Post-liver transplant cholestatic disorder with biliary strictures: de novo versus recurrent primary sclerosing cholangitis.

Cholestatic allograft dysfunction following liver transplantation (LT) can result from many different underlying pathogenetic mechanisms and is a major cause of morbidity and graft loss. Although recurrence of primary sclerosing cholangitis (PSC) is a described entity following LT, the diagnosis is difficult and requires exclusion of common risk factors for stricture formation. There are no reports in the literature of de novo PSC arising in a patient who did not have that disease prior to transplantation. Reported herein is the case of a patient who underwent transplantation for end-stage cryptogenic cirrhosis and who had no underlying risk factors, but who developed late post-LT cholestatic disorder with non-anastomotic biliary strictures. The combined clinical, radiological, and pathological findings resembled those of PSC. Admittedly, it is a challenging proposition but the possibility of a de novo PSC-like syndrome in this patient is raised. A recurrence in a patient who may have had a burnt-out, PSC-like syndrome presenting as cryptogenic cirrhosis, however, cannot be entirely excluded.

Cerebrovascular response to continuous cold perfusion and hypothermic circulatory arrest.

OBJECTIVE: Clinical and laboratory studies have documented changes in cerebrovascular resistance after hypothermic circulatory arrest, both with and without adjunctive cerebral perfusion modalities. This study was designed to clarify whether these changes are due to cerebral edema, resistance vessel abnormalities, or alterations in the cerebral microcirculation. METHODS: Four mature swine underwent hypothermic circulatory arrest for 60 minutes, and 7 mature swine underwent cold cerebral perfusion for 60 minutes to simulate antegrade selective perfusion. All were rewarmed and weaned from cardiopulmonary bypass. Pial vascular diameter and reactivity were measured in vivo through a cranial window and ex vivo in an organ chamber; cerebral microvascular endothelium was studied in culture for release of vasoactive mediators. Cerebral water content was recorded. RESULTS: Cold perfusion caused pial arteriole and venule constriction, whereas hypothermic circulatory arrest alone caused pial arteriole and venule dilatation. Cold perfusion caused a temporal loss of endothelium-dependent vasodilatation, most notably to bradykinin. Hypothermic circulatory arrest caused a loss of nitric oxide-mediated endothelium-dependent vasodilatation. Endothelium-independent vasoreactivity remained intact in both groups. Endothelial cells from the cold group had a vasoconstrictive secretory phenotype, whereas endothelial cells from the hypothermic circulatory arrest group had a vasodilatory phenotype. Cerebral water content was the same in both groups. CONCLUSION: The increase in cerebrovascular resistance observed after cold cerebral perfusion is caused by resistance vessel constriction and may be promoted by an altered microcirculation. Hypothermic circulatory arrest alone is associated with endothelium-dependent vasoparesis. Both could contribute to cerebral injury in the early hours after operation.

Iatrogenic biliary injuries: classification, identification, and management.

Iatrogenic biliary injuries most commonly occur during laparoscopic cholecystectomy. Biliary injuries are complex problems requiring a multidisciplinary approach with surgeons, radiologists, and gastroenterologists knowledgeable in hepatobiliary disease. Mismanagement can result in lifelong disability and chronic liver disease. Given the unforgiving nature of the biliary tree, favorable outcome requires a well-thought-out strategy and attention to detail.

Update on immunosuppressive drugs used in solid-organ transplantation and their nutrition implications.

The success of solid organ transplantation rests heavily on the major advances in immunosuppressive therapy. The early years of organ transplantation were plagued with high failure rates and frequent episodes of acute rejection. With the introduction of improved immunosuppressive agents, successful organ transplantation has become the norm. The emphasis of immunosuppressive therapy has shifted from preventing rejection to balancing acceptable rates of rejection with moderation in adverse effects of the immunosuppressive agents. Among the many possible adverse effects of immunosuppressive therapy is the potential for these agents to affect the nutrition status of the transplant recipient. Given the fact that many patients undergoing transplantation are catabolic and nutritionally vulnerable, it is particularly important for those involved in the care of these patients to be familiar with the nutrition implications of immunosuppressive drugs. In this article, we review the different classes of immunosuppressive medications used in transplantation and emphasize their interactions with the nutrition status of the transplant recipient.

Matrix metalloproteinase and tissue inhibitor expression in atherosclerotic and nonatherosclerotic thoracic aortic aneurysms.

