John Bramis

Association between mutations in the CARD15/NOD2 gene and colorectal cancer in a Greek population

Epidemiological observations suggest that cancer arises from chronically inflamed tissues. Inflammatory bowel disease (IBD) is a typical example since patients with longstanding IBD are at increased risk for development of colorectal cancer (CRC). Therefore, genetic factors predisposing to or implicated in the chronic inflammatory process in IBD may simultaneously predispose to CRC. Recently CARD15/NOD2 has been associated with IBD, which further strengthens the notion that the inflammatory response plays a crucial role in this disease. Several mutations have been identified in the CARD15/NOD2 gene, which appear with significantly higher frequency in patients with IBD. In this report, we have examined the frequency of the 3 major mutations R702W, G908R and 3020insC of the CARD2/NOD2 gene in a series of 104 consecutive Greek patients with sporadic colorectal cancer and 100 healthy individuals. The frequency of all the mutations was significantly elevated compared to the control population (R702W, OR=5.00, p=0.023; G908R, OR=2.78, p=0.025; 3020insC, OR=2.44, p=0.017). Patients with advanced stage tumors were more frequently carriers of at least 1 variant in the CARD15/NOD2 gene (p=0.009). Our results suggest that CARD2/NOD2 may be a genetic factor that predispose to sporadic colorectal cancer.

Assessment of JC polyoma virus in colon neoplasms.

PURPOSEResearch data have recently emphasized an intriguing association of JC polyoma virus with colon carcinogenesis. Tumorigenicity of JC virus is attributed to the T-antigen of its Mad-1 variant. Controversy arose when another research group did not confirm this association. The purpose of this study was to detect JC virus in a series of colon neoplasms from Greek patients.METHODSA nested polymerase chain reaction assay was used to detect JC virus in 80 cancerous, 25 adenomatous specimens of large bowel, and 20 colonoscopic biopsy samples from normal patients without colorectal neoplasia. Quantitation of JC virus DNA was performed by real-time polymerase chain reaction.RESULTSJC polyoma virus nucleotide sequence was detected in 61 percent of colon adenocarcinomas and in 60 percent of adenomas, at a viral load of 9 × 103 to 20 × 103 copies/µg DNA. Adjacent normal mucosa in 35 positive colon adenocarcinoma specimens, and normal mucosa from six patients of the control group, had low viral loads (50–450 copies/µg DNA).CONCLUSIONSJC polyoma virus genome is present in colon neoplasms. JC virus detection in adenomas at comparable viral loads to malignant tumors suggests its implication at early steps of colonic carcinogenesis. Taking into consideration other published data, infection of colonic epithelium with JC virus might be a prime candidate for a role in chromosomal and genomic instability.

Bile Duct Injuries Associated with Laparoscopic and Open Cholecystectomy: An 11-Year Experience in One Institute

PurposeBile duct injury (BDI) represents the most serious complication of laparoscopic cholecystectomy (LC). The aim of this retrospective single-institution study was to evaluate the real incidence of BDI during laparoscopic and open cholecystectomy (OC) in a tertiary academic center in Athens, Greece.MethodsBetween January 1991 and December 2001, 3 637 patients underwent cholecystectomy in our department; as LC in 2 079 patients (LC group) and as OC in 1 558 patients (OC group). All the LCs were performed or supervised by five staff surgeons and all the OCs were performed or supervised by another five staff surgeons.ResultsThere were 13 BDIs associated with LC (0.62%) and 6 associated with OC (0.38%) (P = 0.317). There was one death associated with BDI after LC. Only two (15.4%) of the BDIs associated with LC occurred within the proposed learning curve limit of 50 LCs per individual surgeon.ConclusionLaparoscopic cholecystectomy is safe and is not associated with a higher incidence of BDI than OC. Moreover, we did not find that the learning curve for LC affected BDI occurrence.

