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Colorectal cancer (CRC) is the third most common tumour type worldwide with approximately 1.8 million new cases diagnosed per year. Despite the high incidence of newly diagnosed cases, the majority (70%–80%) of these tumours are resectable. These tumours can present either as an incidental finding during screening colonoscopy or with anaemia symptoms such as general weakness and fatigue (for right sided-tumours) or changes in bowel habits (for left-sided tumours). In advanced cases, loss of weight and loss of appetite are also common presenting symptoms. Less common, yet emergent presentations include large bowel obstruction, severe gastrointestinal haemorrhage and free intra-abdominal perforation. Synchronous CRC (SCRC) cancers, defined as two or more primary tumours existing independently of one another, have an incidence rate of 2.3%–12.4% of overall CRC with male predominance. Presentation of these tumours is usually identical to presentation of solitary CRC. Emergency surgical presentation, with two different surgical indications for operation is very rare. Herein, we present a case of a 71-year-old male patient, who presented with colonic perforation, as well as colo-colic intussusception due to SCRC tumour. Subtotal colectomy, along with end-ileostomy was done. Histopathological report revealed synchronous colonic mucinous cancer and well differentiated colonic adenocarcinoma.

Background Minimally invasive surgery is considered the gold-standard approach for many surgical procedures. However, it requires CO2 insufflation and elevated intra-abdominal pressure (IAP), which may result in adverse pulmonary, cardiovascular, gastrointestinal, and renal changes. The kidneys are highly sensitive to pressure changes, where risk factors such as severe infection, dehydration, older age, and chronic kidney disease may aggravate the likelihood for the development of acute kidney injury (AKI). Unfortunately, the impact of diabetes mellitus on the deleterious effects of elevated IAP-induced AKI was not fully studied so far. The present study was designed to examine the effect of pneumoperitoneum on renal function and the development of AKI in diabetic rats. Materials and methods Sprague Dawley rats were divided into 2 groups: control (nondiabetic) rats (n=7) and diabetic rats (n=10). A Veress needle was introduced through the supravesical incision where inflating CO2 allowing the IAP to be increased to the desired pressures 7, 10, and 14 mm Hg for 45 minutes each and at the end of the experiment, the pressure was deflated to zero. During each pressure point, hemodynamic parameters were recorded and urine and blood samples were collected for analysis. Results The baseline values of renal hemodynamic were significantly lower in diabetic rats. There were no major statistically significant changes from baseline in urinary flow, urinary sodium excretion (UNaV), glomerular filtration rate, and renal plasma flow during 7 mm Hg pressure in both groups. When the IAP was further elevated, a significant deterioration of these parameters was recorded. This trend was more pronounced among diabetic rats. When examining urinary neutrophil gelatinase-associated lipocalin, a linear correlation was observed between the IAP and the biomarker level. This correlation was more significant in the diabetic group. Conclusion The present study demonstrated a direct correlation between IAP elevation and the development of AKI. Diabetic rats were more sensitive to the deleterious effect of pneumoperitoneum, where urinary neutrophil gelatinase-associated lipocalin levels may be used as a future biomarker to predict postoperative AKI, especially in patients with diabetes.

Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET) is a tumor of small round cells arising in skeletal tissues. These tumors rarely arise in the stomach. We present a 31-year-old healthy female patient who was admitted to our surgical ward due to upper gastrointestinal hemorrhage. Upper endoscopy revealed a large ulcerated bleeding mass originating from the lesser curvature. Biopsy revealed tumor cell immunoreactivity positive for CD99, vimentin, and Ki67 (an index of proliferation). These findings were compatible with gastric ES/PNET. The fluorescence in situ hybridization analysis result for the EWSR1 gene rearrangement (11: 22 translocation) was positive. The patient refused neoadjuvant treatment and thus underwent an operation during which a mass at the lesser curvature of the stomach was found. The mass was adhering to the pancreatic tail and to the mesentery of the transverse and descending colon. Total gastrectomy, distal pancreatectomy, splenectomy, and left adrenalectomy were done. The patient refused adjuvant treatment. She is free of disease 3 years after surgery.

