups during the 3-week postoperative follow-up, without significant body weight changes. The duodenojejunal group resulted in stronger positive response of glycemia. CONCLUSION: STZ-induced diabetes in swine leads to a reliable large animal model for assessment of metabolic surgical procedures. STZ is an effective but highly toxic means for inducing stable diabetes in the sensitive porcine model. Duodenojejunal bypass, although less invasive, seems to exert better antidiabetic effects than gastroileal conduit.

A cost-utility analysis of laparoscopic vs open treatment of colorectal cancer in a public hospital of the Greek National Health System.

PURPOSE: Laparoscopic colectomy has been reported as a safe and oncologically similar operation to open colectomy. A number of expensive surgical instruments are necessary for the procedure which should be applied if it is cost-effective for the patient and the health system in general. The purpose of the current study was the economic evaluation of laparoscopic compared to open colectomy for the treatment of colon cancer in the Greek national health system. METHODS: Fifty patients undergoing open colectomy and 42 undergoing laparoscopic colectomy were enrolled in this case-control study. Length of hospital stay, duration of operation, complication rates, cost of equipment used, total costs and three questionnaires measuring quality of life /QoL (EQ-5D, SF-36 and QLQ-C30) at baseline, 1 and 3 months after the operation were recorded. RESULTS: No statistically significant difference in QoL measured by QALYs between laparoscopic and open colectomy was observed. On the other hand, cost utility analysis revealed that laparoscopic colectomy was more expensive considering the advantages it offers. CONCLUSIONS: Laparoscopic colectomy is not superior to open colectomy on a QoL basis in the Greek public hospital system and is less cost-effective compared to the open procedure. Since the expensive equipment used in laparoscopic colectomy seems to be the causative factor for the high cost of this type of operation, an effort should be made to reduce it either by using reusable instruments or by implementing policies aiming at suppliers cutting down equipment charges.

Bougie insertion: A common practice with underestimated dangers.

INTRODUCTION: Esophageal perforation after bariatric operations is rare. We report two cases of esophageal perforation after bariatric operations indicating the dangers of a common practice - like insertion of esophageal tubes - and we describe our management of that complication. PRESENTATION OF CASE: A 56 year old woman who underwent laparoscopic sleeve gastrectomy and a 41 year old woman who underwent laparoscopic adjustable gastric banding respectively. In both operations a bougie has been used and led to esophageal perforation. DISCUSSION: The insertion of bougie and especially of inflated bougie is a common practice. It is an invasive procedure that in most cases is performed by the anesthesiologist team. CONCLUSION: Bougie insertion is an invasive procedure with risks and should always be attempted under direct supervision of surgical team or should be inserted by a surgeon.

Preoperative levosimendan in heart failure patients undergoing noncardiac surgery.

BACKGROUND: Heart failure (HF) is a major cause of perioperative morbidity and mortality in noncardiac surgery. Preoperative optimisation of these patients is, thus, of utmost importance. Levosimendan seems promising for patients undergoing cardiac surgery; however, its safety and efficacy in HF patients undergoing noncardiac surgery have not been evaluated. OBJECTIVE: To evaluate the effects of prophylactic preoperative levosimendan administration on left ventricular function in HF patients undergoing noncardiac surgery. METHODS: HF patients with ejection fraction <30%undergoing elective noncardiac surgery in 2005 were included in this prospective study. Patients were admitted to our surgical intensive care unit one day preoperatively. Under continuous haemodynamic monitoring, the treatment protocol consisted of an initial loading dose (24 microg/kg) for ten minutes followed by a continuous 24-hour infusion (0.1 microg/kg/min) at the end of which patients underwent surgery. Echocardiography was performed before infusion (day 0) and on the 7th postinfusion day (day 7). Measurements included left ventricular ejection fraction (LVEF), velocity time integral(VTI), pre-ejection period (PEP), ejection time (ET),maximum (Pmax) and minimum P(min) transvalvular aortic pressure gradient, and maximum (Vmax) and minimum V(min) aortic velocity. RESULTS: Twelve consecutive patients were enrolled. Levosimendan resulted in a significant increase in LVEF,VTI, P(max), P(min), V(max), and V(min) (p<0.01) and, moreover, a significant reduction in PEP, ET, and PEP/ET (p=0.04) on day 7 compared with day 0 values. No adverse reactions,complications or mortality occurred during 30-day follow-up. CONCLUSION: Prophylactic preoperative levosimendan treatment may be safe and efficient for perioperative optimisation of heart failure patients undergoing noncardiac surgery.

Apoptosis in cells of bronchoalveolar lavage: a cellular reaction in patients who die with sepsis and respiratory failure.

OBJECTIVE: Apoptosis represents a physiologic clearance mechanism in human tissues. The role of apoptosis has not been examined in lung cell populations, such as alveolar macrophages of septic patients, an organ frequently insulted in these patients. This study was designed to examine the effect of sepsis on the apoptosis of alveolar macrophages. DESIGN: Prospective study. SETTING: Intensive care unit and surgical intensive care and trauma unit of a large university hospital in Athens, Greece. PATIENTS: Bronchoalveolar lavage was obtained from 20 consecutive patients who met the criteria for sepsis, admitted to two intensive care units. Bronchoalveolar lavage was obtained from nine volunteers without lung disease who served as controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The specimens were analyzed by using annexin V binding, terminal deoxynucleotidyl transfer-mediated deoxyuridine 5-triphosphate nick end labeling (TUNEL), DNA laddering, light microscopy, and immunohistochemistry. Spontaneous apoptosis of bronchoalveolar lavage cells and particularly of alveolar macrophages was significantly decreased in septic patients compared with nonseptic controls. This finding was confirmed by using morphologic criteria and the TUNEL method. Furthermore, gel electrophoresis of DNA obtained from bronchoalveolar cells revealed that DNA fragmentation was not necessarily associated with apoptotic cell death. The bcl-2 gene was minimally expressed in the control group. An inverse correlation was found between the percentage of apoptotic alveolar macrophages and the severity of sepsis. CONCLUSIONS: The prolonged survival of lung cells in septic patients and especially of alveolar macrophages may be attributable to the inhibition of apoptosis. This seems to represent an initial attempt of the host to increase the defense capacity to kill the invading microorganism, resulting in an unbalanced tissue load of cells and an uncontrolled release of toxic metabolites. Furthermore, the inhibition of apoptosis in septic patients may explain why lung function is impaired, leading to sepsis-induced acute respiratory distress syndrome and death.