Hypoxia, angiogenesis and apoptosis markers in locally advanced rectal cancer

Background and aimsHypoxia-inducible factor 1α (HIF-1α) is a critical regulatory protein of cellular response to hypoxia. HIF-1α triggers the angiogenic process through activation of the vascular endothelial factor (VEGF) gene. The bcl-2 anti-apoptotic and the death promoting p53 genes, regulate the apoptotic cell death. We investigated the relationship between hypoxia, angiogenesis and apoptosis and their prognostic impact in patients with advanced rectal cancer.Patients and methodsThe immunohistochemical expression of HIF-1α, VEGF, p53 and bcl-2 and the determination of microvessel density (MVD), apoptotic index (AI) were carried out in tumour tissue samples obtained from 92 patients with locally advanced rectal cancer (LARC) (T3,4/N±).ResultsHIF-1α high reactivity and VEGF overexpression were noted in 47.8 and 44.6% of the examined cases, respectively. They significantly correlated with lymph node metastasis (P<0.001) and low rectal location (P=0.016). HIF-1α expression was directly correlated with VEGF up-regulation (P<0.001) and MVD (P<0.001). VEGF expression was closely interrelated with MVD (P<0.001). In univariate analysis advanced grade, infiltrative pattern of tumour growth, vascular invasion, positive lymph node status, HIF-1α expression and VEGF upregulation were related to decreased disease-free and overall survival. In multivariate analysis, only high HIF-1α reactivity and positive lymph node status emerged as independent variables of adverse prognostic significance.ConclusionHIF-1α and VEGF may play an important predictive and prognostic role in patients with LARC.

Diagnosing papillary lesions using vacuum-assisted breast biopsy: should conservative or surgical management follow?

Background: This study evaluates the underestimation rate of papilloma lesions diagnosed with vacuum-assisted breast biopsy (VABB), taking into consideration the greater volume excised. Patients and Methods: 56 women with a diagnosis of a papilloma lesion after VABB (Mammotest; Fischer Imaging, Denver, CO, USA) were evaluated. At least 24 cores were excised in all cases (mean 74, range 24–96 cores) and a preoperative diagnosis was established. Subsequently, open surgery using hook-wire localization followed. A second, postoperative diagnosis was independently and blindly made. The association between the pathological types and Breast Imaging Report and Data System (BI-RADS) classification, as well as the discrepancy between preoperative and postoperative diagnoses, was evaluated. Results: The underestimation rate of papillary lesions was 3.6%. When the papillary lesions did not coexist preoperatively with any other precursor breast lesions, the underestimation rate was 0%. The underestimation rate did not differ with age, BI-RADS category or type of lesion. Conclusion: Conservative management of patients with a papillary lesion diagnosis may follow when the extended VABB protocol is adopted and a great tissue volume is excised. However, when diagnosing a coexisting papillary lesion with a precursor breast lesion, open surgery should follow, given the high probability of a postoperative cancer diagnosis.

Interposition of a Reversed Jejunal Segment Enhances Intestinal Adaptation in Short Bowel Syndrome: An Experimental Study on Pigs

BACKGROUND Interposition of a reversed intestinal segment as a factor facilitating intestinal adaptation has been experimentally investigated. Controversy exists about its efficacy in terms of body weight improvement, direction of luminal changes, and underlying mechanisms. This study aims to provide a comprehensive approach. METHODS The pigs were randomly allocated to two groups: (1) short bowel (SB) group (n=8) and (2) short bowel reverse jejunal segment (SB-RS) group (n=8). On postoperative d 3, 30, and 60, intestinal transit time was measured; body weight and serum albumin were measured on baseline, as well as on postoperative d 30 and 60. After sacrifice, histopathologic and immunohistochemical (PCNA, activated caspase-3) evaluation followed. RESULTS Transit time was numerically longer in SB-RS group at all time points; the difference reached statistical significance on d 60. No statistically significant differences were observed concerning body weight or serum albumin. In the SB-RS group, a statistically significant increase in muscle thickness, crypt depth, villus height, and PCNA immunostaining, and a decrease in caspase-3 positive (+) cell count were documented both at the jejunal and ileal level. CONCLUSIONS The reversed jejunal segment seemed able to enhance intestinal adaptation at a histopathologic level, as well as to favorably modify transit time. These putatively beneficial actions were not reflected upon body weight. The decrease in apoptosis was caspase-3-dependent.

