The effect of glutamine and synbiotics on the healing of colonic anastomosis.

INTRODUCTION: Intestinal wound healing is an essential process for surgical reconstruction of the digestive tract. The purpose of this study is to evaluate the effect of perioperative administration of glutamine and synbiotics on the biological behavior of intestinal mucosal barrier and the healing of colonic anastomosis in rats. MATERIAL AND METHODS: 80 Wistar rats were divided in five groups. A: Control. B: Mechanical bowel preparation and antibiotics.C: Glutamine. D: Synbiotics. E: Glutamine and synbiotics. The animals were sacrificed on 3rd and 7th postoperative day. RESULTS: Zero mortality and no septic complications were noted. On 3rd postoperative days, a significant weight loss was observed in all groups in comparison with the preoperative weights, but on the 7th day in groups C and E, in contrast with the other groups, weight loss was not significant. On the 3rd postoperative day, neoangiogenesis, inflammatory infiltration and fibroblast activity were significantly enhanced in group E compared to control. On the 7th postoperative day in group E fibroblast activity was significantly enhanced and inflammatory infiltration was significantly limited compared to control. The bursting pressures as well as the hydroxyproline tissue content were significantly higher in the group E on 3rd and 7th postoperative days. The percentage of positive mesenteric lymph node cultures were significantly limited in group E compared to control. CONCLUSIONS: The administration of synbiotics in conjunction with glutamine resulted in increasing the mechanical strength of the anastomosis, thus increasing the bursting pressure and decreasing or effacing of anastomotic dehiscence and limiting bacterial translocation.

Endoscopic management of retained bile stones with an indwelling T-tube.

BACKGROUND: Endoscopic sphincterotomy (ES) is widely used for the treatment of residual bile duct stones in patients who had common bile duct (CBD) exploration and T-tube insertion. METHODS: In a 4-year period 45 patients were referred for endoscopic removal of residual bile duct stones. All patients had been operated 7-15 days earlier for choledocholithiasis and had a T-tube in the common bile duct (CBD). RESULTS: Four patients were excluded. Three patients had a periampullary carcinoma and the fourth patient had no residual stone seen at cholangiography. All patients had a successful ES, conventional in 34, precut-knife in 3, and with the rendezvous technique in 4 patients. In 24 patients, all having stones distal to the T-tube, complete clearance of the CBD was achieved during one session and the T-tube was removed after 48 h. In the remaining 17 patients (15 having stones proximal to the T-tube), the T-tube had to be removed first and following stone extraction, a plastic stent was inserted in the CBD. Complete bile duct clearance and stent removal was achieved in a second session 3-4 weeks later. There were no serious complications or biliary related symptoms after the procedures and after a mean follow-up period of 18 months. CONCLUSION: The endoscopic technique is safe and efficient for the treatment of residual stones after CBD exploration with a T-tube insertion, offering immediate cure compared to the percutaneous techniques. It is also an ideal method for the diagnosis of periampullary carcinomas.

Current treatment of colorectal liver metastases.

BACKGROUND: The aim of our study is to present our experience in the treatment of liver metastases in patients with colorectal cancer. PATIENTS AND METHODS: Between 1997 and 2003 a total of 12 patients with liver metastases from a primary colorectal cancer were treated in our department. They were 8 males and 4 females with a median age of 64 years (range 56-70 years). RESULTS: Ten patients underwent liver resection. The surgical procedures were 4 major hepatectomies (3 right hepatectomies, 1 left lobectomy) and 9 wedge liver resections. In total, 16 metastatic lesions were resected. Already at the time of the primary tumour, 5 patients presented with a synchronous liver metastasis. In 3 of them, liver metastasis was resected together with the primary tumour, and in the rest, resection was performed 1 month after the initial operation. In 5 patients liver metastases were metachronous and were diagnosed 3-14 months after the initial operation. The median survival of the patients was 39 months. Two patients (one with 2 metastatic lesions) underwent radiofrequency ablation (RFA) of the metachronous metastatic lesions and remain well 3-6 months postoperatively. CONCLUSIONS: Hepatectomy is the treatment of choice for hepatic metastasis of colorectal cancer, whenever feasible. Recent promising treatments such as RFA can further improve the outcome of these patients.

