[Anesthesia and bariatric surgery]. / Anästhesie bei bariatrischer Chirurgie.

Today obesity is accepted as an independent disease. The WHO describes obesity as an epidemic disease occurring worldwide and associated comorbidities affect all organ systems. Bariatric operations lead to an improvement or even complete remission of obesity-correlated comorbidities. Bariatric operations are conducted as restrictive, malabsorptive, or mixed procedures. The preoperative anesthetic evaluation of comorbidities is carried out with a special focus on preexisting impairments of cardiac and lung function (e.g. cardiomyopathy, obstructive respiratory dysfunctions). Extremely obese patients are at risk of aspiration. Airway management at anesthesia induction includes normal intubation or, if additional risk factors are present, either fiber optic awake intubation or rapid sequence induction. The pharmacokinetics of all applicable drugs are altered in extremely obese patients and they are at risk for developing postoperative thromboembolic complications with a high mortality rate. Therefore early and sufficient thrombotic prophylaxis is important.

Effort, safety, and findings of routine preoperative endoscopic evaluation of morbidly obese patients undergoing bariatric surgery.

BACKGROUND: Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients. METHODS: Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 +/- 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings. RESULTS: The patients' mean body mass index was 47.6 +/- 7.9 (range, 35.1-73.3) kg/m(2); 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 +/- 9.3 (range, 5-50) min, and the whole procedure (including preparation and postprocessing) took 58.2 +/- 19 (range, 20-120) min. The mean propofol dosage was 380 +/- 150 (range, 80-900) mg. Two patients had critical events that required bronchoscopic intratracheal O(2) insufflation due to severe hypoxemia (<60% SaO: (2)). Nearly 80% of patients had pathological findings in the upper gastrointestinal tract. Only 20% reported upper gastrointestinal symptoms. Pathologic conditions were found in the esophagus in 23.2% of the patients, in the stomach in 78.2%, and in the duodenum in 11.6%. The prevalence of Helicobacter pylori infection was 8.7%. CONCLUSIONS: Upper gastrointestinal endoscopy can be performed safely. However, careful monitoring and anesthesiological support are required for patients with concomitant diseases and those receiving sedation. Because 80% of the patients with pathological findings were asymptomatic, every morbidly obese patient should undergo endoscopy before bariatric surgery because there may be findings that might change the surgical strategy.

Dysfunction of the lower esophageal sphincter and dysmotility of the tubular esophagus in morbidly obese patients.

BACKGROUND: Morbid obesity is associated with gastroesophageal reflux (GERD). The aim of this prospective study was to determine esophageal motility in asymptomatic morbidly obese patients and compare it to non-obese individuals. METHODS: Forty-seven morbidly obese patients without GERD symptoms and 15 normal weight individuals were divided into four groups according to their body mass index (BMI; group I, <30 kg/m2; group II, 35-39.9 kg/m2; group III, 40-49.9 kg/m2; group IV, >or=50 kg/m2). Standard stationary water-perfused manometry was performed for the assessment of anatomy and function of the lower esophageal sphincter (LES). Twenty-four-hour ambulatory pH-metry and measurement of esophageal motility were performed with a microtransducer sleeve catheter. Data are given as mean+/-SD, and the results of groups II-IV were compared to the non-obese individuals from group I. RESULTS: Patients with morbid obesity had significantly lower LES pressures than non-obese individuals (I, 15.1+/-4.9; II-IV, 10.5+/-5.4, mmHg, p<0.05 vs. I) and showed an altered esophageal motility with respect to contraction frequency (I, 1.8+/-0.7/min; II-IV, 3.6+/-2.5/min; p<0.05 vs. I) and contraction amplitude (I, 38+/-12 mmHg; II-IV, 33+/-17 mmHg; p<0.05 vs. I). Furthermore, these patients had significantly higher DeMeester scores than non-obese individuals. Length and relaxation of the LES as well as propulsion velocity of the tubular esophagus did not differ. CONCLUSION: Patients with morbid obesity (=BMI>40 kg/m2) have a dysfunction of the LES and an altered esophageal motility, even when they are asymptomatic for GERD symptoms.

Two different types of double-strand breaks in Saccharomyces cerevisiae are repaired by similar RAD52-independent, nonhomologous recombination events.