OBJECTIVES: The altered expression of matrix metalloproteinases and their inhibitors influences the formation of atherosclerotic abdominal aortic aneurysms. Their association with thoracic aneurysms is less clear. This study describes the expression of metalloproteinases and their inhibitors in atherosclerotic and nonatherosclerotic thoracic aneurysms, and compares these with age-matched controls. METHODS: Matrix metalloproteinase-2 and 9 activity were measured by antibody capture, and tissue inhibitor-1 and 2 levels were measured by enzyme-linked immunosorbent assay in 24 patients with atherosclerotic aneurysms and in 63 patients with nonatherosclerotic aneurysms. Gene expression was assessed with reverse transcriptase polymerase chain reaction. The results were compared with 17 controls. RESULTS: Data are in nanograms per milligram of protein. Matrix metalloproteinase-2 activity was greater in controls than in the atherosclerotic and nonatherosclerotic groups (80 +/- 67 vs 49 +/- 50 and 35 +/- 44, P = .002). Matrix metalloproteinase-9 activity was greater in the atherosclerotic group than in the nonatherosclerotic group and controls (11.7 +/- 15.7 vs 2.5 +/- 2.2 and 1.7 +/- 1.9, P = .001). Tissue inhibitor-1 and 2 levels were greater in controls than in either aneurysm group (tissue inhibitor of metalloproteinase-1: 376 +/- 192 vs 234 +/- 233 and 174 +/- 148, P = .003; tissue inhibitor of metalloproteinase-2: 143 +/- 74 vs 14 +/- 13 and 27 +/- 43, P < .001). Atherosclerotic aneurysms expressed more matrix metalloproteinase mRNA than controls. CONCLUSIONS: The metalloproteinase/tissue inhibitor phenotype of atherosclerotic thoracic aneurysms is similar to that of abdominal aneurysms. The diminished expression of metalloproteinases and tissue inhibitors in nonatherosclerotic thoracic aneurysms relative to aged controls may represent a loss of smooth muscle cells.

Matrix metalloproteinase activity in thoracic aortic aneurysms associated with bicuspid and tricuspid aortic valves.

OBJECTIVE: Matrix metalloproteinases are endopeptidases that function in cell matrix turnover. Abnormal matrix metalloproteinase activity has been implicated in the formation of atherosclerotic abdominal aortic aneurysms. Recent studies suggest that abnormal matrix metalloproteinase activity may also be associated with the formation of atherosclerotic and nonatherosclerotic thoracic aortic aneurysms. Bicuspid aortic valves are associated with an intrinsic aortic pathology that predisposes to formation of proximal thoracic aneurysms while tricuspid aortic valves are not. The objective of this study was to compare the activities of matrix metalloproteinases and levels of their inhibitors in thoracic aneurysms of patients with bicuspid and tricuspid aortic valves. METHODS: Endogenous and total activity of matrix metalloproteinase-2 and matrix metalloproteinase-9 were measured in proximal nonatherosclerotic thoracic aortic aneurysms of 16 patients with bicuspid aortic valves and 12 patients with tricuspid aortic valves. Levels of tissue inhibitor metalloproteinase-1 and -2 were also measured. Results were standardized to total protein (mg). RESULTS: Total matrix metalloproteinase-2 activity was greater in aneurysms associated with bicuspid valves when compared with those from tricuspid valves (43 +/- 11 ng/mg vs 14 +/- 2 ng/mg, P =.02). Total matrix metalloproteinase-9 activity was also greater in aneurysms associated with bicuspid aortic valves (4.0 +/- 0.9 vs 1.5 +/- 0.3, P =.02). There was no meaningful difference between groups in levels of tissue inhibitor-1 and -2. CONCLUSION: The increased activity of matrix metalloproteinases in the walls of aneurysms associated with bicuspid aortic valves may partly explain the predilection to aneurysm formation in these patients.

Damage control: what is its role in colorectal surgery?

Damage control is an approach that has gained widespread popularity and acceptance in the management of severely injured patients. Although initially popularized in the trauma literature, this technique is being expanded to the management of a broad range of serious, often desperate surgical circumstances that may be encountered, including scenarios confronted by the colon and rectal surgeon. Damage-control surgery is a three-staged process involving a truncated laparotomy, aggressive resuscitation in the intensive care unit, and finally, definitive surgery. This approach may be lifesaving in the setting of presacral hemorrhage, severe coagulopathy, or patient instability.

Wound closure in the lamellipodia of single cells: mediation by actin polymerization in the absence of an actomyosin purse string.

The actomyosin purse string is an evolutionarily conserved contractile structure that is involved in cytokinesis, morphogenesis, and wound healing. Recent studies suggested that an actomyosin purse string is crucial for the closure of wounds in single cells. In the present study, morphological and pharmacological methods were used to investigate the role of this structure in the closure of wounds in the peripheral cytoplasm of sea urchin coelomocytes. These discoidal shaped cells underwent a dramatic form of actin-based centripetal/retrograde flow and occasionally opened and closed spontaneous wounds in their lamellipodia. Fluorescent phalloidin staining indicated that a well defined fringe of actin filaments assembles from the margin of these holes, and drug studies with cytochalasin D and latrunculin A indicated that actin polymerization is required for wound closure. Additional evidence that actin polymerization is involved in wound closure was provided by the localization of components of the Arp2/3 complex to the wound margin. Significantly, myosin II immunolocalization demonstrated that it is not associated with wound margins despite being present in the perinuclear region. Pharmacological evidence for the lack of myosin II involvement in wound closure comes from experiments in which a microneedle was used to produce wounds in cells in which actomyosin contraction was inhibited by treatment with kinase inhibitors. Wounds produced in kinase inhibitor-treated cells closed in a manner similar to that seen with control cells. Taken together, our results suggest that an actomyosin purse string mechanism is not responsible for the closure of lamellar wounds in coelomocytes. We hypothesize that the wounds heal by means of a combination of the force produced by actin polymerization alone and centripetal flow. Interestingly, these cells did assemble an actomyosin structure around the margin of phagosome-like membrane invaginations, indicating that myosin is not simply excluded from the periphery by some general mechanism. The results indicate that the actomyosin purse string is not the only mechanism that can mediate wound closure in single cells.