Clinicopathological evaluation of anoxic mucosal injury in strangulation ileus.

BACKGROUND: In patients with strangulation ileus, the severity of bowel ischemia is unpredictable before surgery. To consider a grading scale of anoxic damage, we evaluated the pathological findings and investigated predictive factors for bowel gangrene. METHODS: We assessed 49 patients with strangulation ileus who underwent a laparotomy between January 2004 and November 2012. Laboratory tests and the contrast computed tomography (CT) were evaluated before surgery. According to the degree of mucosal degeneration, we classified anoxic damages into the following 3 grades. Ggrade 1 shows mild mucosal degeneration with extended subepithelial space. Grade 2 shows moderate degeneration and mucosal deciduation with residual mucosa on the muscularis mucosae. Grade 3 shows severe degeneration and mucosal digestion with disintegration of lamina propria. RESULTS: Resected bowel specimens were obtained from the 36 patients with severe ischemia, while the remaining 13 patients avoided bowel resection. The mucosal injury showed grade 1 in 11 cases, grade 2 in 10 cases, and grade 3 in 15 cases. The patients were divided into two groups. One group included grade 1 and non-resected patients (n = 24) while the other included grades 2 and 3 (n = 25). When comparing the clinical findings for these groups, elevated creatine kinase (P = 0.017), a low base excess (P = 0.021), and decreased bowel enhancement on the contrast CT (P = 0.001) were associated with severe mucosal injury. CONCLUSION: In strangulation ileus, anoxic mucosal injury progresses gradually after rapid spreading of bowel congestion. Before surgical intervention, creatine kinase, base excess, and bowel enhancement on the contrast CT could indicate the severity of anoxic damage. These biomarkers could be the predictor for bowel resection before surgery.

Long-term recovery of exercise capacity and pulmonary function after lobectomy.

OBJECTIVE: The objective of the present study was to perform longitudinal objective evaluations of recovery of exercise capacity based on expired gas analysis during exercise testing up to 1 year after pulmonary resection. METHODS: The study included 18 patients who underwent lobectomy. Expired gas analysis during exercise testing was conducted 1 week before surgery and 2 weeks, 1 month, 3 months, 6 months, and 1 year after surgery. The parameters studied included maximum exercise capacity based on expired gas analysis during exercise testing (maximum oxygen uptake per minute per square meter of body surface area) and assessment of moderate exercise capacity (anaerobic threshold per square meter of body surface area). The changes in postoperative data relative to the preoperative values (baseline) were assessed, including the percent changes from baseline data, which were arbitrarily given a value of 100. RESULTS: Maximum oxygen uptake per minute per square meter of body surface area decreased significantly to 78.6% +/- 14.2% of the baseline value at 2 weeks after surgery and was 80.3% +/- 12.7%, 90.9% +/- 15.9%, 90% +/- 19.7%, and 97% +/- 4.8% of the baseline value at 1, 3, and 6 months, and 1 year, respectively. Anaerobic threshold per square meter of body surface area reached 91.1% +/- 17.5% of the baseline value even 2 weeks after surgery and was 87.1% +/- 17.3%, 97.5% +/- 28.0%, 84.3% +/- 13.2%, and 104% +/- 16.2% of the baseline value at 1, 3, and 6 months, and 1 year, respectively. CONCLUSION: The extent of recovery of exercise capacity at 1 year after surgery was approximately 95%. Furthermore, the anaerobic threshold per square meter of body surface area was restored to the preoperative level by 1 year after surgery.

Expression of matrix metalloproteinases in wound healing after glaucoma filtration surgery in rabbits.

PURPOSE: To investigate the protein and mRNA expressions of matrix metalloproteinases (MMPs), gelatinolytic activity and localization of MMP activity in wounds after glaucoma filtration surgery in rabbits. METHODS: Sixty eyes of 30 rabbits were removed 1, 3, 7, 14 and 120 days after the surgery and used for this experiment. Protein and mRNA expressions were analyzed by immunohistochemistry and laser capture microdissection/real-time RT-PCR, respectively. The gelatinolytic activity was analyzed by gelatin zymography and the localization was studied using in situ zymography. RESULTS: By immunohistochemistry, expression of MMP-1, MMP-2, MMP-3, MMP-9 and MT1-MMP was detected in the wounds, most markedly 3 days after the surgery. MMP-positive cells were predominantly macrophages. Expression of MMP-9 and MT1-MMP mRNAs was verified by RT-PCR. Gelatinolytic activities corresponding to proMMP-2 and the active form of MMP-2 were detected in the wounds 3 and 7 days after surgery. In situ zymography localized gelatinolytic activities at the wound site. These activities were almost completely abolished by an MMP inhibitor, indicating that the gelatinolytic activity belongs to metalloproteinases. CONCLUSIONS: MMPs, particularly MMP-2/MT1-MMP, play important roles in the degradation of the extracellular matrix in the wound healing process after glaucoma filtration surgery and may represent an important target for therapeutic intervention after glaucoma filtration surgery.

Selection of pulmonary resection procedures to avoid postoperative complications.

PURPOSE: We previously found a potential predictive value in a retrospective analysis of spirometry and an expired gas analysis during the exercise. We sought to reduce postoperative cardiopulmonary complications by selecting lung tumor resection procedures based on a combination of specific preoperative cardiopulmonary function test results. METHODS: Out of the 53 patients requiring a lung tumor resection, five preoperative parameters (forced expiratory volume in 1 s for intact-side, maximal oxygen uptake, ejection fraction, occluded pulmonary artery pressure, and occluded total pulmonary vascular resistant index) were used to assign patients to one of five risk categories in order to select the optimal pulmonary resection procedure. The patients were later grouped according to their postoperative course to test the value of this procedure selection method. RESULTS: No patient died or developed severe complications after surgery. Five patients had mild complications, while 46 had a good postoperative course; the 13 deaths, in the cancer cases, included 11 from primary or metastatic cancer and 2 from other causes. The overall five-year survival was 61.4%. CONCLUSION: This method for determining a pulmonary resection procedure avoided postoperative deaths and severe cardiopulmonary complications, while achieving a good outcome.

Preoperative spirometry versus expired gas analysis during exercise testing as predictors of cardiopulmonary complications after lung resection.

PURPOSE: As cardiopulmonary load increases with the amount of lung resected, to perform surgery safely it is important to be able to predict cardiopulmonary insufficiency. However, lung function testing with spirometry and blood gas analysis does not accurately measure cardiopulmonary reserve. We conducted this study to evaluate expired gas analysis during exercise testing for predicting postoperative complications after lung resection. METHODS: Expired gas analysis during exercise and spirometry were done 1 week preoperatively in 211 patients who underwent pulmonary resection for lung cancer. Patients were divided postoperatively according to whether cardiopulmonary complications were absent (group A) or present (group B). RESULTS: In group B there were more men than women (P < 0.01), and the mean age was greater (P < 0.05). There was no difference in disease stage, but more patients underwent pneumonectomy in group B than in group A ( P < 0.005). The results of expired gas analysis during exercise testing and of spirometry showed that maximum oxygen uptake/m(2) (P < 0.0005), anaerobic threshold/m(2) (P < 0.01), vital capacity (VC)/m(2) (P < 0.005), %VC (P < 0.0001), forced expiratory volume in 1 s (FEV(1.0))/m(2) (P < 0.0001), and FEV(1.0%) (P < 0.05) were lower in group B than in group A. CONCLUSIONS: The combination of expired gas analysis during exercise and conventional pulmonary function tests identified patients at risk for postoperative cardiopulmonary complications following pulmonary resection.