In haploid rad52 Saccharomyces cerevisiae strains unable to undergo homologous recombination, a chromosomal double-strand break (DSB) can be repaired by imprecise rejoining of the broken chromosome ends. We have used two different strategies to generate broken chromosomes: (i) a site-specific DSB generated at the MAT locus by HO endonuclease cutting or (ii) a random DSB generated by mechanical rupture during mitotic segregation of a conditionally dicentric chromosome. Broken chromosomes were repaired by deletions that were highly variable in size, all of which removed more sequences than was required either to prevent subsequent HO cleavage or to eliminate a functional centromere, respectively. The junction of the deletions frequently occurred where complementary strands from the flanking DNA could anneal to form 1 to 5 bp, although 12% (4 of 34) of the events appear to have occurred by blunt-end ligation. These types of deletions are very similar to the junctions observed in the repair of DSBs by mammalian cells (D. B. Roth and J. H. Wilson, Mol. Cell. Biol. 6:4295-4304, 1986). When a high level of HO endonuclease, expressed in all phases of the cell cycle, was used to create DSBs, we also recovered a large class of very small (2- or 3-bp) insertions in the HO cleavage site. These insertions appear to represent still another mechanism of DSB repair, apparently by annealing and filling in the overhanging 3' ends of the cleavage site. These types of events have also been well documented for vertebrate cells.

Ambulatory pH: monitoring with a wireless system.

BACKGROUND: Currently, pH monitoring is the gold standard for assessing esophageal acid exposure in patients with gastroesophageal reflux disease (GERD). The shortcomings of 24-h pH-monitoring wires led to the development of a 48-h, catheter-free pH measurement system using the telemetry technique with the BRAVO capsule. This prospective study aimed to compare conventional 24-h pH monitoring with the BRAVO catheter-free pH-monitoring system in patients with GERD, patients after antireflux surgery, and a healthy control group. METHODS: A sample of 133 participants were enrolled in the current trial and divided into three subgroups. Group 1 consisted of 10 healthy volunteers. Group 2 consisted of 123 patients with symptomatic gastroesophageal reflux and endoscopic signs of esophagitis. Group 3 consisted of 43 GERD patients (extracted from group 2) who underwent a laparoscopic 360 degree "floppy" Nissen fundoplication. All the patients underwent both conventional 24-h pH monitoring and BRAVO catheter-free pH monitoring. The data for both methods were recorded and compared in line with the different patient groups regarding their validity and reliability. Additionally, all the patients were interviewed with a standardized questionnaire concerning their subjective perception of the two different methods. RESULTS: Both the 24-h pH monitoring and the 48-h BRAVO catheter-free pH monitoring could be successfully performed for all the patients. During measurement, 122 of the patients (92%) continued working or performing daily activities. A significant difference could not be found regarding objective outcome between the two measurement methods in the three patient groups. The two methods showed comparable results in terms of data and measurement reliability. The validity also was comparable, with no significant differences within the groups. Concerning the patients' subjective estimation of the two methods, the patients reported reduced regular activities and a higher level of discomfort during measurement with the conventional 24-h pH-monitoring system (p < 0.001 and p< 0.0001, respectively). CONCLUSION: Both conventional 24-h pH monitoring and the 48-h catheter-free pH monitoring are valid and reliable recording devices for measuring esophageal acid exposure. However, from the patients' point of view, the BRAVO capsule affords less discomfort in the throat and allows more normal daily activities.

What Are the Advantages of 3D Cameras in Gynaecological Laparoscopy?

Introduction Minimally invasive operative techniques are being used increasingly in gynaecological surgery. The expansion of the laparoscopic operation spectrum is in part the result of improved imaging. This study investigates the practical advantages of using 3D cameras in routine surgical practice. Materials and Methods Two different 3-dimensional camera systems were compared with a 2-dimensional HD system; the operating surgeon's experiences were documented immediately postoperatively using a questionnaire. Results Significant advantages were reported for suturing and cutting of anatomical structures when using the 3D compared to 2D camera systems. There was only a slight advantage for coagulating. The use of 3D cameras significantly improved the general operative visibility and in particular the representation of spacial depth compared to 2-dimensional images. There was not a significant advantage for image width. Depiction of adhesions and retroperitoneal neural structures was significantly improved by the stereoscopic cameras, though this did not apply to blood vessels, ureter, uterus or ovaries. Conclusion 3-dimensional cameras were particularly advantageous for the depiction of fine anatomical structures due to improved spacial depth representation compared to 2D systems. 3D cameras provide the operating surgeon with a monitor image that more closely resembles actual anatomy, thus simplifying laparoscopic procedures.

