OBJECTIVE To record and analyze the views of Greek gastroenterologists on the establishment of the subspecialty of digestive oncology, and to describe their opinions about the specific role of gastroenterologists in the diagnosis and management of patients with digestive malignancies, as well as their proposals on these matters. METHOD A specially designed questionnaire covering all the parameters related to the diagnosis and treatment of patients with digestive malignancy was distributed to Greek gastroenterologists, members of the Hellenic Society of Gastroenterology. Their various opinions and proposals were recorded and analyzed. RESULTS It appeared that Greek gastroenterologists dedicate quite a small part of their daily work to digestive oncology in comparison with their colleagues in other countries. Most of the respondents believed that the gastroenterologist should be an integral part of a multi-disciplinary oncological team devoted to managing the patient with digestive malignancy as a whole. They considered the establishment of the subspecialty of digestive oncology in Greece to be necessary. CONCLUSIONS Most of the gastroenterologists in Greece agree with the necessity for the establishment of the subspecialty of digestive oncology. Their various proposals related to the appropriate training in digestive oncology and the ways of effectively applying the skills acquired during this training are analyzed.

Eur J Clin Invest 2012; 42 (4): 439–446

Patients with obstructive jaundice, especially when exposed to the additional stress of an invasive diagnostic or therapeutic procedure, are prone to septic complications and renal dysfunction contributing to high morbidity and mortality rates. The key-event in the pathophysiology of obstructive jaundice-associated complications is endotoxemia of gut origin because of intestinal barrier failure. Experimental and clinical studies have shown that obstructive jaundice results in increased intestinal permeability. The mechanisms implicated in this phenomenon remain unresolved, but over the last few years mainly experimental studies have shed light on our knowledge in the field. Factors such as altered intestinal tight junctions expression, oxidative stress and apoptosis may play a key role in gut permeability alterations in cases of biliary obstruction. This review summarises the current knowledge on the pathophysiological mechanisms and the potential therapeutic strategies. Clinicians facing this very common clinical problem should not neglect protecting the intestinal barrier function, which may improve their patients’ outcome. Key words: obstructive jaundice, intestinal barrier, intestinal permeability, endotoxemia, bacterial translocation, tight junctions, occludin, claudin-4, apoptosis, oxidative stress

The substantial increase of laparoscopic surgery's clinical applications over the last decade has created interest for the pathophysiologic consequences of pneumoperitoneum. Pneumoperitoneum may create lung atelectasis, reduction of functional residual lung capacity and high pulmonary pressures. Peritoneal CO2 absorption may cause hypercapnia and acidosis, in the absence of adequate hyperventilation. Most studies investigating cardiovascular effects of pneumoperitoneum in healthy individuals, report increase of systemic vascular resistance and mean arterial pressure, accompanied with intraoperative alterations of cardiac index, without significant effect on cardiac frequency. Although main concern is given to global hemodynamic changes, regional circulatory disturbances occurred (i.e. increase of cerebral blood flow, reduction of splanchnic and renal perfusion), which must be considered clinical significant in critical patients who undergo laparoscopic procedures. Complications due to gas insufflation are rare, and can be demonstrated as subcutaneous emphysema, pneumothorax or pneumomediastinum. Air embolism is one of them, and although extremely rare is one of the most serious and lethal complications of laparoscopic procedures. As a conclusion, the most important pathophysiologic alterations during laparoscopy correlate with the increased intra-abdominal pressure and the CO2 usage. It is important for the surgeon, as well as the anesthesiologist to understand the pathophysiology of pneumoperitoneum, concerning its association with the cardiopulmonary function, and the increasing frequency of older patients with serious comorbidities that go through laparoscopic procedures nowadays.

The purpose of this study was to investigate the effect of splenectomy on cellular immunity. We studied the cellular phenotype and type 1 [interferon-gamma, interleukin-2 (IL-2)] and type 2 (IL-4 and IL-10) cytokine-producing peripheral blood CD4+ and CD8+ T lymphocytes in 22 healthy adults who had undergone post-traumatic splenectomy about 1 to 35 years ago. Splenectomy resulted in a long-term reduction of the percentage of CD4+CD45RA+ cells and a late increase of the percentage and absolute numbers of T-cell receptor gamma/delta cells. Stimulation with Staphylococcal enterotoxin B resulted in normal IL-2 production by CD4+ T cells, indicating that the naïve cells were not anergic. Splenectomy also resulted in long-term priming of both CD4+ and CD8+ T cells. During the first 8 years, both type 1 and type 2 CD4+ T cells were primed to varying degrees. About 8 years later, the percentage of primed type 2 CD4+ T cells subsided, but that of type 1 CD4+ T cells, although decreased, remained detectable over a longer period. Priming of CD8+ T cells persisted throughout the study period. The long-term priming of type 1 CD4+ and CD8+ T cells, which may result in partial impairment of T-cell functions, may explain reported defects of immune responses to recall antigens in splenectomized individuals. In addition, changes in the profile of primed CD4+ T cells with time may be clinically relevant to relapses in autoimmune thrombocytopenia after splenectomy.

