Primary colonic lymphoma: report of two cases

Primary colonic lymphoma is a rare condition. It may be associated with immunosuppressed states and inflammatory bowel disease. The pattern of presentation is not specific, this leads to lengthy in diagnosis. Authors report two personal cases and discuss the problem of diagnosis. Surgery followed by adjuvant chemotherapy is the standard treatment. Using this approach 5-years survival ranges from 27-55%.     

Ultradian ghrelin pulsatility is disrupted in morbidly obese subjects after weight loss induced by malabsorptive bariatric surgery

BACKGROUND: Suppression of ghrelin production after Roux-en-Y gastric bypass that suggested its contribution to appetite reduction has been reported. OBJECTIVE: Because biliopancreatic diversion (BPD) does not affect appetite, we compared ghrelin production and 24-h pulsatility between healthy control subjects and obese subjects before and after BPD. DESIGN: A computerized algorithm identified peak heights, clearance rate, and peak frequency of ghrelin over 24 h. Twenty-four-hour energy expenditure was measured in the calorimetric chamber, and energy intakes were computed. Insulin sensitivity was measured with a euglycemic-hyperinsulinemic clamp. RESULTS: Mean (+/-SD) 24-h plasma ghrelin concentrations were significantly (P < 0.0001) higher in control than in obese subjects (338.17 +/- 22.09 and 164.47 +/- 29.19 microg/L, respectively), but they increased to 204.64 +/- 28.51 microg/L in the obese subjects after BPD (P < 0.01). The pulsatility index was 0.098 +/- 0.016 and 0.041 +/- 0.014 microg . L(-1) . min(-1) in control and obese subjects, respectively (P < 0.01), and decreased to 0.025 +/- 0.007 microg . l(-1) . min(-1) after BPD (P < 0.05). Energy intakes before and after BFP did not differ significantly. Although metabolizable energy after BPD was 40% of the energy intake, that (per kg fat-free mass) after BPD did not different significantly from that before BPD. CONCLUSIONS: Weight loss induced by malabsorptive bariatric surgery is associated with greater ghrelin concentrations, which, however, remain consistently lower than those in control subjects, whereas ghrelin pulsatility is subverted. Higher ghrelin concentrations may contribute to the high calorie intakes observed in post-BPD subjects. The lack of normal pulsatility may explain the new impulse of these subjects to eat very frequently.     

The lost gallstone

Laparoscopic cholecystectomy has become the treatment of choice for most patients with gallstones. During this procedure it is not uncommon for the gallbladder to be entered inadvertently, spilling gallstones freely into the peritoneal cavity. Finding and removing all of the spilled gallstones can be difficult and time consuming. The natural history of stones left in the peritoneal cavity, outside the gallbladder, bile ducts, or intestine, is not known.This is a case report of a complication related to several gallstones left in the peritoneal cavity after laparoscopic cholecystectomy. An abscess developed around them, which necessitated the drainage of purulent exudate from the right flank 8 months postoperatively. The abscess and sinus tract did not heal until the stones were removed. If possible, all stones should be removed during laparoscopic cholecystectomy to forestall the development of this type of complication.     

Surgical treatment of T3 lung cancer invading the chest wall

Lung tumors invading the chest wall are classed as belonging to the T3 group and are considered potentially resectable. Their management, however, is controversial, and extrapleural resection, when possible, is preferred to en bloc resection which is regarded as a far more invasive and dangerous operation. Five year survival rates for completely resected cases range in the literature from 25 to 35%, but survival rates are much worse if lymph node metastases are present. These poor outcomes have prompted the development of combined surgical approaches: preoperative radiation therapy, with or without chemotherapy, has been used with an improvement in resectability rates, but only modest results in terms of median survival; in a number of case series, increased operative morbidity and mortality have been reported with this approach. The present report relates to 122 patients treated by en bloc (20 cases) or extrapleural (102 cases) resection, 31 of whom also received neoadjuvant treatment. The operative mortality was 4.6%. Median survival was 17 months after en bloc resection and 19 months after extrapleural resection. Though no statistically significant difference was found, extrapleural resection would appear to yield better results than the en bloc procedure.     