Factors enhancing intestinal adaptation after bowel compensation.

UNLABELLED: Intestinal failure (IF) refers to the condition in which certain causes lead to derangements in nutrient absorption capacity. Gut adaptation occurs in response to IF and it is both morphologic and physiologic in nature and can be mediated by growth factors and nutrients. Our paper reviews certain trophic growth factors that have important interactions relevant for intestinal growth, function and adaptation. DATA SOURCE: The literature was reviewed (data from both animal and human studies) and certain trophic factors that modulate intestinal adaptation are summarized. The factors reviewed are: epidermal growth factor, insulin-like growth factor I and II, transforming growth factor alpha and beta, neurotensin, interleukin-11, glucagon-like peptide-2, keratinocyte growth factor, human growth hormone, short-chain fatty acids, and glutamine. CONCLUSIONS: Growth factors augment intestinal proliferation, diminish programmed apoptosis, and modulate the adaptive process. They also have the potential to improve nutrient absorption in some bowel disease. The enhancement of gut adaptation may allow patients to transition of parenteral/enteral to normal nutrition, in a shorter period of time, which reduce the rate of adverse effects caused by artificial nutrition and improve quality of life.

Management of bile duct injury during and after laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is perhaps the most feared complication of laparoscopic cholecystectomy (LC). Proper management of iatrogenic BDI is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery. METHODS: Twelve patients with BDI after LC were treated. Eight of them were referred to our institution for further treatment. The follow-up evaluation was focused on clinical outcome and biochemical analysis. RESULTS: Five of the patients had minor BDI with leakage. In all of them, the BDI was recognized postoperatively. Two of these patients were managed by endoscopic retrograde cholongio pancreatographic sphincterotomy and stent placement. The other three patients underwent open laparotomy and bile duct ligation. Seven of the patients had major BDI. In two patients, biliary injuries were identified at the time of LC, and the procedure was converted to laparotomy. At the time of conversion, primary suture repair with T-tube drainage of the injured bile duct was performed. Strictures developed in these patients after 2 and 6 months, respectively, and they were treated with a Roux-en-Y hepaticojejunostomy. In five additional patients, BDI was recognized postoperatively. One of these patients died because of delayed detection of biliary peritonitis. At this writing, during a median follow-up period of 52 months, neither clinical nor biochemical evidence of biliary disease has been found in the remaining patients. CONCLUSIONS: Laparoscopic BDI has a high morbidity and mortality rate. Late recognition of the BDI remains a problem.

Effect of early postoperative enteral feeding on the healing of colonic anastomoses in rats. Comparison of three different enteral diets.

This experimental study compares the effects of early postoperative administration of three enteral diets of different compositions on the healing of colonic anastomoses. Sixty Wistar rats were subjected to colonic anastomoses. Following surgery, the rats were randomly allocated to four groups of 15 each. The rats in control group A received an electrolyte and glucose solution, the rats in group B received a complete balanced nutrition, in group C a complete balanced nutrition supplemented with fiber and in group D an isocaloric specialized elemental nutrition enriched with glutamine. The rats were sacrificed on day 7 following operation. Rupture of the anastomosis was higher in rats of the control group compared to the other three groups. Adhesion formation was more extensive in group A in comparison to the other three groups. The anastomotic bursting pressures were statistically significantly higher in groups C and D compared to the other two groups (p < 0.05). There was no statistically significant difference between group C and D (p > 0.05) while a statistically significant difference was noted between group B and group A (p < 0.05). Histological examination showed more profound inflammatory reaction in group A compared to the other three groups. There was also a statistically significant difference between group B and groups C and D while inflammatory reaction was of no statistically significant difference between group C and group D. Healing of the anastomoses was statistically significantly impaired in group A compared to the other three groups. There was no statistically significant difference between group C and group D while a statistically significant difference was found between group B and groups C and D. In conclusion, early postoperative enteral feeding improves healing of experimental colonic anastomoses in rats. This effect was more evident when fiber-supplemented diets or diets enriched with glutamine were administered.