It is generally accepted that early and specialized pre-hospital patient treatment improves outcome in terms of mortality and morbidity, in emergency cases. The focus of this paper is to present the implementation and the evaluation of an ambulance located telemedicine system for pre-hospital patient treatment. The primary emphasis is on the vital sign transmission from the accident site or the moving ambulance to the consultation site, using the GSM mobile telephony network. There, the experts evaluate the patient data, decides about the treatment protocol and provide directions to the ambulance's medical staff concerning on the patient handling until the arrival to the hospital.

Combined radiation therapy and chemotherapy are adjuvant treatments given after surgery to patients with rectal carcinoma. Because apoptosis seems to play a role in tumor response to radiotherapy, the current study investigates whether there is a correlation between the ratio of bcl-2 oncoprotein and bax expression in rectal adenocarcinoma and the clinical response to radiotherapy. Elective colectomy for primary rectal adenocarcinoma followed by adjuvant radiotherapy and chemotherapy was performed on 35 patients. Tumors were staged as B2 (n = 30) and C (n = 5), and were classified as radiation resistant (n = 19, group A) and radiation nonresistant (n = 16, group B). Immunohistochemical study, using the streptavidin-biotin complex technique and monoclonal antibody to bcl-2 and polyclonal antibody to bax protein was used on paraffin sections. Cases were considered positive if at least 5% of tumor cells displayed cytoplasmic staining for bcl-2 or bax. In each tumor, the bcl-2/bax ratio was calculated dividing the percentage of bcl-2-positive cells by the percentage of bax-positive cells. For statistical analysis, the Mann-Whitney rank sum test and Kruskal-Wallis analysis of variance test were used. Rectal tumors of group A displayed significantly greater bcl-2 immunoreactivity (40.2 +/- 4.2) compared with group B (20.2 +/- 3.8). In contrast, expression of bax protein was less in group A (30.3 +/- 3.3) compared with group B (41.3 +/- 2.3). The bcl-2/bax ratio was greater in group A (1.3 +/- 0.1) compared with group B (0.49 +/- 0.1), and was correlated with poor responsiveness to radiotherapy. The current study indicates that in patients with rectal carcinoma an elevated bcl-2/bax ratio in tissue specimens suggests increased tumor resistance to adjuvant radiotherapy. Thus, in such patients, the bcl-2/bax ratio may serve as a potential molecular marker for prediction of tumor prognosis.

Bronchobiliary fistula (BBF) is a rare condition. It may present as a complication of echinococcal or amebic liver disease. Management of such a fistula can be very difficult and is often associated with a high rate of morbidity and mortality. We report the case of a 70-year-old woman who presented with a BBF after a one-stage operation for hydatid cysts of the liver and lung that were approached via thoracotomy and transdiaphragmatic incision. The cause of the BBF was an inflammatory collection in the residual liver cavity due to inadequate drainage. This collection eroded the sutured diaphragm, and because of the existing adhesions, it perforated directly into the bronchial system at the area of the previous cystectomy. Initially, endoscopic sphincterotomy was performed to achieve biliary decompression by equalizing intrabiliary and duodenal pressure, but no significant improvement was seen. Subsequently, nasobiliary drainage was instituted by means of an endoscopically inserted, nasobiliary catheter, which further reduced biliary pressure and facilitated biliary flow to the duodenum, as opposed to the fistulous tract. The fistula was successfully closed in a short time. This conservative method reduces the risks of reoperation. Therefore, it should be considered the treatment of choice in the management of bronchobiliary fistula.

nerve sarcoma 407 Autotransplant 181 Axial transomphalic drainage 348 Bacterial translocation 571 Barrett esophagus 306 Barrier 57 Basal ganglia 190 Bile, composition 459 -duct cancer 36 --stricture 395 Biliary bypass 143 -system 297 Bleeding complications 602 -isolated gastric varices 23 Boerhaave syndrome 631 Bowel preparation 66 Bradycardia 513 Bradykinin 3 Caecum 281 Carbohydrate antigen 209 Carbon dioxide 513 Carcinoembryonic antigen 209 Carcinoid tumour

