Gallbladder inflammation is associated with increase in mucin expression and pigmented stone formation.

Mucin is a high molecular weight glycoprotein that plays an important role in protecting the gallbladder epithelium from the detergent effect of bile. However, it also participates in gallstone formation. There is little information about a possible relationship between gallbladder inflammation and mucin expression or gallbladder stones' characteristics. The aims of this study were to investigate stone characteristics and patterns of mucin expression in the gallbladder epithelium and bile of gallstone patients, in relation to inflammation. Gallbladder bile and tissue samples from 21 patients were obtained at surgery. Mucin content was evaluated by gel filtration on a Sepharose CL-4B column. Dot blot for bile mucin apoproteins and immunohistochemistry staining for gallbladder mucosal mucin apoproteins were performed with antibodies to MUC2, MUC3, MUC5AC, MUC5B and MUC6. Staining intensity score (0-3) was used for assessment of antigen expression and the level of inflammation. Gallstone cholesterol content was determined in 16 patients. MUC 5AC and MUC 5B were demonstrated in 95.4 and 100% of gallbladder bile samples, respectively. Immunohistochemistry staining with antibodies to MUC 2, MUC 3, MUC 5AC, MUC 5B and MUC 6 were positive in 0, 100, 85.7, 100 and 95.4% of the gallbladder mucosal samples, respectively. Pigmented brown stones were associated with a higher level of gallbladder inflammation. Mucin species expressed in gallbladder epithelium are MUC3, MUC5AC, MUC5B and MUC6. MUC5AC and MUC5B are secreted into bile. Inflammation of the gallbladder is accompanied by a higher level of MUC5AC expression and is associated with pigmented brown stones.

Preoperative chemoradiation in rectal cancer: Retrospective comparison between capecitabine and continuous infusion of 5-fluorouracil.

BACKGROUND: We compared the efficacy and toxicity of oral capecitabine and continuous infusion of 5-fluorouracil (5-FU) in the preoperative chemoradiation treatment of patients with rectal cancer. PATIENTS AND METHODS: The files of 89 patients with rectal cancer, 43 treated preoperatively with oral capecitabine and 46 with intravenous 5-FU, were reviewed, and the outcome of the groups was compared. RESULTS: There was no statistically significant difference in the complete pathological response rate between the capecitabine and the 5-FU groups (30% vs. 17%, P = 0.15). The downstaging rate was higher in the capecitabine group (77% vs. 50%, P = 0.009). Toxicity was mild in both groups. The rate of Grade 3 gastrointestinal toxicity was similar in the two groups (diarrhea 2% vs. 4%, proctitis 5% vs. 7%), except for one patient in the 5-FU group (2%) who developed a rectovaginal fistula. In the capecitabine group, one patient (2%) had Grade 3 hand-foot syndrome, and another had an acute myocardial infarction. In the 5-FU group, two patients (4%) had Grade 3 hematological toxicity, and three (6%) had complications from Port-a-Cath insertion. CONCLUSION: Preoperative chemoradiation with oral capecitabine appears to be safe and well tolerated, and at least as good as continuous 5-FU.

Colonic anastomosis performed with a memory-shaped device.

BACKGROUND: The present study was prompted by our previous successful experience with the compression anastomosis clip (CAC) on animals followed by a study on 20 patients scheduled for colonic resection. METHODS: Sixty patients with colonic cancer were assigned randomly to undergo an anastomosis either with the CAC or a stapler. To perform anastomosis with CAC, the 2 edges of the resected colon are aligned. Two 5-mm incisions are made close to the edges, through which (using a special applier) the CAC, after being cooled in ice water, is introduced in an open position. In response to the body temperature, the clip resumes its original (closed) position, thereby clamping the 2 bowel segments together. At the same time, a small scalpel incorporated in the applier makes a small incision through the clamped walls for the passage of gas and feces. The clip is detached from the applier to be left inside the intestine. The 2 5-mm incisions are sutured. The clip is expelled with the stool within 5 to 7 days, creating a perfect uniform compression anastomosis. RESULTS: Neither group had anastomotic complications such as leakage or obstruction. All the other parameters were better in the study group than in the control patients. CONCLUSIONS: The use of the CAC for colonic surgery is safe, simple, efficient, shortens operation time, and is almost what we call the "no-touch concept" in surgery and may decrease infection.

Treatment of rectal cancer by chemoradiation followed by surgery: analysis and early clinical outcome in 66 patients.

