Liver Resection: Prolonged Inflow Occlusion in Human Cirrhotic Livers

To evaluate the tolerance of the cirrhotic liver to extended warm ischaemia, 47 patients with cirrhosis who underwent liver,resection over a 4-year period were studied retrospectively. Three groups of patients were identified. In group 1 (14 patients) liver resection was performed under conditions of portal triad occlusion ranging from 50 to 75 (mean 57.1) min. Group 2 (12 patients) was treated with portal occlusion for a period ranging from 30 to 42 (mean 33.1) min. Group 3 comprised 21 patients who underwent hepatectomy using conventional techniques. Mean blood loss was significantly reduced by portal triad occlusion (819 ml in group 1,523 ml in group 2) compared with the conventional techniques (1652 ml in group 3) (P<0.05, group 1 versus group 3; P<0.01, group 2 versus group 3). Hospital death occurred in three of the 21 patients in group 3 but in no patient who underwent portal triad occlusion. The morbidity rate was lower in the two occlusion groups (four of 26 patients) than in group 3 (six of 21). Bilirubin metabolism was substantially better after surgery in the occlusion groups (P<0.05, groups 1 and 2 versus group 3 at day 14). Although the serum levels of transaminases were significantly raised until day 3 in patients undergoing long term occlusion, the cirrhotic liver withstood the ischaemia-reperfusion insult, as assessed by changes in hepatic microcirculation, lipid peroxidation and the morphology of hepatic sinusoids. It is concluded that prolonged ischaemia during liver resection can be sustained in patients with cirrhosis and without high-risk factors

Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study

ABSTRACT: INTRODUCTION: Ventilator-associated pneumonia (VAP) is usually caused by aspiration of pathogenic bacteria from the oropharynx. Oral decontamination with antiseptics, such as chlorhexidine (CHX) or antibiotics, has been used as prophylaxis against this complication. We hypothesised that the probiotic bacteria Lactobacillus plantarum 299 (Lp299) would be as efficient as CHX in reducing the pathogenic bacterial load in the oropharynx of tracheally intubated, mechanically ventilated, critically ill patients. METHODS: Fifty critically ill patients on mechanical ventilation were randomised to either oral mechanical cleansing followed by washing with 0.1% CHX solution or to the same cleansing procedure followed by oral application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and at defined intervals thereafter. RESULTS: Potentially pathogenic bacteria that were not present at inclusion were identified in oropharyngeal samples from eight of the patients treated with Lp299 and 13 of those treated with CHX (p = 0.13). Analysis of tracheal samples yielded similar results. Lp299 was recovered from the oropharynx of all patients in the Lp299 group. CONCLUSIONS: In this pilot study, we found no difference between the effect of Lp299 and CHX used in oral care procedures, when we examined the effects of those agents on colonisation of potentially pathogenic bacteria in the oropharynx of intubated, mechanically ventilated patients

Adhesion of the probiotic bacterium Lactobacillus plantarum 299v onto the gut mucosa in critically ill patients: a randomised open trial

INTRODUCTION: To achieve any possible positive effect on the intestinal mucosa cells it is important that probiotics adhere tightly onto the intestinal mucosa. It has been shown in healthy volunteers that Lactobacillus plantarum 299v (Lp 299v) (DSM 9843), a probiotic bacterium, given orally in a fermented oatmeal formula adheres onto the intestinal mucosa, but whether this also occurs in critically ill patients is unknown. METHODS: After randomisation, nine enterally fed, critically ill patients treated with broad-spectrum antibiotics received an oatmeal formula fermented with Lp 299v throughout their stay in the intensive care unit; eight patients served as controls. Biopsies of the rectal mucosa were made at admission and then twice a week, and the biopsies were analysed blindly. RESULTS: Four patients in the control group were colonised with Lp 299v at admission but thereafter all their biopsies were negative (Lp 299v is an ingredient in a common functional food, ProViva(®), in Sweden). Of the treated patients none was colonised at admission but three patients had Lp 299v adhered on the mucosa from the second or third biopsy and in the following samples. CONCLUSION: This study shows that Lp 299v could survive the passage from the stomach to the rectum and was able adhere onto the rectal mucosa also in critically ill, antibiotic-treated patients

Implantable Drainage After Major Abdominal Surgery in Compromised Patients

The risk of superinfection following routine abdominal drainage after major surgery is debated. Especially in patients with malignant diseases and a compromised host defense, this might be a factor increasing morbidity and mortality. During a 3-year period (1986–1988) 41 patients operated on for malignant abdominal conditions received a peritoneal catheter connected to a subcutaneous portal inserted in order to participate in a trial on postoperative intraperitoneal chemotherapy using 5- Fluorouracil. No abdominal drains were inserted. In 15 patients, the subcutaneous portal was used for evacuation of postoperative fluid accumulation within the abdomen. The mean age was 53 (range 41–70) years. Inserted catheters were used for drainage up to 14 days postoperatively. The daily amount of fluid drained varied from 20 to 2 000 ml with a mean of 610 ml/patient and day. One patient required removal of the catheter due to infection around the subcutaneous chamber. Otherwise, the catheter system was not associated with any other complications or complaints. One patient developed a postoperative left subphrenic abscess drained percutaneously by the guidance of ultrasonography, a complication that could not be attributed to the catheter system but merely to the major operation per se. An implantable device for peritoneal access thus also seem useful for drainage of postoperative fluid collection, as evaluated in this preliminary report

The mucosa-associated bacteria from the sigmoid colon of nine healthy 60 years old individuals, identified by bacterial 16S rDNA

