Photodynamic therapy for the treatment of complex anal fistula.

BACKGROUND: Photodynamic therapy (PDT) is a new procedure for the treatment of anal fistula. This preliminary study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula. METHODS: Ten patients were treated with PDT. Intralesional 5-aminolevulinic acid (ALA) 2% was directly injected into the fistula. The internal and external orifices were closed. After an incubation period of 2 h, the fistula was irradiated using an optical fibre connected to a red laser (MULTIDIODE 630 PDT, INTERmedic, Spain) operating at 1 W/cm for 3 min (180 Joules). Patient demographics, operation notes and complications were recorded. RESULTS: There were no complications. The average length of patient follow-up was 14.9 months (range 12-20 months). We could observe primary healing in eight patients (80%). Two patients (20%) showed persistence of suppuration after the operation. No patient reported incontinence postoperatively. CONCLUSIONS: PDT is a potential sphincter-saving procedure that is safe, simple and minimally invasive and has a high success rate.

Changes in P-glycoprotein expression in gastric carcinoma with respect to distant gastric mucosa may be influenced by p53.

BACKGROUND: The effectiveness of some chemotherapeutic agents used to treat gastric carcinoma patients may be impaired by the presence of P-glycoprotein (P-gp) and the status of p53. A modulation of P-gp expression by p53 or other alterations during tumorigenesis have been reported. The authors analyzed P-gp expression in relation to p53 and histopathologic features in gastric carcinoma. METHODS: Forty-one resected gastric carcinomas and mucosa distant from the tumor were assessed for P-gp expression by immunohistochemistry with C494 and JSB-1 antibodies. p53 expression was also immunohistochemically assessed by DO7 antibody in tumor samples. P-gp and p53 expression were semiquantitatively analyzed according to the percentage of stained cells. Histologic type, grade, vessel invasion, and stage were also studied. RESULTS: Moderate or high P-gp expression was detected in gastric carcinoma in 29 cases (71%) and in gastric mucosa remote from the tumor in 36 cases (88%). This reduction in P-gp expression was observed in 22% of the carcinomas, all but 1 being p53 immunonegative tumors. Thus, 8 (42%) of the p53 immunonegative carcinomas showed a loss of P-gp expression compared with their distant gastric mucosa. All p53 immunopositive carcinomas coexpressed P-gp. No correlation between P-gp expression and histologic type, grade, vessel invasion, or stage was found. CONCLUSIONS: P-gp expression in gastric carcinomas is frequent and coexpression with p53 is found. The analysis of P-gp expression in carcinomas and distant mucosa show that it is not regulated by p53, but a loss of P-gp detected in some of these carcinomas is mainly associated with a lack of p53 protein accumulation.

Comparative study of two androgen-induced markers (apolipoprotein D and pepsinogen C) in female and male breast carcinoma.

BACKGROUND: Male breast cancer (MBC) is a rare tumor in comparison to the same disease in the female population (FBC). Classical prognostic factors (tumor size, node status, estrogen receptor positivity, histological grade) have a similar prognostic value in both tumors, but MBC seems to have a worse outcome. Several markers under estrogen control have been shown with a similar incidence in breast tumors of both sexes, while androgen-induced markers have been detected in a higher percentage of breast tumors in males. AIMS AND METHODS: Our purpose was to compare in 68 MBC and in 68 FBC the expression of Pepsinogen C (Pep C) and Apolipoprotein D (Apo D), two proteins under androgen control, by immunohistochemical methods. RESULTS: Pep C was expressed by 52 of 68 (76.4%) MBC patients, whereas 34 of 68 (50%) FBC showed positive staining. Apo D was expressed by 57 of 68 (83.8%) MBC patients, while 40 of 68 (41.2%) FBC stained positively. Differences between percentages of positive expression were significant (p<0.005 for Pep C; p<0.0001 for Apo D). Moreover, differences between expression levels of Pep C and Apo D in both populations of patients were significant. The mean value of Pep C was significantly higher in male breast tumors (HSCORE = 141.3) than in the females (HSCORE = 80.3) (p<0.0001). Similarly, Apo D mean value was significantly higher in MBC (HSCORE = 161.5) than in FBC (HSCORE = 102.3) (p=0.006). CONCLUSION: These differences can open the field of a more selective hormonal therapy that should not be based on estrogen receptor status only, but also on androgen receptor status.

Expression of pepsinogen C in gynecomastias and male breast carcinomas.