Is zero underestimation feasible? Extended Vacuum-assisted breast biopsy in solid lesions – a blind study

BackgroundVacuum-Assisted Breast Biopsy (VABB) is effective for the preoperative diagnosis of non-palpable mammographic solid lesions. The main disadvantage is underestimation, which might render the management of atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS) difficult. This study aims to develop and assess a modified way of performing VABB.Patients and methodsA total of 107 women with non-palpable mammographic breast solid tumors BI-RADS 3 and 4 underwent VABB with 11G, on the stereotactic Fischers table. 54 women were allocated to the recommended protocol and 24 cores were obtained according to the consensus meeting in Nordesterdt (1 offset-main target in the middle of the lesion and one offset inside). 53 women were randomly allocated to the extended protocol and 96 cores were excised (one offset-main target in the middle of the lesion and 7 peripheral offsets). A preoperative diagnosis was established. Women with a preoperative diagnosis of precursor/preinvasive/invasive lesion underwent open surgery. A second pathologist, blind to the preoperative results and to the protocol made the postoperative diagnosis. The percentage of the surface excised via VABB was retrospectively calculated on the mammogram. The discrepancy between preoperative and postoperative diagnoses along with the protocol adopted and the volume removed were evaluated by Fishers exact test and Mann-Whitney-Wilcoxon test, respectively.ResultsIrrespectively of the protocol adopted, 82.2% of the lesions were benign. 14.0% of the lesions were malignancies (5.1% of BI-RADS 3, 5.3% of BI-RADS 4A, 25% of BI-RADS 4B, and 83.3% of BI-RADS 4C lesions). 3.7% of the biopsies were precursor lesions. There was no evidence of underestimation in either protocols. In the standard protocol, the preoperative/postoperative diagnoses were identical. In the extended protocol, the postoperative diagnosis was less severe than the preoperative in 55.5% of cases (55.5% vs. 0%, p = 0.029), and preoperative ADH was totally removed. The phenomenon of discrepancy between diagnoses was associated with larger volume removed (8.20 ± 1.10 vs. 3.32 ± 3.50 cm3, p = 0.037) and higher removed percentage of the lesion (97.83 ± 4.86% vs. 74.34 ± 23.43%, p = 0.024)ConclusionThe extended protocol seems to totally excise precursor lesions, with minimal underestimation. This might possibly point to a modified management of ADH lesions.

Alkaline Reflux Gastritis: Early and Late Results of Surgery

BackgroundAlkaline gastritis is caused by excessive reflux of alkaline duodenal content into the stomach or gastric remnant following procedures that resect or defunctionalize/deviate the pyloric sphincter. The symptoms may be intractable and surgery may be required in a selected subgroup of patients. The goal of this study was to present our experience regarding surgical management of alkaline reflux gastritis.Materials and MethodsDuring a 15-year period, 26 patients underwent surgery for the management of refractory alkaline reflux gastritis. Preoperative evaluation included a detailed history, endoscopy, and histology; alkaline reflux gastritis was characterized as mild, moderate, or severe based on the results of this evaluation. The patients underwent remedial gastric surgery when conservative management was ineffective and the patient’s symptoms—despite medical treatment—persisted for at least 2 years and affected quality of life. Most patients had previously undergone subtotal gastrectomy/gastrojejunostomy (the Billroth II procedure) (22/26, 84.6%); three patients (11.5%) had vagotomy and gastrojejunostomy, and 1 patient (3.9%) had vagotomy and pyloroplasty. In most patients (14/26, 54%), symptoms appeared 1–3 years after initial gastric surgery. Epigastric pain and bilious vomiting were reported by all (26/26, 100%) and by 25/26 (96%) of patients, respectively, while anemia and weight loss were observed in 11/26 (42.3%) and 18/26 (69.2%), respectively. Severe, moderate, and mild gastritis was present in 12, 9, and 5 patients, respectively. Most patients (18/26, 69%) were treated by Roux-en-Y anastomosis, and 8 (31%) by the Tanner (Roux-19) procedure. Long-term follow-up was completed in 23 patients (mean: 7.3 years), by clinical assessment (n = 18), or by questionnaire (n = 5). Results were assessed by using the Visick grading.ResultsOne patient died from massive pulmonary embolism (mortality: 3.8%). Morbidity was 57%, with the Roux stasis syndrome being the most frequent complication (n = 9). Both procedures achieved good early results, particularly regarding pain relief and absence of vomiting (84% and 96%, respectively). Endoscopic findings were ameliorated 6 months following surgery, whereas histological changes remained relatively unchanged. Eleven patients (47.8%) reported excellent (Visick I), 9 (39.2%) good, and 3 (13%) unsatisfactory late results.ConclusionsRemedial gastric surgery was effective and achieved symptom relief in a significant percentage (87%) of our patients. The Roux stasis syndrome is a frequent complication following Roux-en-Y reconstruction, but quality of life is significantly improved. Careful patient selection is essential to achieve satisfactory results.