Parental regulation of central patterns of estrogen receptor alpha.

Reduced levels of estrogen receptor alpha (ERalpha) in the medial amygdala (MeA) and bed nucleus of stria terminalis (BST) have been hypothesized to play a significant role in the expression of male behaviors associated with monogamy. Therefore, the regulation of ERalpha could be a critical factor in determining male behavior and the evolution of monogamy. Central expression of ERalpha immunoreactivity was compared in hybrid offspring from crosses between two phenotypically distinct populations of prairie voles (Microtus ochrogaster). Illinois voles (IL) are socially monogamous and display low levels of ERalpha, while Kansas voles (KN) display some characteristics associated with polygyny and have higher levels of ERalpha. In offspring from hybrid crosses, the pattern of ERalpha expression was dependent upon parentage; the two types of hybrid crosses did not produce the same ERalpha pattern in the offspring. In the BST and MeA, hybrid males expressed ERalpha patterns consistent with those of males from their mother's population, while hybrid females had ERalpha patterns typical of females belonging to their father's population. The parental-specific patterns of ERalpha expression are suggestive of genomic imprinting, therefore, the vole ERalpha (Esr1) gene was cloned and sequenced, and examined for allele-specific expression. Results from this study indicate that while maternal factors may play a major role the expression of ERalpha in their male offspring, genomic imprinting is unlikely to be involved, suggesting another mechanism is responsible.

Two-dimensional DNA gel electrophoresis as a method for analysis of eukaryotic genome structure: evaluation using Tetrahymena thermophila DNA.

There is growing interest in mapping and analyzing complete eukaryotic genomes. Yee and Inouye (in Experimental Manipulation of Gene Expression, pp. 279-290, Academic Press, New York) demonstrated that bacterial chromosomes can be resolved into interpretable patterns of DNA fragments by means of restriction enzyme digestion and electrophoresis in two dimensions. We have begun to explore applications of this procedure to analysis of eukaryotic genomes, which are far more complex. Tetrahymena thermophila was selected as a model organism because its genome is small, roughly equivalent to that of a single human chromosome. In addition, each Tetrahymena cell contains two nuclei which differ in sequence composition and methylation. Our results demonstrate that the Tetrahymena genome can be resolved into complex patterns of fragments in two dimensions. Hybridization to Southern blots of these gels with a multiply repeated sequence probe yielded analyzable patterns of a subset of the genome. The blots reveal alterations in genome structure due to methylation and rearrangement. Future extensions of the method are discussed.

Neonatal manipulations of oxytocin alter expression of oxytocin and vasopressin immunoreactive cells in the paraventricular nucleus of the hypothalamus in a gender-specific manner.

Early postnatal manipulations of oxytocin have long-term behavioral and physiological consequences; the present study examined the hypothesis that oxytocin or its absence influences the subsequent expression of either oxytocin or arginine vasopressin in the CNS. On postnatal day 1 female and male prairie voles (Microtus ochrogaster) received a single i.p. injection of oxytocin (3 microg), oxytocin antagonist (0.3 microg), or 50 microl of isotonic saline or were only handled. On postnatal days 1, 8 and 21, brains were fixed, sectioned and stained for oxytocin or vasopressin immunoreactivity and analyzed as a function of age, treatment and sex. Both oxytocin and vasopressin immunoreactivity were observed on day 1 in the supraoptic and paraventricular nuclei (PVN) of the hypothalamus. Numbers of oxytocin and vasopressin neurons increased with age in both nuclei. Females treated on postnatal day 1 with oxytocin or oxytocin antagonist displayed a significant increase in oxytocin immunoreactivity on day 21 in the PVN. In contrast, males treated with antagonist tended to have decreased vasopressin immunoreactivity in the same region. These results revealed that the effects of neonatal manipulation of oxytocin are age-dependent, site-specific and sexually dimorphic. The long-lasting effects of neonatal exposure to exogenous oxytocin and oxytocin antagonist indicate a role for oxytocin in the development of the CNS during the neonatal period, affecting the development of the oxytocinergic system in females and the vasopressinergic system in males. The developmental effects observed suggest one possible mechanism by which neonatal exposure to oxytocin or neonatal inhibition of endogenous oxytocin produces long-lasting behavioral and physiological alterations and could play a role in the development of male- and female-typical behavior.

