A prospective, randomized comparison of pain, inflammatory response, and short-term outcomes between single port and laparoscopic cholecystectomy

Background

The purpose of this study was to compare the postoperative inflammatory response and severity of pain between single-incision laparoscopic surgery (SILS) cholecystectomy and conventional laparoscopic cholecystectomy (LC).

Methods

Two groups of 20 patients were prospectively randomized to either conventional LC or SILS cholecystectomy. Serum interleukin-6 (IL-6) levels were assayed before surgery, at 4–6 h, and at 18–24 h after the procedure. Serum C-reactive protein (CRP) levels also were assayed at 18–24 h after surgery. Pain was measured at each of three time points after surgery using the visual analogue scale (VAS). The number of analgesia doses administered in the first 24 h after the procedure also was recorded and 30-day surgical outcomes were documented.

Results

The groups had equivalent body mass index (BMI), age, and comorbidity distribution. Peak IL-6 levels occurred 4–6 h after surgery, and the median level was 12.8 pg/ml in the LC and 8.9 pg/ml in the SILS group (p = 0.5). The median CRP level before discharge was 1.6 mg/dl in the LC and 1.9 mg/dl in the SILS group (p = 0.38). There was no difference in either analgesic use or pain intensity as measured by the VAS between the two groups (p = 0.72). The length of the surgical procedure was significantly longer in the SILS group (p < 0.001). No intraoperative complications occurred in either group.

Conclusions

Single-incision laparoscopic surgery does not significantly reduce systemic inflammatory response, postoperative pain, or analgesic use compared with LC.     

Robotic-assisted laparoscopic prostatectomy (RALP): a new way to training

The implementation of RALP program is usually associated with a steep learning curve (LC). Fellows are proctored for few cases, with long operating times, inferior outcomes and an increased number of complications. We report the initial results of 100 RALP procedures performed in Rio de Janeiro, Brazil, with the implementation of a structured program. Our goal was to evaluate if our approach to training would yield a safer outcomes for patients undergoing the procedure during the LC. From October 2012 to January 2014, five surgeons began a training program in RALP. Each surgeon attended a certification course, wet lab, dry lab, didactic course and observed live cases. Each trainee performed 20 cases of RALP under supervision of an experienced preceptor. The median surgical time was 175 min [interquartile range (IQR) 141–180 min]. There were four complications Clavien II (4 %) and three Clavien IIIa (3 %), no conversions nor transfusions. The median estimated blood loss was 200 ml (IQR 150–300 ml). The median hospital stay was 2 days (IQR 1–2 days). The median catheterization time was 7 days (IQR 6–7 days). Overall positive surgical margin rate (PM) was 19 %; stage-specific PSM rates were 12 % in pT2 and 53 % in pT3. The biochemical recidive-free survival rate (PSA < 0.01 ng/ml) was 91 % over an average follow-up of 6 months. The continence rates were (no pad) 74 % within 3 months and 94 % within 6 months. The implementation of a training program with advanced precepting allowed us to overcome the initial LC with reasonable results and with minimal complications.     

Isolated mediastinal amyloidosis mimicking a neoplastic lesion

Isolated mediastinal amyloidosis is a rare condition. We report an unusual case of amyloid presented as an isolated mass, entirely confined within anterior mediastinum and FDG-avid, mimicking a neoplastic lesion. Because the differential diagnosis included several diseases as lymphoma, a biopsy via mediastinotomy was attended to avoid unnecessary sternotomy. The pathological results diagnosed to be an amyloidosis. The patient was asymptomatic and biopsy allowed an exact diagnosis, thus we decided against the complete excision. No monoclonal gammopathy and/or amyloid deposition were found. Thus, other treatments as high-dose melphalan and/or autologous stem cell transplantation were not indicated.     

Mutations in the HFE gene and their interaction with exogenous risk factors in hepatocellular carcinoma

The possible role of iron in facilitating the development of liver cancer is still debated. The aims of this study were to define the prevalence of the mutations 845G --> A and 187C --> G (C282Y and H63D) in the HFE gene associated with hereditary hemochromatosis in Italian patients with hepatocellular carcinoma occurring in cirrhosis and to analyze the interaction between these mutations and other established risk factors for hepatocellular carcinoma. The HFE gene mutations, performed by polymerase chain reaction, were analyzed in 81 patients (63 males, 18 females) with hepatocellular carcinoma. None of the patients had a phenotype compatible with homozygous hereditary hemochromatosis. Interaction between HFE mutations and exogenous risk factors was analyzed by collecting information on alcohol consumption, hepatitis B and C virus infections, and iron status at the time of diagnosis of chronic liver disease. This analysis was performed only in males to rule out gender influence on patients' iron status by using the case-only approach specifically designed to estimate departure from multiplicative risk ratios under the assumption of independence between genotype and environmental exposure. The prevalence of the C282Y mutation was significantly higher in patients with hepatocellular carcinoma than in normal controls (8.6% vs 1.6%, P < 0.03). At univariate analysis, iron overload was significantly associated with both HFE mutations (P < 0.0001), whereas ongoing hepatitis B virus infection was associated with the C282Y mutation (P < 0.05). By multivariate analysis, a trend for an increased risk of being positive for hepatitis virus markers (OR 2.9, CI 95% 0.9-9.5) and of having been alcohol abusers (OR 3, CI 95% 0.7-14) was observed in patients heterozygous for the HFE mutations. These data indicate that the prevalence of the main mutation associated with hereditary hemochromatosis is significantly higher in cirrhotic Italian patients with hepatocellular carcinoma compared to a normal population and suggest that heterozygotes for HFE mutations exposed to hepatitis virus infections or who had been alcohol abusers could have an increased risk of developing cirrhosis and later liver cancer than people without the mutations exposed to the same risk factors.     