Apoptotic death of renal tubular cells in experimental sepsis.

BACKGROUND AND PURPOSE Renal dysfunction attributable to sepsis was long considered a result of hemodynamic instability and subsequent local ischemia. Recent data show that apoptosis may be implicated also. The purpose of this study was to evaluate the role of apoptosis and the expression of the bax, bcl-2, caspase-8, and cytochrome c proteins in the renal parenchymal cells of rats with sepsis. METHODS Sepsis was induced using cecal ligation and puncture (CLP) in 62 male Wistar rats, which were euthanized 6, 12, 24, 36, 48, or 60 h later. Ten sham-treated animals served as a control group. Another group of 50 animals were subjected to CLP and then supervised for 60 h. Renal apoptosis was evaluated using light and transmission electron microscopy, in situ nick-end labeling (TUNEL), and flow cytometry using 7-amino-actinomycin D (7-AAD). Caspase-mediated apoptosis was assessed using M30 antibody. The expression of the apoptosis-regulator proteins B-cell lymphoma 2 (bcl-2), bcl-2-associated x protein (bax), caspase-8, and cytochrome c was detected immunohistochemically. RESULTS Sepsis increased inflammatory infiltration (p < 0.001) and necrosis (p < 0.001) in renal parenchyma. Apoptosis was significantly more common than in the kidneys of control animals (p = 0.02). Nuclei stained by the TUNEL technique were predominant in the tubular cells of non-survivors (p = 0.05). The time distribution of all types of cell death was increased significantly 6 h after the induction of sepsis, and declined subsequently. Caspase-generated cytokeratin 18 (CK18) new epitope (M30) was significantly more abundant in the kidneys of animals with sepsis than in control rats, with peaks at 6 h and 60 h post-procedure (p < 0.001). In addition, cells initiating apoptosis were significantly more common at 6 h than at 48 h post-CLP (p = 0.014). Caspase-8 protein immunodetection followed the same time pattern as cell death, increasing as early as 6 h post-CLP and decreasing thereafter (p = 0.013). Bax protein expression was elevated significantly early in the course of sepsis (p = 0.037), whereas the other members of the mitochondrial-dependent pathway remained constant. Animals dying from sepsis had a significantly greater prevalence of bax- (p = 0.037) and caspase-8- (p = 0.031) immunoreactive renal cells. CONCLUSION Apoptosis in renal tissue was significantly more common in animals with sepsis than in controls. The time distribution of cell death markers showed a consistent pattern, making early sepsis the likely initiator of the apoptotic events.

Adrenaline attenuates the acute lung injury after intratracheal lipopolysaccharide instillation: an experimental study.

Endotoxin is a major cause of endotoxinemia, sepsis, and pneumonia due to gram-negative bacteria. Experimental endotoxin administration via the tracheal route has been extensively used to study the biological and pathophysiologic pathways of inflammation. In particular, experimental endotoxin instillation in the respiratory tree has allowed an extended research with regard to the local response of the lungs to the pathogenic stimulus. This study aims (a) to define early events in the inflammatory cascade and (b) to evaluate the efficacy of adrenaline to ameliorate the acute pulmonary inflammation in vivo after administration of intratracheal lipopolysaccharide (LPS) in an in vivo animal model. Two groups of animals were used for that purpose, a control group (single LPS administration) and a study group (subcutaneous adrenaline infusion following LPS administration). We found that mononuclear recruitment, along with an increased population of CD4+ T lymphocytes, is an early event during the course of LPS-challenged inflammation. In the study group, we determined that adrenaline mediated the lung inflammation in a statistically significant degree. By the use of immunohistochemistry, we identified (1) an increased population of CD4+ T lymphocytes in the inflammatory infiltrate, further endorsing the hypothesis that T-helper lymphocytes, along with macrophages, secrete cytokines which amplify the inflammatory response, and (2) an upregulation of ICAM-1 expression, suggesting an important role in the early pathogenesis of LPS-induced acute lung injury. Our study establishes that systemic adrenaline administration after LPS instillation may ameliorate the inflammatory lung response in vivo.