Lymphadenectomy in the surgical treatment of bronchogenic carcinoma

Bronchogenic carcinoma is one of the tumors with the statistically most markedly rising incidence, at least in western countries. For many years both the resectability and the long-term results have remained invariable due to the serious delay with which the disease is usually diagnosed. In addition, the success of treatment appears to be closely correlated with disease stage; in particular lymph node involvement has a major influence on the long-term survival following adequate treatment. As a consequence, a strong conviction has established itself in recent years, that radical removal of all mediastinal lymph node stations ipsilateral to the operated lung represents not only a necessary staging procedure, but also a useful measure to improve the prognosis of these patients. However, the real utility of radical lymphadenectomy is questioned by a number of groups: on the one hand the supporters of lymph node "sampling", inasmuch as the usefulness of radical lymphadenectomy has not been demonstrated by randomized clinical trials; on the other hand those workers, in particular from Japan, who on the basis of observations of the lymphatic flow in the mediastinum stress the necessity to extend lymph node clearance to the nodal station contralateral to the tumor. The current opinion is changing under the influence of recent developments, for instance the possible use of the sentinel technique also in lung cancer, and the possibility of "reasonable" or targeted lymphadenectomies, planned in relation to the lobar location of individual tumor. Whichever of these approaches is chosen--and this choice is still a matter of debate--many agree about the importance of neoadjuvant treatment not only to render patients eligible for surgery but also to improve the prognosis for patients at the most advanced stages of the disease.     

Normalization of Insulin Sensitivity in the Obese Patient after Stable Weight Reduction with Bilio-Pancreatic Diversion

Insulin resistance is a common feature in obese patients. To evaluate the modifications in insulin sensitivity after a bariatric operation such as Bilio-pancreatic diversion (BPD), three groups of subjects (14 normal controls (N); seven eX-obese patients (X) with at least 2 years at weight-stable conditions after BPD surgery; and eight morbidly obese patients (O)) were studied with intravenous (IVGTT) and oral (OGTT) glucose tolerance tests. The ratio of the area under the curve (AUC) for glucose over that of insulin was used as a measure of insulin sensitivity. All the following tests were conducted as Bonferroni-corrected pairwise t-tests, in case overall ANOVA was significant. No significant difference was found between N and X subjects, while obese patients showed a reduced AUCg/AUCi ratio with respect to the normal controls (O vs N: 0.01164 ± 0.00039 vs 0.02392 ± 0.0039, p < 0.05). IVGTT, AUCs: significant differences were found in each case: N vs X: 0.0591 ± 0.0075 vs 0.1402 ± 0.0399, p < 0.05; N vs O: 0.0591 ± 0.0075 vs 0.0223 ± 0.0031, p < 0.01; X vs O: 0.1402 ± 0.0399 vs 0.0223 ± 0.0031, p < 0.05. IVGTT-derived data were also analyzed using the minimal model of glucose kinetics; with this method, glucose effectiveness was significantly different between normal subject and obese subjects (0.0248 ± 0.00288 vs 0.00905 ± 0.00135 per min, p < 0.001). The insulin sensitivity index was not significantly different between normal and ex-obese subjects, while both of these groups were significantly different from obese patients (N vs O: 12.04 × 10⁻⁵ ± 2.61 × 10⁻⁵ vs 3.29 × 10⁻⁵ ± 0.61 × 10⁻⁵, p < 0.066; X vs O: 16.42 × 10⁻⁵ ± 4.23 × 10⁻⁵ vs 3.29 × 10⁻⁵ ± 0.61 × 10⁻⁵ per min per pM, p < 0.02). In conclusion, the present study indicates that, after a body weight reduction operation capable of almost re-establishing ideal body weight like BPD, obese individuals with a family history of obesity show a normalization of insulin response to glucose load.     

Prevention of pin track infection in external fixation with silver coated pins: clinical and microbiological results

Pin tract infection is a frequent complication of external fixation; according to literature its frequency ranges from 2-30%. The recent introduction of silver coating of polymeric materials was found to decrease bacterial adhesion; its clinical use with Foley catheters and central venous catheters led to significant results. To verify the ability of the same silver coating to decrease the bacterial colonization on external fixation screws, a prospective randomized study was carried out on 24 male patients; a total of 106 screws were implanted in the lower limb to fix femoral or tibial diaphyseal fractures: 50 were coated with silver and 56 were commercially available stainless steel screws. Although the coated screws resulted in a lower rate of positive cultures (30.0%) than the uncoated screws (42.9%), this difference was not statistically significant (p = 0.243). The clinical behavior of the coated screws did not differ from that of the uncoated ones. Furthermore, the implant of silver-coated screws resulted in a significant increase in the silver serum level. These results led us to consider it ethically unacceptable to continue this investigation.