Pepsinogen C is a proteolytic enzyme involved in the digestion of proteins in the stomach; it is also synthesized by a significant percentage of female breast carcinomas. In addition, it has been demonstrated that pepsinogen C is one of the few proteins induced by androgens in breast carcinoma cells. Here we evaluate the expression of pepsinogen C by immunoperoxidase staining in normal breast tissue from 3 male patients, 15 gynecomastia tissues, 2 male in situ breast carcinomas, and 68 male invasive breast carcinomas. Pepsinogen C immunostaining values were quantified in male breast tumors using the HSCORE system, which considers both the intensity and the percentage of cells staining at each intensity. The results indicated positive immunohistochemical staining for pepsinogen C in all gynecomastia tissues, the two in situ ductal carcinomas, and 52 of 68 invasive breast carcinomas (76.4%). The three normal breast tissues analyzed showed negative staining for pepsinogen C, whereas invasive tumors showed clear differences among them with regard to the intensity and percentage of staining cells. In addition, pepsinogen C scores were significantly higher in well-differentiated (grade I, 188.7) and moderately differentiated (grade II, 145.8) tumors than in poorly differentiated (grade III, 98.5) tumors (p = 0. 032). Similarly, significant differences in pepsinogen C content were found between estrogen receptor (ER)-positive tumors and ER-negative tumors (158.5 vs. 44.3, respectively; p = 0.009). Patients with pepsinogen C-positive tumors reached longer relapse-free and overall survival periods than did those with tumors with negative staining, but no statistical differences were observed between survival curves calculated for these two groups of patients. This results demonstrate expression of pepsinogen C by gynecomastias and by a high percentage of male breast carcinomas and may indicate an important role of pepsinogen C in the pathophysiology of male breast diseases.

Detection of P-glycoprotein in frozen and paraffin-embedded gastric adenocarcinoma tissues using a panel of monoclonal antibodies.

AIMS: Most chemotherapeutic regimens used against gastric carcinoma include anthracyclines whose effectiveness can be impaired by the presence of P-glycoprotein. In order to obtain a reliable pattern of P-glycoprotein expression in these tumours an immunohistochemical study using a panel of anti-P-glycoprotein antibodies was performed in frozen and paraffinized tissues. METHODS AND RESULTS: Frozen and paraffinized samples from 25 gastric carcinomas were immunohistochemically analysed using a panel of four anti-P-glycoprotein monoclonal antibodies including C219, MRK16, JSB-1 and C494. Semiquantitative analysis indicated that moderate or high P-glycoprotein levels were detected in 40% to 76% of gastric adenocarcinomas, depending on the anti-P-glycoprotein antibody used. The antibody C494 was the most sensitive in detecting P-glycoprotein in both frozen and paraffinized gastric carcinoma samples. Moreover, C494 showed a pattern of staining exclusively associated with the plasma membrane, in contrast to the cytoplasmic with reinforcement of plasma membrane pattern displayed by the other three antibodies. Significant differences in P-glycoprotein levels were obtained when C494 and MRK16 were used in frozen tissues. Finally, detection of P-glycoprotein in frozen samples did not improve when compared to paraffinized ones. CONCLUSIONS: It appears that P-glycoprotein is frequently expressed in gastric adenocarcinomas, and the use of C494 complemented by JSB-1 is recommended for reliable detection of P-glycoprotein in this neoplasm.

[An experimental study of the efficacy of politetrafluoroethylene grafts in tracheal surgery]. / Estudio experimental de la eficacia de injertos de politetrafluoroetileno en cirugía traqueal.

We studied the efficacy of polytetrafluoroethylene (PTFE) grafts in the surgical correction of extensive tracheal defects in rabbits. Results showed anastomotic stenosis in 100% of the animals after primary reconstruction when a total of six complete rings were resected. We did not appreciate tracheal stenosis in no animal when we applied a PTFE prosthesis placed around the anastomotic site. Results were not satisfactory upon repairing partial tracheal defect by means of a spindle of PTFE prosthesis. We concluded that the external tutor is useful for the surgical correction of the tracheal stenosis induced after resection of six rings in the cervical tracheal of the animal.

Study of pancreatic secretion after subtotal gastrectomy followed by different methods of reconstruction.

To study the effect subtotal gastrectomies have on exocrine pancreatic function, 12 dogs were prepared with gastric and duodenal cannulas using a modified technique of Thomas. In our study protocol, we collected pancreatic juice by selective ductal cannulation after having applied two types of stimulation [tryptophan intraduodenally together with secretin intravenously (i.v.) and cholecystokinin i.v. together with secretin i.v.]. Our results did not show a significant increase in pancreatic juice after performing the gastrectomies. In both cases the concentration of bicarbonate decreased significantly in contrast to that in the control group. After Billroth I anastomosis, however, a significant decrease in the first periods of stimulation in relation to the gastrojejunostomy was appreciated. In the case of proteins, a loss of the dose/effect relation in these parameters was seen only after Billroth II anastomosis.