Background Congestive heart failure (CHF) entails a complex interaction between the heart and the kidney that represents a clinical entity called cardiorenal syndrome (CRS). One of the mechanisms underlying CRS includes increased intra-abdominal pressure (IAP). We examined the effect of elevated IAP on kidney function in rats with low- and high-output CHF. Methods and Results Rats with compensated and decompensated CHF induced by means of aortocaval fistula, rats with myocardial infraction (MI) induced by means of left anterior descending artery ligation, and sham control rats were subjected to either 10 or 14 mm Hg IAP. Urine flow (V), Na+ excretion (UNaV), glomerular filtration rate (GFR), and renal plasma flow (RPF) were determined. The effects of pretreatment with tadalafil (10 mg/kg orally for 4 days) on the adverse renal effects of IAP were examined in decompensated CHF and MI. Basal V and GFR were significantly lower in rats with decompensated CHF compared with sham control rats. Decompensated CHF rats and MI rats subjected to 10 and 14 mm Hg IAP exhibited more significant declines in V, UNaV, GFR and RPF than compensated and sham controls. Elevated IAP also induced tubular injury, as evidenced by significantly increased absolute urinary excretion of neutrophil gelatinase–associated lipocalin. In addition, in a nonquantitative histologic analysis, elevated IAP was associated with increase in necrosis and cell shedding to the tubule lumens, especially in the decompensated CHF subgroup. Pretreatment of decompensated CHF rats and MI rats with tadalafil ameliorated the adverse renal effects of high IAP. Conclusions Elevated IAP contributes to kidney dysfunction in high– and low–cardiac output CHF. IAP induces both hemodynamic alterations and renal tubular dysfunction. These deleterious effects are potentially reversible and can be ameliorated with the use of phosphodiesterase-5 inhibition.

The intragastric migration of a surgically placed adjustable gastric band is believed to occur slowly, over months to years. Band removal procedures necessitate surgical laparotomy, thus increasing the risk of complications. The endoscopic technique for band removal described in this case-series provides a minimally invasive approach. Fifteen patients referred for endoscopic removal of a partially migrated intragastric band. The partially migrated intragastric bands were all successfully removed in a mean of 1.1 endoscopic sessions. No patient required subsequent surgical intervention, and there were no immediate or delayed adverse events including no infections, bleeding, or perforations. Endoscopic removal of partially migrated intragastric bands appears feasible, effective, safe, and is a minimally invasive alternative to repeat surgery.

Aims Congestive heart failure (CHF) is associated with impaired renal function. Previously, we have demonstrated that rats with decompensated CHF exhibited exaggerated sensitivity to the adverse renal effects of increased increased intra-abdominal pressure (IAP) as compared with normal controls. This study tested whether phosphodiesterase 5 (PDE5) inhibition protects against the adverse renal effects of increased IAP in rats with CHF. Methods and results Following baseline periods, rats with compensated and decompensated CHF induced by the placement of an aorto-caval fistula (ACF), rats with myocardial infarction (MI) induced by left anterior descending (LAD) artery ligation, and sham controls were subjected to consecutive IAPs: 7, 10, or 14 mmHg. Urine flow (V), Na+ excretion (UNaV), glomerular filtration rate (GFR), and renal plasma flow (RPF) were determined. The effects of pre-treatment with tadalafil on the adverse renal effects of IAP were examined in rats with decompensated CHF and MI. Elevation of IAP to 10 and 14 mmHg produced linear reductions in these parameters. Basal renal function and haemodynamics were lower in CHF rats. Decompensated CHF rats and MI rats that were subjected to 10 and 14 mmHg exhibited exaggerated declines in V, UNaV, GFR, and RPF. In contrast, no adverse renal effects were observed in rats with compensated CHF subjected to IAP. Pre-treatment of decompensated CHF rats and MI rats with tadalafil ameliorated the adverse renal effects of high IAP. Conclusion Decompensated CHF and MI rats are vulnerable to the adverse renal effects of IAP. Tadalafil abolishes IAP-induced renal dysfunction, supporting a therapeutic role for PDE5 inhibition in CHF associated with ascites.