Laparoscopic cholecystectomy in two patients with symptomatic cholelithiasis and situs inversus totalis.

BACKGROUND: Situs inversus viscerum is a rare condition with a genetic predisposition. We report 2 patients with situs inversus totalis and symptomatic cholelithiasis successfully treated via laparoscopic cholecystectomy. PATIENTS AND METHODS: The first patient was a 61-year-old female presenting with pain in the left upper quadrant associated with fever, chills, nausea and vomiting. The abdomen was tender with guarding and rebounding pain in the same region. Abdominal ultrasound and CT scan confirmed the diagnosis of gallstones as well as situs inversus with the liver and gallbladder on the left side and the spleen on the right. The second patient was a 37-year-old male with known situs inversus who presented with biliary colic due to cholelithiasis. In both patients cholecystectomy was performed laparoscopically in a reverse fashion. RESULTS: Laparoscopic cholecystectomy was carried out successfully despite the reversed anatomic relationships and both patients made a smooth recovery. CONCLUSION: Cholelithiasis occurring with situs inversus totalis is rare and may present a diagnostic problem. Laparoscopic cholecystectomy can be safely and effectively applied in the setting of situs inversus, although attention must be paid to the details of left-right reversal.

Management of large rectal wall defects with open pedicle grafts of small intestine. An experimental study.

The aim of this study was to evaluate the possible repair of large rectal wall defects using an open pedicle ileal graft as a mucosal patch. This experiment was carried out in 14 adult mongrel dogs. By excision of a portion of the antimesenteric wall comprising 50-70% of the circumference and measuring 5-6 cm in length, a suitable full thickness defect was created in the lower part of the rectum. A segment of the distal ileum was then isolated on a mesenteric pedicle and opened from its antimesenteric border. This was sutured over the defect in two layers. The animals were observed for a period of 15 days to 12 months. All the animals survived the operation apart from 1 dog that died of fecal peritonitis. Function of the rectum generally remained normal. Barium X-ray did not show any obstruction, shrinkage of the patch, lumen dilatation or extravasation. At the time of autopsy pedicles of ileal grafts appeared intact and pulsating. On gross examination there was no evidence of focal hemorrhage, ulceration or any cicatricial thickening of the grafts. Healing was good and the ileal mucosa retained its villi and general characteristics without any major inflammatory reactions. There was an increase in the number of goblet cells which returned to normal in 6 months.

External biliary fistula.

We report 210 cases of external biliary fistula treated in our clinics between 1970-1992. In 7 cases, fistulas were formed after iatrogenic bile duct injury, in 4 cases after exploration of common bile duct, in 4 cases due to disruption of biliary-intestinal anastomosis, and in 2 cases due to liver trauma. In 85 cases bile leak was observed after cholecystomy, in 103 cases after hydatid disease surgery, and in 4 cases after the passage of P.T.C. catheter. In one patient the appearance of the fistula was due to spontaneous discharge of a gallbladder empyema. 173 cases were managed conservatively, and 37 cases surgically.

Splanchnic ischemia during laparoscopic cholecystectomy.