421 Postgraduate Course: Common Laparoscopic Procedures from Revolution to Standard of Care Chairpersons: Hunter, J. (USA); Lacy, A. (Spain) Ongoing Clinical Trials Section Editor: S. Galandiuk, MD, Louisville 427 Oncology 431 Inflammatory Bowel Disease 431 Surgical Infection/Sepsis 433 Miscellaneous 435 Questionnaire for Trial Submission 437 EDS News 438 Announcement Review 439 Human Islet Autotransplantation to Prevent Diabetes after Pancreas Resection White, S.A.; Robertson, G.S.M.; London, N.J.M.; Dennison, A.R. (Leicester)

We studied whether programmed cell death (or apoptosis) is the predominant mechanism in radiation-induced cell damage to rat intestinal mucosa and investigated the mechanism of the protective effect of GH and IGF-I in the same model. Male albino Wistar rats were divided into four groups: controls, radiation, radiation plus GH and radiation plus IGF-I. Radiation was administered on the first day and on day 4. All animals were sacrificed and segments of the terminal ileum were stained with hematoxylin-eosin. Apoptosis of the epithelial cells was identified at the cellular level by the TUNEL stain and was distinguished from necrosis by the characteristic morphology of the cells (cytoplasmic shrinkage, marginal chromatin condensation and generation of nuclear apoptotic bodies). Apoptotic cells in the control animals were few and detected only at the tips of the villi while in the irradiated animals almost all the epithelial cells were apoptotic, distributed from the crypts to the tips of the villi and the mucosa showed severe epithelial atrophy and ulceration. The histologic picture of the mucosa in the GH and IGF-I treated animals was similar to normal controls and apoptotic cells were restricted only at the tips of the villi. DNA and RNA from the mucosa cells were isolated and analyzed by electrophoresis. DNA fragmentation and RNA 28s band ribonuclease cleavage was observed only in the irradiated animals. We have shown that abdominal radiation causes intestinal epithelial cell damage mainly through the induction of apoptosis and the treatment with GH and IGF-I inhibits apoptosis of the cells and preserves the mucosal integrity.

SUMMARY Objectives: This is an experimental study in rats, examining bacterial translocation and endotoxemia in obstructive jaundice, as well as the effect of per os administration of non-absorbable antibiotics (neomycin & cefazoline). Method: Male Wistar rats were used, divided in four groups: I=control, II=sham, III=common bile duct ligation and IV=common bile duct ligation+antibiotics. Aerobic cultures of mesenteric lymph nodes (MLN) and liver were performed and endotoxin was measured in the portal vein and aorta. The aerobic bacterial concentration in the cecum was determined and the terminal ileum was evaluated histologically. Results: The study showed that obstructive jaundice resulted in increased bacterial translocation to MLNs and liver, increased systemic and portal endotoxemia and increased concentration of aerobic bacteria in the cecum. Treatment with neomycin and cefazoline reduced significantly endotoxemia, reduced the number of aerobic bacterial in the cecum as well as the bacterial translocation to the liver. There was no effect on bacterial translocation to MLNs. Histologic changes in intestinal morphology observed in jaundiced animals were not influenced by the administration of antibiotics. Conclusion: Our results indicate that administration of non-absorbable antibiotics per os in jaundiced rats reduces bacterial translocation to the liver as well as portal and systemic endotoxemia and decreases the aerobic cecal flora, but has not effect on bacterial translocation to MLNs. These findings may be of clinical significance in preventing septic complications in patients with obstructive jaundice.

SUMMARY Despite considerable improvement in the diagnostic and therapeutic approach to patients with acute upper gastrointestinal (GI) bleeding, several studies suggest there has been no overall change in mortality. The aim of this study was to evaluate prospectively the effect of early emergency diagnostic and therapeutic endoscopy and medico‐surgical collaboration in the clinical outcome of 1534 patients with acute upper GI bleeding treated in our hospital over the past five years. Emergency endoscopy and injection haemostasis were performed within 24 hours of admission, or immediately after resuscitation, in patients with massive bleeding; patients were then treated with close co‐operation between surgeons and gastroenterologists. We observed an increase in the incidence of peptic ulcer (67%) with a simultaneous decrease in the incidence of gastroduodenitis (13.5%) as a cause of bleeding compared with the previous decade. In peptic ulcer bleeding, emergency surgical haemostasis was required in 92 patients (8.9%), while none of the patients with erosive gastroduodenitis required surgical intervention. Overall mortality was 2.9%, and in peptic ulcer bleeding patients 2.1% with a postsurgical mortality of 8.7%. Peptic ulcer remains the main cause of upper GI bleeding. Improved clinical outcome and low mortality can be achieved with early diagnostic and therapeutic endoscopy and medico‐surgical collaboration.