Changes in erythropoiesis, iron metabolism and oxidative stress after half-marathon

OBJECTIVE: In marathon runners changes in red blood cell count, haematocrit and haemoglobin in relation to haemodilution have been reported. Moreover, it has been hypothesized that strenuous exercise induces oxidant stress through several different mechanisms. This study investigated the haematological variables, iron status and oxidative indices before, immediately and 48 h after a race in 8 healthy trained males aged 33-44 years running a 21-km marathon in 79 +/- 3 min. METHODS: The haematological parameters were determined by standard procedures. Erythropoietin and soluble-transferrin receptor were evaluated immunoenzymatically. Nontransferrin-bound iron (NTBI) was assayed by high-performance liquid chromatography after nitrilotriacetic acid chelation. Malonyldialdehyde (MDA) concentration was assayed colorimetrically. RESULTS: The total number of reticulocytes rose significantly after the run with a significant increase in the high-RNA-content fraction (14 +/- 5, p < 0.0006). Erythropoietin rose by 26% (15.0 +/- 2.8 mU/ml, p < 0.004) and by 25% (14.9 +/- 2.13 mU/ml, p < 0.02) immediately and 48 h after the race, respectively. Serum iron and serum ferritin remained unchanged but NTBI and serum MDA increased significantly immediately after running (1.16 +/- 0.40 mmol/l, p < 0.0008; 0.76 +/- 0.16 mmol/l, p < 0.0001). Significant positive correlations at any time between MDA and polymorphonuclear neutrophils (p = 0.0005), MDA and NTBI (p = 0.0018), polymorphonuclear neutrophils and NTBI (p = 0.0008) and between lactate dehydrogenase and NTBI (p = 0.0212) were observed. CONCLUSIONS: The erythropoietic changes observed in marathon runners are the results of several interacting mechanisms that involve either the haemopoietic system per se or erythrocyte haemolysis and oxidative stress.     

Trigeminal neuralgia and pain related to multiple sclerosis

Although many patients with multiple sclerosis (MS) complain of trigeminal neuralgia (TN), its cause and mechanisms are still debatable. In a multicentre controlled study, we collected 130 patients with MS: 50 patients with TN, 30 patients with trigeminal sensory disturbances other than TN (ongoing pain, dysaesthesia, or hypoesthesia), and 50 control patients. All patients underwent pain assessment, trigeminal reflex testing, and dedicated MRI scans. The MRI scans were imported and normalised into a voxel-based, 3D brainstem model that allows spatial statistical analysis. The onset ages of MS and trigeminal symptoms were significantly older in the TN group. The frequency histogram of onset age for the TN group showed that many patients fell in the age range of classic TN. Most patients in TN and non-TN groups had abnormal trigeminal reflexes. In the TN group, 3D brainstem analysis showed an area of strong probability of lesion (P < 0.0001) centred on the intrapontine trigeminal primary afferents. In the non-TN group, brainstem lesions were more scattered, with the highest probability for lesions (P < 0.001) in a region involving the subnucleus oralis of the spinal trigeminal complex. We conclude that the most likely cause of MS-related TN is a pontine plaque damaging the primary afferents. Nevertheless, in some patients a neurovascular contact may act as a concurring mechanism. The other sensory disturbances, including ongoing pain and dysaesthesia, may arise from damage to the second-order neurons in the spinal trigeminal complex.     

The iron status of Italian subjects with beta-thalassemia trait

Serum iron, transferrin saturation, serum ferritin and urinary iron excretion have been tested in a group of Italian subjects with beta-thalassemia trait. A number of these subjects, mostly men, had signs of increased iron load. Serum ferritin was the most sensitive index among those measured for detection of iron overload and was positively correlated with desferrioxamine-induced urinary iron excretion. Italian males with beta-thalassemia trait may be at high risk of developing iron overload even without prolonged iron or transfusional therapy.     

MicroRNAs miR-1, miR-133a, miR-133b, miR-208a and miR-208b are dysregulated in Chronic Chagas disease Cardiomyopathy

Background/methods

Chagas disease is caused by an intracellular parasite, Trypanosoma cruzi, and it is a leading cause of heart failure in Latin America. The main clinical consequence of the infection is the development of a Chronic Chagas disease Cardiomyopathy (CCC), which is characterized by myocarditis, hypertrophy and fibrosis and affects about 30% of infected patients. CCC has a worse prognosis than other cardiomyopathies, like idiopathic dilated cardiomyopathy (DCM). It is well established that myocardial gene expression patterns are altered in CCC, but the molecular mechanisms underlying these differences are not clear. MicroRNAs are recently discovered regulators of gene expression, and are recognized as important factors in heart development and cardiovascular disorders (CD). We analyzed the expression of nine different miRNAs in myocardial tissue samples of CCC patients in comparison to DCM patients and samples from heart transplant donors. Using the results of a cDNA microarray database on CCC and DCM myocardium, signaling networks were built and nodal molecules were identified.

Results

We observed that five miRNAs were significantly altered in CCC and three in DCM; importantly, three miRNAs were significantly reduced in CCC as compared to DCM. We observed that multiple gene targets of the differentially expressed miRNAs showed a concordant inverse expression in CCC. Significantly, most gene targets and involved networks belong to crucial disease-related signaling pathways.

Conclusion

These results suggest that miRNAs may play a major role in the regulation of gene expression in CCC pathogenesis, with potential implication as diagnostic and prognostic tools.