BACKGROUND: Experimental studies have shown that elevation of intraabdominal pressure by means of gas insufflation produces hemodynamic disturbances in the peritoneal viscera, leading to splanchnic ischemia. The purpose of this clinical investigation is to reproduce the experimental data in humans undergoing laparoscopic cholecystectomy. METHODS: Sixteen females participated in this study. Eight of them (the control group) were subjected to open laparotomy for biliary surgery, while on the remaining eight laparoscopic cholecystectomy was performed. In all patients hepatic microcirculation was registered during the time of operation using the laser-Doppler technique. A single-fiber laser-Doppler microprobe was introduced transcutaneously within the hepatic parenchyma, through a Chiba needle, under direct or laparoscopic vision. Additionally, gastric intramucosal/intramural pH, a low level of which indicates tissue ischemia, was assessed by means of a tonometric nasogastric catheter. Hepatic microcirculation and gastric intramucosal/intramural pH were assessed between controls and pneumoperitoneum-subjected patients, and within the laparoscopic surgery group, i.e., during pneumoperitoneum and after abdominal deflation. RESULTS: Hepatic microcirculation was found to be significantly decreased in laparoscopic surgery patients in relation to controls (22.21 +/- 5.48 vs 57.52 +/- 18.06 perfusion units of flow, P = 0.0001) as was gastric intramural pH (7.15 +/- 0.16 vs 7.37 +/- 0.02, P = 0.003). Similarly, immediately after abdominal deflation, hepatic microcirculation exhibited a sudden elevation (22.21 +/- 5.48 vs 67.49 +/- 7.93 perfusion units of flow, P = 0.0001), while gastric intramural pH return to its normal values (7.15 +/- 0.16 vs 7.43 +/- 0.07, P = 0.0001). CONCLUSIONS: It is concluded that during laparoscopic cholecystectomy abdominal organs are hypoperfused, leading to a splanchnic ischemia environment. The clinical significance of these events remains to be clarified.

Ultrastructural alterations of the rat intestinal epithelium fed with polymeric, oligopeptidic or elementary full diet, following starvation.

In this study the ultrastructure of rat jejunal epithelial cells was examined, following a starvation period of 72 hours and an enteral refeeding period of 12 days, with either Nutrison, Pepti 2000, or Nutri 2000. Most changes occurred in the animals examined immediately after the 72-hour starvation period; these mainly included a significant decrease in microvilli population, occasional cell membrane disintegration, and a usual microvesicular appearance and degranulation of the rough endoplasmic reticulum. No alterations were found in the normally-fed animals (control group). This was also practically the same for the Pepti 2000 group. In the Nutrison group, a small amount of changes were found, while in the Nutri 2000 group many alterations were detected, which nevertheless were fewer than in the starved animals. The results demonstrate that the micromorphological alterations of the intestinal epithelium caused by starvation improve faster when an oligopeptidic formula is provided, which consequently results in faster and better absorption of the nutrients.

Intracerebroventricular infusion of neurotensin suppresses gastric acid secretion in dogs.

Synthetic neurotensin (NT) was infused intracerebroventricularly in 14 mongrel dogs to study the effects of the peptide on gastric secretion and on gastrin and NT levels. The infusion was performed with a specific apparatus, and gastric fluid was collected with a Pavlov pouch. NT was given in two series of experiments: as a bolus intracerebroventricular injection of 269.8 pmol/kg and as a continuous intracerebroventricular infusion at a rate of 539.6 pmol/kg/h for 30 min. The bolus injection caused a very significant decrease of gastric fluid volume, a significant decrease of HCl output and a significant increase of its pH, while serum immunoreactive gastrin increased significantly. The continuous infusion of NT caused similar changes in gastric secretion. The plasma NT levels did not change. In conclusion, the intracerebroventricular administration of NT increases the serum gastrin levels, decreases the volume and HCl content of gastric fluid, and increases its pH.

Changes in gastric secretion after intracerebroventricular infusion of bombesin in dogs.

Synthetic bombesin (BBS) was infused intracerebroventricularly in 14 mongrel dogs, to study the effects of the peptide on gastric secretion and on gastrin and neurotensin levels. The infusion was performed with a specific apparatus, and gastric fluid was collected with a Pavlov pouch. BBS was given in two series of experiments: as a bolus intracerebroventricular injection of 308.6 pmol/kg and as a continuous intracerebroventricular infusion at a rate of 617.3 pmol/kg/h for 30 min. The bolus injection caused a very significant decrease of gastric fluid volume, a significant decrease of HCl output, and a significant increase of its pH, while serum immunoreactive gastrin increased significantly. The continuous infusion of BBS caused similar changes in gastric secretion. The plasma neurotensin levels did not change. In conclusion, the intracerebroventricular administration of BBS increases the serum gastrin levels, decreases the volume and HCl content of gastric fluid, and increases its pH.