Congestive heart failure is associated with impaired renal function. Previously we noted that increased intra-abdominal pressure (pneumoperitoneum) in normal rats induced renal dysfunction. In this study we investigated the renal effects of pneumoperitoneum in rats with compensated (urinary Na(+) excretion greater than 1,200 μEq per 24 hours) and decompensated (urinary Na(+) excretion less than 200 μEq per 24 hours) congestive heart failure, and the possible involvement of nitric oxide in these effects.After a baseline period rats with congestive heart failure induced by aorto-caval fistula and sham operated controls underwent consecutive intra-abdominal pressures of 7, 10 or 14 mm Hg for 45 minutes each. Urinary flow, urinary Na(+) excretion, glomerular filtration rate, renal plasma flow and urinary nitric oxide metabolites were determined.There were no changes in urinary flow, urinary Na(+) excretion, glomerular filtration rate or renal plasma flow during 7 mm Hg insufflation in controls. However, significant decreases in these parameters were observed during 10 and 14 mm Hg in correlation with intra-abdominal pressure. Baseline renal function and hemodynamics were lower in rats with congestive heart failure in correlation with disease severity. Rats with decompensated congestive heart failure that underwent 10 and 14 mm Hg showed aggravated decreases in urinary flow, urinary Na(+) excretion, glomerular filtration rate and renal plasma flow. In contrast, no adverse renal effects were observed in rats with compensated congestive heart failure under identical intra-abdominal pressure conditions. Despite unaltered baseline urinary nitric oxide metabolites in the 2 congestive heart failure subgroups, the decompensated group showed decreased urinary nitric oxide metabolites after 14 mm Hg. Finally, rats with compensated congestive heart failure pretreated with the nitric oxide synthase inhibitor L-NAME showed worse renal function in response to pneumoperitoneum.Decompensated congestive heart failure renders rats susceptible to the adverse renal effects of pneumoperitoneum, a phenomenon that may involve alterations in the renal nitric oxide system.

Previously, the authors demonstrated that an intraabdominal pressure (IAP) of 14 mmHg in normal rats reduced kidney function/hemodynamics. These adverse effects are related to interference with the nitric oxide (NO) system. This study was designed to compare the effects of NO synthase (NOS) inhibition on kidney function/hemodynamics during increases in IAP from 0 mmHg to 7, 10, and 14 mmHg.The rats were divided into six groups. After an IAP of 0 (baseline), the first three groups were subjected to increasing IAPs as follows: 7 mmHg (group 1), 10 mmHg (group 2), and 14 mmHg (group 3). Each pressure was applied for 1 h, followed by a deflation period of 60 min (recovery). An additional three groups were pretreated with nitro-L: -arginine methyl ester (L: -NAME), an NOS inhibitor, before pressures of 7 mmHg (group 4), 10 mmHg (group 5) and 14 mmHg (group 6) were applied for 1 h. Urine flow rate (V), Na(+) excretion (U(Na)V), glomerular filtration rate (GFR), and renal plasma flow (RPF), were determined throughout the experiments.There were no significant changes in V, U(Na)V, GFR, or RPF during 7-mmHg insufflation. However, significant reductions in these parameters were observed during 10 and 14 mmHg, with V decreasing from 9.95 + or - 1.34 microl/min to 6.8 + or - 1.1 and 6.1 + or - 0.5 microl/min (p0.05) and U(Na)V decreasing from 1.29 + or - 0.28 to 0.43 + or - 0.32 muEq/min (p0.05), and 0.39 + or - 0.09 muEq/min (p0.05). These alterations in excretory functions were associated with considerable declines in GFR, from 1.98 + or - 0.2 to 1.05 + or - 0.18 ml/min (p0.05) and 0.95 + or - 0.06 ml/min (p0.05) and RPF from 8.66 + or - 0.62 to 3.94 + or - 0.88 ml/min (p0.05) and 3.08 + or - 0.71 ml/min (p0.05), respectively. When the animals were pretreated with L: -NAME, the adverse renal effects of an IAP of 14 mmHg, but not 10 mmHg, were substantially aggravated.Decreased renal function/perfusion is induced by IAP pressures of 10 and 14 mmHg but not 7 mmHg. Inhibition of NOS aggravates the adverse renal effects of high (14 mmHg) but not low (7 or 10 mmHg) IAP, indicating that NO deficiency may contribute to the renal dysfunction during high IAP.