Trace element homeostasis during continuous sedation with propofol containing EDTA versus other sedatives in critically ill patients.

OBJECTIVE: To evaluate changes in serum and urinary zinc, cobalt, copper, iron, and calcium concentrations in critically ill patients receiving propofol containing disodium edetate (disodium ethylenediaminetetraacetic acid [EDTA]) versus sedative agents without EDTA. DESIGN: This was a randomised, open-label, parallel-group study with randomisation stratified by baseline Acute Physiology and Chronic Health Evaluation (APACHE II) scores. SETTING: Intensive care units (ICU) in 23 medical centres. PATIENTS: Medical, surgical, or trauma ICU patients 17 years of age or older who required mechanical ventilator support and sedation. INTERVENTIONS: A total of 106 patients received propofol containing 0.005 % EDTA (propofol EDTA), and 104 received other sedative agents without EDTA (non-EDTA). Only the first 108 patients were assessed for urinary trace metal excretion. Twenty-four-hour urine samples were collected on days 2, 3, and 7 and every 7 days thereafter for determination of zinc, cobalt, copper, iron, and calcium excretion; EDTA levels; urine osmolality; albumin levels; and glucose levels. The first 143 patients were assessed for serum concentration of zinc, cobalt, copper, iron, and calcium; creatinine; blood urea nitrogen; and albumin at baseline and once during each 24-hour urine collection. MEASUREMENTS AND RESULTS: For the assessment of trace metals, patients receiving propofol EDTA demonstrated increased mean urinary excretion of zinc, copper, and iron compared with the normal range. All patients receiving sedatives demonstrated increased urinary excretion of zinc and copper above normal reference values. Compared with the non-EDTA sedative group, the propofol EDTA group demonstrated increased urinary excretion of zinc and iron. Mean serum concentrations of zinc and total calcium were decreased in both patient groups. Serum zinc concentrations increased from baseline to day 3 in the non-EDTA sedative group but not in the propofol EDTA group. Renal function, measured by blood urea nitrogen, serum creatinine, and creatinine clearance, did not deteriorate during ICU sedation with either regimen. CONCLUSION: This study showed that critical illness is associated with increased urinary losses of zinc, copper, and iron. Propofol EDTA-treated patients had greater urinary losses of zinc and iron and lower serum zinc concentrations compared with the non-EDTA sedative group. No adverse events indicative of trace metal deficiency were observed in either group. The clinical significance of trace metal losses during critical illness is unclear and requires further study.

Prophylactic antibiotics for severe acute pancreatitis: the beginning of an era.

Death from acute severe pancreatitis results from infection and multiple organ system failure occurring late in the course of illness. Patients with necrotizing pancreatitis involving at least one-third of the organ are at highest risk of secondary infection and death. We conducted a MEDLINE search to identify human trials of prophylactic antibiotics in acute pancreatitis. Results of early studies of prophylactic ampicillin to avoid secondary infection and death were negative, but the studies included patients with mild disease who are at low risk for infection. Antibiotics were beneficial in four recently completed studies: imipenem significantly reduced pancreatic and nonpancreatic sepsis (p< or =0.01); cefuroxime reduced all infectious complications (p<0.01) and deaths (p=0.0284); a regimen of ceftazidime, amikacin, and metronidazole reduced all infectious complications (p<0.03); and protocol use of imipenem significantly reduced pancreatic infection compared with nonprotocol antibiotics (p=0.04) and no antibiotics (p<0.001). Based on these results, we suggest early antibiotic prophylaxis in patients with necrotizing pancreatitis, but the best drug and duration of therapy are unknown.

The fluconazole era: management of hematogenously disseminated candidiasis in the nonneutropenic patient.

