A possible protocol for postoperative management in laparoscopic cholecystectomy

The goal of the "Prospect" programme (sponsored by Pfizer) is to create possible evidence-based protocols related to the management of postoperative pain after certain type of surgical intervention (e.g. hernia repairs, hysterectomies, etc.). This article is introducing the protocol for laparoscopic cholecystectomy for both day-case and longer hospital admission cases. The protocol is designed for preoperative, intra and postoperative period, choosing only those measures which were effective for postoperative pain, published in the literature. We are also presenting an analyze of our 13,000 laparoscopic cholecystectomies, from "Prospect" protocol point of view, and what we should do to improve the management of postoperative pain.     

Evidence that total extract of Hypericum perforatum affects exploratory behavior and exerts anxiolytic effects in rats

Clinical trials have extensively reported the ability of Hypericum perforatum extracts to exert a significant antidepressant activity. Hypericin, the main constituent of H. perforatum extract, is no more regarded as the active principle of the antidepressant activity of the drug. Hence, the question of which constituents are involved in the basic activity of the total extract, is still waiting for an answer. In the present study we focused our attention on the potential anxiolytic activity of H. perforatum total extract, and of some pure components such as protohypericin and a fraction containing hypericin and pseudohypericin. Herein we report that the total extract of H. perforatum increases the locomotor activity in the open field and exerts anxiolytic activity in the light-dark test, whereas the single components did not show any effect. Interestingly, the anxiolytic activity of the total extract was blocked by pretreatment of rats with the benzodiazepine antagonist Flumazenil, hence suggesting an implication of benzodiazepine receptor activation in the anxiolytic effect of H. perforatum extract. Electrophysiological studies, performed to gain more information on the mechanism of action, showed that hypericin reduced the GABA-activated chloride currents, while pseudohypericin did an opposite effect. Furthermore, both hypericin and pseudohypericin inhibited the activation of NMDA receptors.     

Gastrojejunocolic fistula--a rare complication of stomach surgery

The gastrojejunocolic fistula represents a clinical entity that occurs very rarely following gastro-jejunal anastomoses and manifests itself clinically and paraclinically by a severe malabsorption syndrome. The results of the physiopathological approach may be summed up as follows: reduced level of seric proteins, fluid and electrolytic depletion, deficiencies in the absorption of the vitamins soluble in fats and water, which may all vary from mildness to severeness, depending on the flow rate of the fistula. Most often, the diagnosis is set by performing barium enema, which is positive for all cases, whereas the barium passage is less efficient, enabling diagnosis in only 33% of the cases. The radiological image may be reduced on principle to one single sign: the abnormal fistulous trajectory (barium passes from the stomach directly into the colon or the enema fills the gastric lumen). It is recommended that surgical treatment be performed in a single stage, by resecting the entire fistula and re-establishing the gastro-jejunal and colic continuity. We report a case of gastrojejunocolic fistula in a patient that underwent 2/3 gastric resection for gastric ulcer 9 years ago.     

Gastrojejunocolic fistula: report of six cases and review of the literature

Six gastrojejunocolic fistulae were recorded at our service between 1995-2005. All the fistulae occurred in men who had gastric resection performed for duodenal ulcer. METHOD: Diarrhea, weight loss, postprandial pain and fecal breath were the clinical findings present in descending frequency. Preoperative diagnosis was possible in 5 patients by endoscopy and barium contrast studies. In five patients the option was a one-stage procedure with revision gastrectomy and segmental resection of the transverse colon. In one case simple dismantling of the fistula was performed. RESULTS: Although in two patients anastomotic leakage developed no mortality was recorded.     