Background/Aims: Endothelin (ET)-1 is produced by most renal cell types. Renal tubular and vascular cells express both the ET receptors ETA and ETB. Since significant amounts of ET-1 of renal origin were detected in human urine, urinary ET-1 has been used as an index for the capacity of renal ET-1 production. Here, we determine the existence of additional components of the intrarenal ET system, namely the ETA and ETB receptor subtypes, in the urine of normal and hypertensive subjects. Methods: ETA and ETB receptors were detected in urine samples that were concentrated by TCA precipitation, Speedvac or ProteoSpin™. Results: Analysis of the human urine extracts revealed the existence of approximately 50 and 55 kDa of immunoreactive proteins, corresponding to ETB and ETA, respectively, indicating that intact ETA and ETB are excreted in the urine of healthy subjects and hypertensive patients. Normotensive and hypertensive subjects had statistically comparable ETB excretion normalized to creatinine (0.58 ± 0.16 vs. 0.83 ± 0.17 μg/mg creatinine, respectively; p = 0.304). In contrast, ETA excretion was higher among hypertensive subjects (0.05 ± 0.01 vs. 0.11 ± 0.02 μg/mg creatinine; p = 0.0451). Immunostaining of ETA and ETB in the human urinary system revealed expression of both receptors, principally in tubular cells (mainly in medullary collecting ducts) and in the bladder urothelium, and ETA expression in the peritubular capillaries and arterioles. Urinary ET receptors closely and inversely correlated with indices of urine concentration, suggesting that their shedding is principally affected by urine flow. Conclusion: ET receptors are present in human urine, conceivably originating within the urinary system. Their excretion is principally affected by urinary concentration. It remains to be determined whether urinary ETA/ETB is of physiological/pathophysiological relevance.

Arginine vasopressin (AVP) plays an important role in renal hemodynamic alterations, water retention, and cardiac remodeling in congestive heart failure (CHF). The present study evaluated the acute and chronic effects of vasopressin V(1a) receptor subtype (V(1a)) and vasopressin V(2) receptor subtype (V(2)) antagonists on renal function and cardiac hypertrophy in rats with CHF. The effects of acute administration of SR 49059 [(2S)1-[(2R,3S)-5-chloro-3-(2-chlorophenyl)-1-(3,4-dimethoxybenzene-sulfonyl)-3-hydroxy-2,3-dihydro-1H-indole-2-carbonyl]-pyrrolidine-2-carboxamide)] (0.1 mg/kg) and SR 121463B (1-[4-(N-tert-butylcarbamoyl)-2-methoxybenzenesulfonyl]-5-ethoxy-3-spiro-[4-(2-morpholinoethoxy)cyclohexane]indol-2-one, fumarate; equatorial isomer) (0.3 mg/kg), V(1a) and V(2) antagonists, respectively, on renal function, and of chronic treatment (3.0 mg/kg/day for 7 or 28 days, via osmotic minipumps or p.o.), on water excretion and cardiac hypertrophy were studied in rats with aortocaval fistula and control rats. CHF induction increased plasma AVP (12.8 +/- 2.5 versus 32.2 +/- 8.3 pg/ml, p0.05). Intravenous bolus injection of SR 121463B to controls produced dramatic diuretic response (from 5.5 +/- 0.8 to 86.3 +/- 21.9 microl/min; p0.01). In contrast, administration of SR 49059 did not affect urine flow. Likewise, administration of SR 121463B, but not SR 49059, to rats with CHF significantly increased urinary flow rate from 20.8 +/- 6.4 to 91.6 +/- 26.5 microl/min (p0.01). The diuretic effects of SR 121463B were associated with a significant decline in urinary osmolality and insignificant change of Na+ excretion. In line with its acute effects, chronic administration of SR 121463B to CHF rats increased daily urinary volume 2 to 5-fold throughout the treatment period. Both SR 121463B and SR 49059 significantly reduced heart weight in CHF rats when administered for 4 weeks, but not 1 week. These results suggest that V(2) and V(1a) antagonists improve water balance and cardiac hypertrophy in CHF and might be beneficial for the treatment of water retention and cardiac remodeling in CHF.

