Immunomodulation in surgical practice.

BACKGROUND: Immunomodulation may represent a potential way to improve surgical outcome. These types of interventions should be based on detailed knowledge of the underlying mechanisms involved. The aim of the present review is to summarize some experience on the acute phase response, potential ways of intervention and experiences from critical illness and HPB disease. DISCUSSION: Mechanisms of the acute phase response are discussed including the individual parameters and local changes that take part. Mechanisms involved in failure of the gut barrier are presented and include changes in gut barrier permeability, effects on gut-associated immunocompetent cells, and systemic implications. As examples of HPB disease, mechanisms of the acute phase response and potential ways of intervention in obstructive jaundice and acute pancreatitis are discussed. Nutritional pharmacology and lessons learned from immunomodulation and immunonutrition in critical illness and major abdominal surgery, including upper GI and HPB surgery, are referred to. Overall, immunomodulation represents a potential tool to improve results but requires a thorough mapping of underlying mechanisms in order to achieve individualized treatment or prevention based on patients' specific needs.

Incidence, management and recurrence rate of acute pancreatitis.

BACKGROUND: Acute pancreatitis is a common condition that is still associated with substantial morbidity and mortality rates. Management, outcome and recurrence rate in acute pancreatitis in a clinical setting using a conservative management approach are described. METHODS: A total of 1376 consecutive cases representing 2211 hospitalizations due to acute pancreatitis treated at the Dept. of Surgery, Lund University Hospital, Lund, were reviewed retrospectively. Management, outcome and recurrence rate were recorded. RESULTS: Incidence, including recurrences, was 300 per million per year; 21% of patients had recurrent (> or =2) attacks. In relapsing disease, two-thirds of patients had the first attack within 3 months. Mortality decreased over the period studied, but overall it was 4.2%; mortality in relapsing attacks was 2.5%, related to multiple organ dysfunction (MODS) in 67% and occurring within the first week in 36%. CONCLUSIONS: Despite a conservative approach in the management of acute pancreatitis, mortality is still substantial, frequently occurs early after admission, is associated with MODS and is also seen in relapsing disease. Early cholecystectomy and bile duct clearance could decrease recurrent attacks of biliary pancreatitis.

Synovitis in Legg-Calvé-Perthes disease. Evaluation with MR imaging in 84 hips.

PURPOSE: To evaluate, by means of MR imaging, the degree and persistence of synovitis in the hip joint in Legg-Calvé-Perthes disease and to correlate the degree of synovitis with the degree of epiphyseal necrosis. MATERIAL AND METHODS: A total of 170 MR images in 72 patients (84 hips) were examined. The T2-weighted MR images were taken in the coronal plane in order to evaluate the degree of synovitis in the hip joint. RESULTS: MR revealed synovitis in all cases in the early phase of the disease. In Catterall group II, synovitis was discreet to moderate for up to 6 months after diagnosis. Hips with more severe necrosis, Catterall groups III and IV, had moderate or intense degrees of synovitis. There was a correlation between the degree of synovitis and the lateral pillar classification according to HERRING et al. Also, there was a good correlation between the extent of signal changes in the epiphysis on MR imaging and the degree of synovitis. There was no difference when signal changes were evaluated on T1- or T2-weighted images. Signs of synovitis could be seen for up to 30 months after diagnosis in Catterall group I hips, and in Catterall groups II and III for up to 36 months, and in 2 cases even longer. Some Catterall group IV hips had discreet or mild synovitis for 60 months or more, after diagnosis. CONCLUSION: The degree of synovitis on MR imaging correlates to the extent of epiphyseal necrosis seen on radiographs or MR imaging as well as to the lateral pillar classification, i.e. to a poor clinical outcome. In Catterall group IV hips, synovitis can even persist for up to 60 months after diagnosis.

Magnetic resonance imaging and early remodeling of the femoral head after femoral varus osteotomy in Legg-Calvé-Perthes disease.