The bacterial flora of the gastro intestinal (GI) tract may be involved in chronic inflammation and colon cancer and affected by antibiotics, cytotoxic drugs and radiotherapy, trauma and intensive care therapy. It is important to map the mucosa-associated flora in healthy individuals to clarify the pathogenic risk under stressed conditions. The aim was to achieve an overview of the mucosa-associated bacterial flora in the sigmoid colon by direct 16S rDNA identification by sampling nine 60-years old volunteers, without clinical symptoms or medication. The bacterial flora was estimated by sequence analysis of cloned 16S rDNA as enriched by PCR from biopsies. 26% of the clones had ≥99% similarity to known species (36% had ≥98% similarity). The largest number of identified clones was related to Escherichia coli, Bacteroides vulgatus and Ruminicoccus torques. Most frequently distributed between the volunteers were Bacteroides uniformis and Bacteroides vulgatus (7 individuals). Bacteroides caccae, Bacteroides distasonis, Bacteroides putredinis, Bacteroides thetaiotaomicron and Ruminicoccus torques were found in 5 persons. Opportunistic pathogens found in more than one individual were Bacteroides fragilis, Escherichia coli and Bilophila wadsworthia. Acinetobacter baumannii, Brachyspira aalborgi, Cardiobacterium hominis, Clostridium perfringens, Klebsiella pneumoniae and Veillonella parvula were found in single individuals. A majority of the individuals had a heterogeneous flora but in one person, 91% of the clones were related to E. coli. The GI-flora differs between healthy individuals in respect to both composition and diversity, and it can include several opportunistic pathogens

Streptococcal M1 protein triggers farnesyltransferase-dependent formation of CXC chemokines in alveolar macrophages and neutrophil infiltration in the lung.

M1 serotype of Streptococcus pyogenes plays an important role in streptococcal toxic shock syndrome. Simvastatin, a HMG-CoA reductase inhibitor, has been shown to inhibit streptococcal M1 protein-induced acute lung damage although downstream mechanisms remain elusive. Protein isoprenylation, such as farnesylation and geranylgeranylation, has been suggested to regulate anti-inflammatory effects exerted by statins. Herein, we examined the effect of a farnesyltransferase inhibitor (FTI-277) on M1 protein-triggered lung inflammation. Male C57BL/6 mice were treated with FTI-277 prior to M1 protein challenge. Bronchoalveolar fluid and lung tissue were harvested for quantification of neutrophil recruitment, edema and CXC chemokine formation. Flow cytometry was used to determine Mac-1 expression on neutrophils. Gene expression of CXC chemokines was determined in alveolar macrophages by using quantitative RT-PCR. We found that administration of FTI-277 markedly decreased M1 protein-induced accumulation of neutrophils, edema formation and tissue damage in the lung. Notably, inhibition of farnesyltransferase abolished M1 protein-evoked production of CXC chemokines in the lung and gene expression of CXC chemokines in alveolar macrophages. Moreover, FTI-277 completely inhibited chemokine-induced neutrophil migration in vitro. However, farnesyltransferase inhibition had no effect on M1 protein-induced expression of Mac-1 on neutrophils. Our findings suggest that farnesyltransferase is a potent regulator of CXC chemokine formation in alveolar macrophages and that inhibition of farnesyltransferase not only reduces neutrophil recruitment but also attenuates acute lung injury provoked by streptococcal M1 protein. We conclude that farnesyltransferase activity is a potential target in order to attenuate acute lung damage in streptococcal infections

Blueberry Husks and Probiotics Attenuate Colorectal Inflammation and Oncogenesis, and Liver Injuries in Rats Exposed to Cycling DSS-Treatment.

Long-term colonic inflammation promotes carcinogenesis and histological abnormalities of the liver, and colorectal tumours frequently arise in a background of dysplasia, a precursor of adenomas. Altered colonic microbiota with an increased proportion of bacteria with pro-inflammatory characteristics, have been implicated in neoplastic progression. The composition of the microbiota can be modified by dietary components such as probiotics, polyphenols and dietary fibres. In the present study, the influence of probiotics in combination with blueberry husks on colorectal carcinogenesis and subsequent liver damage was evaluated.Colorectal tumours were induced in rats by cyclic treatment with dextran sulphate sodium (DSS). Blueberry husks and a mixture of three probiotic strains (Bifidobacterium infantis DSM 15159, Lactobacillus gasseri, DSM 16737 and Lactobacillus plantarum DSM 15313) supplemented a basic diet fortified with oats. The condition of the rats was monitored using a disease activity index (DAI). A qualitative and quantitative histological judgement was performed on segments of distal colon and rectum and the caudate lobe of the liver. The formation of short-chain fatty acids, bacterial translocation, the inflammatory reaction and viable count of lactobacilli and Enterobaceriaceae were addressed.Blueberry husks with or without probiotics significantly decreased DAI, and significantly reduced the number of colonic ulcers and dysplastic lesions. With a decreased proportion of blueberry husk in the diet, the probiotic supplement was needed to achieve a significant decrease in numbers of dysplastic lesions. Probiotics decreased faecal viable count of Enterobacteriaceae and increased that of lactobacilli. Blueberry husks with or without probiotics lowered the proportion of butyric acid in distal colon, and decreased the haptoglobin levels. Probiotics mitigated hepatic injuries by decreasing parenchymal infiltration and the incidence of stasis and translocation. The results demonstrate a dietary option for use of blueberry husks and probiotics to delay colonic carcinogenesis and hepatic injuries in the rat model