Increased intra-abdominal pressure (IAP) (pneumoperitoneum) during laparoscopic surgery may result in adverse effects on kidney function. The mechanisms underlying this phenomenon have not been fully determined.The present study was designed to: (1) investigate the effects of incremental increases in IAP on renal function in normal rats and (2) evaluate whether the nitric oxide (NO) system is involved in renal dysfunction characterizing pneumoperitoneum.Male rats were organized into two groups. The first group was subjected to IAP of 0 (baseline), 7 or 14 mmHg, over 1 h for each pressure, followed by a deflation period of 60 min (recovery). Two additional groups were pretreated with: (1) non-depressor dose of nitroglycerine (NTG) and (2) nitro-L-arginine-methylester (L-NAME), an NO synthase inhibitor, before applying 14 mmHg for 1 h. Urine flow rate (V), Na+ excretion (U(Na)V), glomerular filtration rate (GFR), renal plasma flow (RPF), and blood pressure were determined throughout the experiments.There were no significant changes in V, U(Na)V, GFR, and RPF during 7 mmHg insufflation. However, significant reductions in these parameters were observed during 14 mmHg: V from 8.49 +/- 0.92 to 6.12 +/- 0.54 microl/min, U(Na)V from 1.29 +/- 0.28 to 0.39 +/- 0.09 microEq/min, and FE(Na) from 0.37 +/- 0.11 to 0.27 +/- 0.04%. These alterations in excretory functions were associated with a considerable decline in GFR from 1.85 +/- 0.09 to 0.88 +/- 0.09 ml/min, p0.05, (-46.3 +/- 5.2% from baseline) and RPF from 8.66 +/- 0.62 to 4.33 +/- 0.49 ml/min, p0.05, (-51.93 +/- 5.24% from baseline), without a significant change in mean arterial blood pressure (MAP). When the animals were pretreated with NTG, the adverse effects of pneumoperitoneum on V, U(Na)V, GFR, and RPF were substantially improved, suggesting that NO system plays a beneficial counter-regulatory role during laparoscopy. In line with this notion, pretreatment with L-NAME remarkably aggravated pneumoperitoneum-induced renal hypoperfusion and dysfunction.Decreased renal perfusion and function are induced by IAP pressure of 14 mmHg. These adverse effects are probably related to interference with the NO system, and could be partially ameliorated by pretreatment with NTG.

Epidemiologic studies demonstrated higher incidence of thyroid cancer in patients with multinodular goiters compared to the general population. The aim of this study was to evaluate the risk of finding significant thyroid cancer in patients undergoing thyroidectomy for presumed benign disease.The records of 273 patients operated for indications other than cancer or indeterminate cytology were reviewed and analyzed.202 (74%) patients had a preoperative fine-needle aspiration (FNA) performed. FNA was benign in 96% of patients and non-diagnostic in 4%. Malignancy was unexpectedly found in 50 (19%) patients. Papillary carcinoma constituted 94% of cancers and 86% of cancers were incidental microcarcinomas. Only 7 (2.6%) patients of the entire cohort had tumors greater than 1 cm, of those only 3 had a previous benign FNA (false-negative rate 1.5%).The rate of significant thyroid cancer found unexpectedly in resected goiters is extremely low. A negative FNA excludes significant cancer with near certainty.

Much of the understanding about the pathophysiological responses to chronic cardiac overload has been gained by the use of rat and dog models of aortocaval fistula (ACF). The use of a similar model in genetically manipulated mice may further elucidate the molecular mechanisms in these responses. The only reports about ACF in mice to date have applied a needle puncture to create the ACF, which may result in an uncontrolled and irreproducible size of the shunt, and require several weeks to induce the characteristic cardiac changes. In order to obtain a more consistent approach to characterize this mode of cardiac hyperfunction, we present a surgical murine model of ACF that results in rapid progression of the typical systemic and cardiac changes. A sutureless side-to-side infrarenal surgical anastomosis of 0.6-0.8 mm in diameter was created between the abdominal aorta and inferior vena cava in ICR (Institute of Cancer Research) mice. Six to 7 days later, significant cardiac hypertrophy developed. The heart/body weight ratio increased from 0.45 +/- 0.02% in control mice to 0.77 +/- 0.03% in mice with ACF (p < .003). The dry heart weight ratio increased from 0.099 +/- 0.0033% to 0.13 +/- 0.008% (p < .006). The ACF dramatically induced the atrial and ventricular expression of atrial natriuretic factor mRNA, and increased the total cardiac content of endothelin-1 (162.5 +/- 50.6 vs. 83.9 +/- 9.0 pg). Mean arterial pressure in anesthetized mice with ACF decreased from 69.8 +/- 4.9 to 54.8 +/- 5.5 mm Hg (p < .025). Urinary sodium excretion returned to preoperative levels several days following surgery. These results demonstrate that cardiac hypertrophy could be rapidly and reproducibly achieved in mice by the placement of a surgical ACF. This model, when applied in genetically manipulated mice, may be a valuable tool for functional genomic studies about the pathogenesis of cardiac hypertrophy and heart failure.