We studied 21 children with Legg-Calvé-Perthes Disease with a prognostically poor development, including lateralization, poor containment, anterolateral flattering, and deformation of the femoral head, as evaluated on serial magnetic resonance (MR) imaging. These children were treated with proximal femoral varus derotation osteotomy. The sphericity of the cartilaginous and bony femoral epiphysis was evaluated postoperatively on serial radiography and MR imaging. There was an early postoperative continuous spherical remodeling over a follow-up period of 3.0 years (1.0-5.1; SD, 1.3).

Increased levels of proteoglycan fragments and stromelysin in hip joint fluid in Legg-Calvé-Perthes disease.

The concentrations of proteoglycan fragments and stromelysin were analyzed in joint aspirates in 19 children with Legg-Calvé-Perthes disease. We found increased levels of proteoglycan fragments and stromelysin consistent with the presence of synovitis, an important clinical and possibly also prognostic factor in these children.

Metaphyseal histology and magnetic resonance imaging in Legg-Calvé-Perthes disease.

Cylindrical biopsy specimens from the proximal femoral metaphysis were obtained in conjunction with surgery in 22 patients with Legg-Calvé-Perthes disease. The histopathological examination revealed fat necrosis, vascular proliferation, and focal fibrosis indicating previous episodes of ischemia. There was no correlation between the histopathological findings and the corresponding magnetic resonance images.

Growth in 110 children with Legg-Calve-Perthes' disease: a longitudinal infancy childhood puberty growth model study.

Growth in 110 children with Legg-Calve-Perthes' disease (LCPD) was longitudinally followed throughout the growth period. The infancy childhood puberty (ICP) growth model, which has the advantage that reference values can be adjusted for the individual age at pubertal maturation, was used. On the average, the children were slightly shorter at birth and they remained short throughout the entire growth period to maturity. At maturity, the boys were 4.4 cm and the girls were 2.5 cm below the reference mean. The growth velocity was normal at the time of diagnosis, prepubertally, and during puberty. Boys and girls differed only in that the boys were more overweight.

Sonography and intracapsular pressure in Perthes' disease. 39 children examined 2-36 months after onset.

39 children with Legg-Calvé-Perthes Disease (LCPD) and with a radiographically unsatisfactory development were examined with sonography regarding synovitis and with intracapsular pressure recording and aspiration performed 15 (2-36) months after the onset of symptoms. The mean anterior sonographic capsular distension was 3.0 (1.0-7.0) mm greater than that of the contralateral, asymptomatic hip. The mean intracapsular pressure was 4.5 (0-11.5) kPa with the hips in extension and neutral rotation, 9.7 (1.3-27.3) kPa with the hips in extension and inward rotation and 0.9 (-0.8-4.7) kPa in 45 degrees of flexion. We conclude that these children have synovitis as diagnosed sonographically. This synovitis is probably symptomatically and prognostically important in LCPD due to increased intracapsular pressure, with pain, a decreased range of motion and, potential joint contracture.

Femoral head shape in Legg-Calvé-Perthes disease. Correlation between conventional radiography, arthrography and MR imaging.

Twenty-three children with Legg-Calvé-Perthes disease were examined to determine the femoral head shape. We evaluated and correlated conventional radiography, arthrography and MR imaging. In the a.p. view, measurements were obtained from the center of the femoral head along the bony or cartilaginous outline at 30 degrees intervals. Maximum flattening of the cartilaginous outline appeared laterally, 60 degrees from the center of the baseline of the epiphyseal index and the caput index. Maximum flattening of the bony outline was found at 75 degrees. Arthrography and MR imaging gave the same information about the shape of the femoral head cartilage. The bony femoral head shape on conventional radiographs in the a.p. view did not reflect the cartilage shape obtained by MR and arthrography.

Fracture of the lateral malleolus. Comparison of 2 fixation methods in cadavers.

20 pairs of lateral malleolar fracture were created by an osteotome at autopsy of elderly patients and repaired on one side with staples and cerclage wire and on the other side with plate and screws. The stability of the fixation was then tested in an apparatus creating outward rotational load. The breaking load in fractures fixated with staples and wire was about 60 percent (18 SD 7.6 Nm) of the plated fibular fractures (32 SD 11 Nm). However, at an outward deflection up to 30 degrees there was no difference in breaking load with the two methods of fixation.