Effect of atropine and truncal vagotomy on the exocrine pancreatic function in dogs stimulated with intraduodenal tryptophan.

The purpose of this experimental study was to analyze the effect of different doses of atropine and bilateral transthoracic truncal vagotomy on pancreatic secretion. We chose the dog as our experimental model and used the modified Thomas method to obtain gastric juice, removing the gastric acid with a gastric cannula. An additional duodenal cannula was used for the selective intubation of the greater pancreatic duct in order to obtain pure pancreatic juice. To stimulate pancreatic secretion the pancreas was stimulated with intravenous secretin at a constant dose and intraduodenal tryptophan at gradually increasing doses. The juice was collected at 10-min intervals and volume, output of bicarbonate and protein were determined. The results obtained show that low doses of atropine (0.65, 1.25 and 5 micrograms/kg/h) strengthen the suppressive effect of truncal vagotomy on the hydrobicarbonate secretion. Greatest suppression was found in the highest dosage of atropine in response to the intraduodenal tryptophane at gradually increasing doses. The above results suggest the possible existence of local enteropancreatic cholinergic reflexes that are readily suppressed by atropine and vagotomy. Suppression is not global though, since there is no significant reduction in the pancreatic protein secretion, which shows a dosage-effect curve in response to the gradually increasing doses of intraduodenal tryptophan released by the action of endogenous cholecystokinin. Our hypothesis is that there exists a nonvagal enteropancreatic cholinergic reflex.

Gastric carcinoma: study of the most eminent prognostic factors.

In order to analyse some prognostic factors in relation to gastric cancer, 218 patients were included in a prospective protocol at 'Hospital General de Elche' (Spain) with a follow-up of 100%. Survival curves were calculated using Kaplan-Meier analysis and compared using the log-rank test. The number of patients who underwent resection was 122 (63.5%). In 70 cases (36.5%) the resection was not possible. The postoperative mortality was 4.9%. In the survival of patients with gastric cancer we find the following prognostic factors are significant: age, tumour site, macroscopic type, depth of gastric wall affection, presence of lymph nodes, staging, resectability and surgical intention (curative vs palliative).

[Metabolic disorders in the gastrectomized patient]. / Estudio de los trastornos metabólicos en el enfermo gastrectomizado.

The present study attempts on one hand to study the metabolic disorders which may present themselves in the gastrectomized patient, such as the malabsorption of fat, vitamin B12, folic acid and iron as well as the possible correlation between steatorrhea and the presence of exocrine pancreatic insufficiency. For this purpose a group of 71 patients have been studied who have undergone a subtotal gastrectomy (70.42%) or total (29.58%) in the General Surgery Services of Elche. The results obtained show the presence of ferropenic or megaloblastic anemia in 61.97% of the group, serious steatorrhea in only 3 patients (4.22%) and calciumphosphorous metabolism alterations appeared in 21.13%. With this we conclude that anemia is the most frequent ferropenic alteration in the gastrectomy patient; steatorrhea does not seem to be produced exclusively by the presence of exocrine pancreatic insufficiency and bone alterations in the gastrectomized patient appear in an insidious manner, being more a question of biochemical alterations than actual clinical lesions.

[Immuno-nutritional prognostic factors in acute cholecystitis]. / Estudio de factores pronósticos inmunonutricionales en la colecistitis aguda.

A set of parameters that could be used to identify possible immunonutritional disturbances and serve as clinical evolution markers were measured in 210 patients diagnosed of acute cholecystitis (136 females and 74 males, 64.8 and 35.2% respectively) who were admitted into the Surgery Service of the Hospital General de 1++Elche. The prognostic evaluation indices were: a) Nutritional: hematocrit, hemoglobin, total protein, albumin, transferrin; b) Immunological: total lymphocytes and delayed hypersensitivity reaction test. The results obtained were analyzed and compared to those of the literature in this field.

[Bacteriologic findings as a prognostic factor in the course of acute cholecystitis]. / Hallazgos bacteriológicos como factor pronóstico en la evolución de la colecistitis aguda.

We made a bacteriological study of bile in a consecutive study of 210 patients studied in the General Surgery Department of the General Hospital of Elche (Spain) who underwent cholecystectomy for acute lithiasic cholecystitis, as a prognostic factor in the clinical evolution of these patients. The results obtained led us to the following conclusions. 1. The presence of positive bile culture is a risk factor predisposing to postoperative septic complications. 2. Bile cultures were more frequently positive in patients over 60-years-old. 3. In the early stages of the disease, positive cultures were more frequent. 4. The organism most often isolated was E. coli, so antibiotic treatment should be directed mainly against this agent.