Much debate surrounds the one-stage surgical management of acute left colon obstruction. Many surgeons are still reluctant to perform primary anastomosis in unprepared bowel fearing the risk of anastomotic dehiscence. Although intraoperative lavage and subtotal colectomy have recently proved effective for preventing fecal loading, both of these procedures have drawbacks and the search for additional alternative surgical procedures continues. We conducted an experimental study to examine a new one-stage operation, consisting of the interposition of a jejunal segment to the resection site of the colon, to manage acute left colon obstruction.The colons of 20 domestic pigs were obstructed, and 2 days later, segmental resection and either primary colo-colonic anastomosis or interposition of a jejunal segment was performed. Autopsies were done 6 weeks after the operations and the anastomotic regions were subjected to bursting pressure analysis.The operating time was longer in the interposition group at 49 +/- 14 vs 38 +/- 12 min ( P0.01). There was no mortality or clinical signs of anastomotic dehiscence in either group. A perianastomotic abscess was detected on autopsy in one animal from the primary colo-colonic anastomosis group. The bursting pressures of the jejunocolic anastomoses were significantly higher ( P0.001) than those of the primary colo-colonic anastomoses.These experimental results suggest that jejunal interposition may be a feasible alternative to primary colonic anastomosis to create intestinal continuity after resection for acute obstruction of the left colon.

An implementation of a high voltage power supply with a voltage multiplier using a DSP-based controller is proposed. The DSP controller is used to close the feedback loop from the output voltage to the PWM signals of the power stage. By using the MATLAB/Simulink embedded coder design time is greatly reduced and errors are far less likely to manifest. The design, consisting of a DSP controller, does not require additional components and is simple compared to more conventional analog control techniques. Experimental results using the Texas Instruments (TI) DSP TMS320F28335 Microcontroller show a rapid convergence and good real-time behavior. For example, the output of a 12-link multiplier with a rise time lower than 5mS and a low ripple of under 0.1% is actively corrected by the digital feedback loop.

Background: The population of obese patients is progressively growing and bariatric operations are becoming increasingly common. Morbidly obese patients require special anesthetic care and are often considered to be difficult to ventilate and intubate. The VivaSight™ Single Lumen tube is an endotracheal tube with a camera embedded in its tip. The view from the tip appears continuously on a monitor in the anesthesiologist's vicinity. The aim of this study was to assess the VivaSight™ in comparison with conventional endotracheal tube as an aid in the intubation and surveillance of tube position during surgery of obese patients. Methods: This is a prospective study of 72 adult obese patients who underwent laparoscopic sleeve gastrectomy. The patients were randomly assigned to be intubated by either the VivaSight™ (40 patients, test group) or a conventional endotracheal tube (32 patients, control group). Data on the patients, the pre-operative airway evaluation, the endotracheal intubation and the post-operative outcome were collected and compared. Results: The Mallampati scores were significantly higher in the test group than in the control group. Endotracheal intubation took 29 ± 10 and 24 ± 8 seconds using the VivaSight™ and a conventional tube respectively (p = 0.02). Three of the patients in the control group, while none of those in the test group, had soft tissue injury (p < 0.05). Conclusion: We found the VivaSight™ SL to be helpful in the endotracheal intubation and continuous surveillance of tube position in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.

Single adenoma is the cause of 80 % of primary hyperparathyroidism (PHPT) resulting in wide acceptance of minimally invasive parathyroidectomy (MIP). The incidence of PHPT increases with age. Little information is available regarding the prevalence of multiglandular disease (MGD) in older patients.The records of 537 patients that underwent parathyroid surgery between January 2005 and October 2012 at two endocrine surgery referral centers were retrospectively reviewed. Comparison was performed between patients younger than 65 and older than 65 years of age. Clinical variables included preoperative laboratories and imaging, extent of neck exploration, number of glands excised, and intraoperative parathyroid hormone levels during surgery.There were 374 (70 %) patients in the younger age group (YG) and 163 (30 %) patients in the older age group (OG). The mean age was 50 ± 0.5 and 71 ± 0.4 years, respectively. There was no difference between the groups in terms of gender or laboratory results. MGD was significantly more common in the OG (24 % vs. 12 %; p = 0.001) and similarly MIP was less commonly completed in the OG (49 % vs. 68 %; p0.001). Cure rates were comparable between the OG and YG (93 % vs. 95 %; p = 0.27). In the OG, patients with MGD had significantly smaller glands as compared to patients with single adenomas in this group (331 ± 67 vs. 920 ± 97 mg; p = 0.006, respectively).MGD in PHPT was found to be more prevalent in older patients. Planning a bilateral neck exploration should be considered in older patients, especially when a relatively small gland is suggested by imaging or encountered during surgery.