Hematogenously disseminated candidiasis arising from nosocomial fungal infection is a life-threatening complication in critically ill, nonneutropenic patients. The overall nosocomial fungal infection rate in United States hospitals doubled from 1980-1990. Until recently, amphotericin B was the only agent available for the treatment of life-threatening candidal infections, but its use is plagued by toxicities including nephrotoxicity and infusion-related reactions such as rigors and hypotension. The availability of fluconazole, which is regarded as much less toxic than amphotericin B, prompted a surge in research to determine if it is as efficacious in the management of candidemia and hematogenously disseminated candidiasis. Complicating the interpretation of studies is the broad range of infection severity, from candidemia that may be transient and self-limiting to life-threatening hematogenously disseminated candidiasis. Clinical trials comparing fluconazole and amphotericin B demonstrate the efficacy of fluconazole for catheter-associated candidemia in critically ill patients when the likely pathogen is Candida albicans. Amphotericin B should remain the first-line agent for the management of candidemia and hematogenously disseminated candidiasis in all other patients.

A 16-channel 8-parameter waveform electrotactile stimulation system.

We have developed a general-purpose electrotactile (electrocutaneous) stimulation system as a research tool for studying psychophysiological performance associated with various stimulation waveforms. An experimenter-defined command file specifies the stimulation current and waveform of each of the 16 channels. The system provides burst onset delay of 0-20 ms, phase current of 0-50 mA, interphase interval of 0-1000 microseconds, number of pulses per burst from 1-100, pulse repetition rate of 0.1-25 kHz, phase width of 2-1000 microseconds, and functionally-monophasic pulses (with zero dc current) or balanced-biphasic pulses (with equal positive and negative phases). The system automatically delivers the desired stimulation, prompts the subject for responses, and then logs subject responses. Key features of the system are 1) very flexible choice of bursts of pulsatile waveforms, 2) real-time control of all of the waveform parameters as mathematical functions of external analog inputs, and 3) high-performance electrode-driver circuitry.

Biomechanical evaluation of lumbar spinal stability after graded facetectomies.

In an in vitro experiment using fresh human lumbar functional spinal units, the effects of the division of the posterior ligaments (consisting of the supraspinous/interspinous ligaments) and graded facetectomies were investigated. The graded facetectomies consisted of unilateral and bilateral medial facetectomies, and unilateral and bilateral total facetectomies. Six kinds of moments were applied and ranges of motion (ROM) and neutral zones (NZ) were determined three-dimensionally by stereophotogrammetric methods. Range of motion was not affected by the division of the supraspinous/interspinous ligaments for all load modes. In flexion, ROM increased slightly after unilateral medial facetectomy. In right axial rotation, ROM increased after left unilateral total facetectomy. Range of motion was not affected, even by bilateral total facetectomies, in extension and lateral bendings. This study suggested that medial facetectomy does not affect lumbar spinal stability, and conversely, total facetectomy, even created unilaterally, makes the lumbar spine unstable.

Criteria used to judge obese persons in the workplace.

Researchers have speculated that employers are less likely to hire obese persons for more publicly visible jobs, although this hypothesis remains untested. In the present study, 54 undergraduate students rated 40 jobs on several items, including the likelihood they would hire an obese person for each job. Multidimensional scaling showed a one-dimensional solution, labeled as physical activity, with participants less likely to hire obese persons for more active jobs. For hiring likelihood ratings for jobs at either end of the dimension appear to be most similar for men and individuals with more positive attitudes toward obese persons versus women and individuals with more negative attitudes toward obese persons. Implications for both theory and practice are discussed.

Smartphone based face recognition tool for the blind.

The inability to identify people during group meetings is a disadvantage for blind people in many professional and educational situations. To explore the efficacy of face recognition using smartphones in these settings, we have prototyped and tested a face recognition tool for blind users. The tool utilizes Smartphone technology in conjunction with a wireless network to provide audio feedback of the people in front of the blind user. Testing indicated that the face recognition technology can tolerate up to a 40 degree angle between the direction a person is looking and the camera's axis and a 96% success rate with no false positives. Future work will be done to further develop the technology for local face recognition on the smartphone in addition to remote server based face recognition.