Nongenomic regulation of glutamatergic neurotransmission in hippocampus by thyroid hormones

Thyroid hormones (THs) are well known for their genomic effects but recently attention has focused also on their nongenomic actions as rapid modulators of membrane receptors. Here we show that thyroxine (T4) and 3,3',5'-l-triiodothyronine (T3) rapidly decrease N-methyl-d-aspartate (NMDA)-evoked currents in rat hippocampal cultures with potency in the micromolar range. The effect is not mediated by glutamate or glycine binding sites as an increase in agonist or glycine concentration does not alter TH potencies. Furthermore THs' effect on NMDA receptors is independent of voltage and of subunit composition. The mechanism of THs' antagonistic effect does not involve PKC phosphorylation of NMDA receptors since neither blocking nor stimulating PKC changed THs' modulation. T3, but not T4, inhibits also kainate-evoked currents in hippocampal neurons in culture. In hippocampal pyramidal neurons in slice, T3, but not T4, significantly reduced the frequency of miniature excitatory postsynaptic currents (mEPSCs) without affecting their amplitude and decay. In cultured rat cortical neurons THs prevented glutamate-induced neuronal death at concentrations similar to those effective on glutamatergic receptors. Taken together our data show for the first time that THs can rapidly affect ionotropic glutamatergic receptors in hippocampal neurons, an effect that could have an important role in their modulation of brain function in physiological and pathological states.     

Influence of recombinant gamma-aminobutyric acid-A receptor subunit composition on the action of allosteric modulators of gamma-aminobutyric acid-gated Cl- currents.

gamma-Aminobutyric acid (GABA)-activated Cl- currents in neonatal rat cortical neurons and in cultured cells engineered for the expression of specific molecular forms of the GABAA receptor alpha, beta, and gamma subunits, were recorded with the patch-clamp technique in the whole-cell configuration. The effects of various allosteric modulators of GABAA receptors were determined. Diazepam and clonazepam showed greater efficacy as positive modulators of GABA-elicited currents in alpha 2 beta 1 gamma 2 or alpha 3 beta 1 gamma 2 receptors than in alpha 1 beta 1 gamma 2 or alpha 5 beta 1 gamma 2 receptors or in cortical neurons. Alpidem was more efficacious at alpha 1 beta 1 gamma 2 or alpha 2 beta 1 gamma 2 receptors than at alpha 1 beta 1 gamma 2 or alpha 5 beta 1 gamma 2 receptors or in cortical neurons. Conversely, zolpidem was equally efficacious for all these receptors except for alpha 5 beta 1 gamma 2. Both imidazopyridines (alpidem and zolpidem) were virtually ineffective at modulating the GABA response of alpha 5 beta 1 gamma 2 receptors and in almost all the receptors assembled from alpha 1, alpha 2, alpha 3 or alpha 5 subunits together with beta 1 and gamma 1 subunits. The beta-carboline derivatives methyl-6,7-dimethoxy-4-ethyl-beta-carboline-3-carboxylate (DMCM) and methyl-beta-carboline-3-carboxylate (beta-CCM) elicited a positive allosteric modulation of alpha 1 beta 1 gamma 1 or alpha 2 beta 1 gamma 1 receptors, whereas they acted as negative allosteric modulators at nearly all other receptors tested, as they do in cortical neurons. Although the positive allosteric modulation by beta-carbolines never exceeded a doubling of the GABA response, DMCM was more efficacious at alpha 1 beta 1 gamma 1 receptors and beta-CCM was more efficacious at alpha 2 beta 1 gamma 1 receptors. DMCM was inactive at alpha 3 beta 1 gamma 1 receptors, whereas beta-CCM was virtually inactive at alpha 5 beta 1 gamma 1 receptors. The benzodiazepine 4'-chlorodiazepam, which is a negative modulator resistent to flumazenil inhibition, acted at all the various GABAA receptors that contained a gamma subunit.     

Treatment of recurrent genital prolapse by the abdominal approach. Apropos of a series of 92 cases surgically treated with prosthetic material

Over a period of 16 years, 92 patients presenting recurrent genital prolapse, following one or several surgical interventions, were operated on via the abdominal route with the insertion of prosthetic material. The current technique used consists of promonto-fixation of the cervix using 2 Mersylene* bands, combined in the majority of cases with a retropubic colopopexy. The anatomical failure rate was 9.2% after a mean follow up of 6.7 years. Morbidity associated with this surgical technique was low: no septic or occlusive complications were noted. This technique provides a satisfactory and long lasting solution, both anatomically and functionally, to the delicate surgical problem of recurrent genital prolapse.