Acute kidney injury (AKI) is a common clinical problem that still lacks effective treatment. Phosphodiesterase-5 (PDE5) inhibitors possess anti-apoptotic and anti-oxidant properties, making it a promising therapy for ischemia-reperfusion (I/R) injury of various organs. The present study evaluated the early nephroprotective effects of Tadalafil, a PDE5 inhibitor, in an experimental model of renal I/R. Sprague-Dawley rats were divided into two groups: vehicle-treated I/R ( n = 10), and Tadalafil (10 mg/kg po)-treated I/R group ( n = 11). After removal of the right kidney and collection of two baseline urine samples, the left renal artery was clamped for 45 min followed by reperfusion for 60, 120, 180, and 240 min. Functional and histological parameters of the kidneys from the various groups were determined. In the vehicle-treated I/R group, glomerular filtration rate was significantly reduced compared with that in normal kidneys. In addition, the ischemic kidney showed remarkable cast formation, necrosis, and congestion, a consistent pattern of acute tubular necrosis. Furthermore, urinary excretion of NGAL and KIM-1, two novel biomarkers of kidney injury, substantially increased following I/R insult. In contrast, Tadalafil treatment resulted in a significant improvement in kidney function and amelioration of the adverse histological alterations of the ischemic kidney. Noteworthy, the urinary excretion of NGAL and KIM-1 markedly decreased in the Tadalafil-treated I/R group. These findings demonstrate that Tadalafil possesses early nephroprotective effects in rat kidneys subjected to I/R insult. This approach may suggest a prophylactic therapy for patients with ischemic AKI.

Obstructive jaundice and cirrhosis are associated with impaired renal function. Previously we demonstrated that increased intra-abdominal pressure (IAP, pneumoperitoneum) in normal rats induced renal dysfunction. This study investigated the renal effects of pneumoperitoneum in rats with acute jaundice and cirrhotic rats. Following a baseline period, rats with obstructive jaundice or cirrhosis induced by acute or chronic bile duct ligation (BDL), respectively, and their sham-controls were subjected to consecutive IAPs of 10 and 14 mmHg for 45 min each. Urine flow (V), Na+ excretion (UNaV), glomerular filtration rate (GFR), renal plasma flow (RPF), and urinary NO metabolites ( $$ {\text{U}}_{{{\text{NO}}_{ 2} + {\text{NO}}_{ 3} }} $$ ) and cGMP (UcGMP) were determined. Elevating IAP from 0 to 10 and 14 mmHg in normal rats caused IAP-dependent reductions in V, UNaV, GFR, RPF, $$ {\text{U}}_{{{\text{NO}}_{ 2} + {\text{NO}}_{ 3} }} , $$ and UcGMP. Basal renal function and hemodynamics were lower in rats with obstructive jaundice. In contrast to normal rats, application of elevated IAP of 10 and 14 mmHg significantly improved V, UNaV, GFR, RPF, and MAP along with increased $$ {\text{U}}_{{{\text{NO}}_{ 2} + {\text{NO}}_{ 3} }} $$ and preserved UcGMP. Similarly, when identical IAP conditions were applied to cirrhotic rats, no deleterious changes in V, UNaV, GFR or RPF were observed. Application of pneumoperitoneum to rats with acute BDL improves kidney function and renal hemodynamics. Likewise, increased IAP does not exert adverse renal effects in cirrhotic rats. These effects are distinct from the deleterious renal consequences of increased IAP in normal rats. Perturbations in the generation of NO/cGMP during IAP in normal rats but not in rats with BDL or cirrhosis may contribute to these differences.