BACKGROUND: Abdominoperineal resection entails the need for a permanent colostomy, which significantly reduces patient self-image and quality of life. OBJECTIVE: To investigate the effectiveness of preoperative chemoradiation in increasing the resectability rates of rectal cancer and increasing the anal sphincter preservation rate. METHODS: The study group included 66 patients aged 33-84 years with T2-T3 rectal carcinoma who were treated in our institute from 1997 to 2002 with preoperative chemoradiation followed by surgery 6 weeks later. All patients underwent preoperative transrectal endoscopic ultrasound for tumor staging and localization. The duration of follow-up was 25 months. RESULTS: Chemoradiation led to tumor downstaging in 61 patients (92.4%), all of whom underwent low anterior resection. Only 11.4% of this group needed a temporary (6 weeks) loop colostomy/ileostomy. None of the 16 patients with post-treatment T0 tumors had evidence of malignant cells on pathologic study. Five patients (7.6%) failed to respond to chemoradiation and underwent APR. There were no major complications, such as leakage, and no deaths. CONCLUSIONS: Neoadjuvant chemoradiation is an effective modality to downstage advanced rectal cancer, improving patient quality of life by significantly reducing the need for a terminal permanent colostomy, or even a temporary one.

Laparoscopic repositioning of Heliogast gastric band after anterior slippage.

BACKGROUND: Gastric slippage is a well-described complication of gastric banding. The Heliogast band is equipped with a locking mechanism that enables its straightforward reopening and repositioning. Our experience with Heliogast band salvage after anterior slippage is reported. METHODS: The study sample comprised 418 consecutive patients who underwent 2-step laparoscopic gastric banding with the Lap-Band first (n=235) followed with the Heliogast band (n=183). Gastric slippage was diagnosed by symptoms of dysphagia and vomiting and was confirmed with Gastrografin swallow. Patients who did not respond to conservative treatment were laparoscopically reoperated. In the Heliogast group, the band was dissected free, unlocked, and repositioned. In the Lap-Band group, when reopening proved impossible, the band was removed with or without replacement. RESULTS: 10 patients (2.4%) underwent reoperation for anterior slippage, 5 with a Lap-Band (2.1%) and 5 with a Heliogast band (2.7%). Band repositioning was feasible in all 5 patients in the Heliogast group, but in only one of the patients in the Lap-Band group; in the others, the band was removed. Band repositioning was confirmed radiologically. No postoperative complications were recorded, and all patients were discharged on the first day after surgery. At a median 10 months' follow-up after Heliogast repositioning, all patients had satisfactory weight loss. CONCLUSION: Laparoscopic Heliogast band salvage after anterior slippage is comparatively simple and safe, with excellent postoperative results and no interference with continued weight loss. This constitutes an important means of management for the bariatric surgeon.

Colonic anastomosis with the nickel-titanium temperature-dependent memory-shape device.

BACKGROUND: This study was prompted by our successful experience with a compression anastomosis clip (CAC) in an animal model. METHODS: The study sample included 20 patients scheduled for colonic resections, of whom 10 underwent anastomosis with the CAC and 10 with staplers. RESULTS: Neither group had anastomotic or other complications, except for 1 patient in the CAC group in whom a subphrenic infected hematoma developed after left hemicolectomy with splenectomy. CONCLUSIONS: Our study demonstrates that this CAC is safe and simple to use, coming close to the "no touch surgery concept" and is of low cost compared with the staples used today.

Percutaneous transhepatic cholecystostomy: effective treatment of acute cholecystitis in high risk patients.

BACKGROUND: The mortality rate for cholecystectomy for acute cholecystitis in the elderly is 10% in low risk patients and increases threefold in high risk patients. Ultrasound-guided percutaneous transhepatic cholecystostomy may serve as a rapid and relatively safe tool to relieve symptoms of sepsis and decrease gallbladder distension. OBJECTIVE: To determine the safety and effectiveness of PTC in the treatment of acute cholecystitis in elderly debilitated high risk patients. METHODS: The study sample included 10 patients aged 63-88 (mean 77.6 years) with clinical and sonographic signs of acute cholecystitis for more than 48 hours (fever, white blood cells > 12,000/mm, positive Murphy sign and distended gallbladder) who underwent ultrasound guided PTC. All had severe underlying disease (coronary heart disease, renal failure, chronic obstructive pulmonary disease, and others) that places them at high risk for surgical intervention. RESULTS: Eight patients showed rapid regression of the clinical symptoms following PTC drainage. One patient with bacterial endocarditis was febrile for 5 days after catheter insertion, but with rapid resolution of the biliary colic and sepsis. One patient died from perforation of the gallbladder and small bowel. PTC catheters were withdrawn 3-25 days after the procedure and the patients remained free of biliary symptoms. Two patients underwent successful elective cholecystectomy 3 weeks later. CONCLUSION: PTC may be a safe and effective treatment for high risk elderly patients with acute cholecystitis. It can be followed by elective cholecystectomy if the underlying condition improves, as soon as the patient stabilizes and no sepsis is present, or by conservative management in high surgical-risk patients.

[Minimally invasive surgery for gastric cancer].

The use of laparoscopic surgery in the treatment of gastric cancer has not yet met with widespread acceptance. Hence, it should be regarded as still in the developmental phase. We present our experience with laparoscopic gastrectomy in four patients with gastric cancer during the last few months. The postoperative course was uneventful in all patients. It seems that although it remains a challenging procedure, laparoscopic gastrectomy should be considered as a possibility when planning this procedure.