Rho-dependent kinases serve as downstream effectors of several vasoconstrictor systems, the activities of which are upregulated in congestive heart failure (CHF). We evaluated renal and cardiac effects of Y-27632, a highly selective Rho kinase inhibitor, in an experimental model of volume-overload CHF. Effects of acute administration of Y-27632 (0.3 mg/kg) on renal hemodynamic and clearance parameters and effects of chronic treatment (10.0 mg·kg−1·day−1 for 7 days via osmotic minipumps) on cardiac hypertrophy and cumulative Na+ excretion were studied in male Wistar rats with aortocaval fistula and control rats. The Y-27632-induced decrease in renal vascular resistance (from 40.4 ± 4.6 to 26.0 ± 3.1 resistance units, P < 0.01) in CHF rats was associated with a significant increase in total renal blood flow (+34%) and cortical and medullary blood flow (approx +37 and +27%, respectively). These values were significantly higher than those in control rats and occurred despite a decrease in mean arterial pressure (−15 mmHg). Despite the marked renal vasodilatory effect, Y-27632 did not alter glomerular filtration rate and renal Na+ excretion. Chronic administration of Y-27632 did not alter daily or cumulative renal Na+ excretion in CHF rats but was associated with a significant decrease in heart-to-body weight ratio, an index of cardiac hypertrophy: 0.32 ± 0.007, 0.46 ± 0.017, and 0.37 ± 0.006% in control, CHF, and CHF + Y-27632 rats, respectively. The findings suggest that Rho kinase-dependent pathways are involved in the mechanisms of renal vasoconstriction and cardiac hypertrophy in rats with volume-overload heart failure. Selective blockade of these signaling pathways may be considered an additional tool to improve renal perfusion and attenuate cardiac hypertrophy in heart failure.

The management of penetrating abdominal stab wounds has been the subject of continued reappraisal and controversy. In the present study a novel method which combines the use of diagnostic laparoscopy and DPL, termed laparoscopic diagnostic peritoneal lavage (L-DPL) is described Five trauma patients with penetrating injuries to the lower chest or abdomen were included. Standard videoscopic equipment is utilized for the laparoscopic trauma evaluation of the injured patient. When no significant injury is detected, the videoscope is withdrawn and 1000 mL of normal saline is infused through the abdominal trochar into the peritoneal cavity, and the effluent fluid studied for RBCs, WBC, amylase debry, bile as it is uced in regular diagnostic peritoneal lavage Laparoscopic peritoneal lavage (L-DPL) was then performed and proved to be negative in all 5 patients. RBC lavage counts above 100,000/mcrl were not considered as a positive lavage result, because the bleeding source was directly observed and controlled laparoscopically. All patients recovered uneventfully and were released within 3 days. This procedure combines the visual advantages of laparoscopy together with the sensitivity and specificty of DPL for the diagnosis of significant penetrating intra-abdominal injury, when the diagnostic strategy of selective consevatism for abdominal stab wounds is adopted. A method of laparoscopic diagnostic peritoneal lavage (L-DPL) in hemodynamically stable patients with penetrating lower thoracic or abdominal stab wounds is described. The method is especially applicable for trauma surgeons with only basic experience in laparoscopic technique. This procedure is used to obtain conclusive evidence of significant intra-abdominal injury, confirm peritoneal penetration, control intra-abdominal bleeding, and repair lacerations to the diaphragm and abdominal wall. The combination of laparoscopy and DPL afforded by the L-DPL method adds to the sensitivity and specificity of DPL, and avoids under or over sesitivty, that have limited the use of DPL in the hemodynamically stable trauma patients with suspicious or proven peritoneal penetration.

Introduction: Loss of the cell-cycle inhibitory protein p27 is associated with aggressive tumor behavior and poor prognosis in colorectal cancer. The decrease in p27 levels is the result of increased proteasome-dependent degradation, mediated and rate-limited by its specific ubiquitin ligase subunits Skp2 and Cks1. We recently found that overexpression of Skp2 and Cks1 in colorectal cancer correlated with low p27 levels and poor tumor differentiation. The potential role of Skp2 and Cks1 as independent prognostic markers, however, is unknown. Methods: Tissue samples from 100 patients operated for colorectal cancer at 1997 were subjected to Western blot analysis and immunohistochemistry using highly specific monoclonal antibodies against p27, Skp2 and Cks1. Results were plotted against patients’ characteristics, disease stage and overall survival using Cox analysis and the Kaplan-Meier method. Results: Skp2 and Cks1 expression strongly correlated with overall survival (HR 7.672; p < 0.001 and HR 5.026; p < 0.001, respectively). Thus, high levels of these proteins, alone or in combination, accurately predicted poor prognosis whereas low levels predicted good overall survival rates. The strength of these proteins as independent prognostic markers was also valid after controlling for age, sex, grade and stage. Moreover, after having stratified for p27 levels, both Skp2 and Cks1 expression significantly enhanced the predictive value for survival (HR 4.530; p < 0.001 and HR 4.236; p < 0.001, respectively). The strongest additive effect was observed in patients with stage II disease. Conclusions: Skp2 and Cks1 expression strongly correlate with overall survival and may thus be used as novel prognostic markers in colorectal cancer.