Kinetic Characterization and Computational Modeling of Escherichia coli Heptosyltransferase II: Exploring the Role of Protein Dynamics in Catalysis for GT-B Glycosyltransferase.

Glycosyltransferase (GT) enzymes promote the formation of glycosidic bonds between a sugar molecule and a diversity of substrates. Heptosyltransferase II (HepII) is a GT involved in the lipopolysaccharide (LPS) biosynthetic pathway that transfers the seven-carbon sugar (l-glycero-d-manno-heptose, Hep) onto a lipid-anchored glycopolymer (heptosylated Kdo2-Lipid A, Hep-Kdo2-Lipid A, or HLA). LPS plays a key role in Gram-negative bacterial sepsis, biofilm formation, and host colonization, and as such, LPS biosynthetic enzymes are targets for novel antimicrobial therapeutics. Three heptosyltransferases are involved in the inner-core LPS biosynthesis, with Escherichia coli HepII being the last to be quantitatively characterized in vivo. HepII shares modest sequence similarity with heptosyltransferase I (HepI) while maintaining a high degree of structural homology. Here, we report the first kinetic and biophysical characterization of HepII and demonstrate the properties of HepII that are shared with HepI, including sugar donor promiscuity and sugar acceptor-induced secondary structural changes, which results in significant thermal stabilization. HepII also has an increased catalytic efficiency and a significantly tighter binding affinity for both of its substrates compared to HepI. A structural model of the HepII ternary complex, refined by molecular dynamics simulations, was developed to probe the potentially important substrate-protein contacts. Ligand binding-induced changes in Trp fluorescence in HepII enabled the determination of substrate dissociation constants. Combined, these efforts meaningfully enhance our understanding of the heptosyltransferase family of enzymes and will aid in future efforts to design novel, potent, and specific inhibitors for this family of enzymes.

European Society of Coloproctology guidance on the use of mesh in the pelvis in colorectal surgery.

This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

Anorectal angle at rest predicting successful sacral nerve stimulation in idiopathic fecal incontinence-a cohort analysis.

PURPOSE: Sacral nerve stimulation is an effective treatment for patients suffering from fecal incontinence. However, less is known about predictors of success before stimulation. The purpose of this study was to identify predictors of successful sacral nerve stimulation in patients with idiopathic fecal incontinence. METHODS: Consecutive female patients, receiving peripheral nerve evaluation and sacral nerve stimulation between September 2008 and October 2014, suffering from idiopathic fecal incontinence were included in this study. Preoperative patient's characteristics, anal manometry, and defecography results were collected prospectively and investigated by retrospective analysis. Main outcome measures were independent predictors of treatment success after sacral nerve stimulation. RESULTS: From, all in all, 54 patients suffering from idiopathic fecal incontinence receiving peripheral nerve evaluation, favorable outcome was achieved in 23 of 30 patients after sacral nerve stimulation (per protocol 76.7%; intention to treat 42.6%). From all analyzed characteristics, wide anorectal angle at rest in preoperative defecography was the only independent predictor of favorable outcome in multivariate analysis (favorable 134.1 ± 13.9° versus unfavorable 118.6 ± 17.1°). CONCLUSIONS: Anorectal angle at rest in preoperative defecography might present a predictor of outcome after sacral nerve stimulation in patients with idiopathic fecal incontinence.

Diversity of Ginsenoside Profiles Produced by Various Processing Technologies.

Ginseng is a traditional medicinal herb commonly consumed world-wide owing to its unique family of saponins called ginsenosides. The absorption and bioavailability of ginsenosides mainly depend on an individual's gastrointestinal bioconversion abilities. There is a need to improve ginseng processing to predictably increase the pharmacologically active of ginsenosides. Various types of ginseng, such as fresh, white, steamed, acid-processed, and fermented ginsengs, are available. The various ginseng processing methods produce a range ginsenoside compositions with diverse pharmacological properties. This review is intended to summarize the properties of the ginsenosides found in different Panax species as well as the different processing methods. The sugar moiety attached to the C-3, C-6, or C-20 deglycosylated to produce minor ginsenosides, such as Rb1, Rb2, Rc, Rd→Rg3, F2, Rh2; Re, Rf→Rg1, Rg2, F1, Rh1. The malonyl-Rb1, Rb2, Rc, and Rd were demalonylated into ginsenoside Rb1, Rb2, Rc, and Rd by dehydration. Dehydration also produces minor ginsenosides such as Rg3→Rk1, Rg5, Rz1; Rh2→Rk2, Rh3; Rh1→Rh4, Rk3; Rg2→Rg6, F4; Rs3→Rs4, Rs5; Rf→Rg9, Rg10. Acetylation of several ginsenosides may generate acetylated ginsenosides Rg5, Rk1, Rh4, Rk3, Rs4, Rs5, Rs6, and Rs7. Acid processing methods produces Rh1→Rk3, Rh4; Rh2→Rk1, Rg5; Rg3→Rk2, Rh3; Re, Rf, Rg2→F1, Rh1, Rf2, Rf3, Rg6, F4, Rg9. Alkaline produces Rh16, Rh3, Rh1, F4, Rk1, ginsenoslaloside-I, 20(S)-ginsenoside-Rh1-60-acetate, 20(R)-ginsenoside Rh19, zingibroside-R1 through hydrolysis, hydration addition reactions, and dehydration. Moreover, biological processing of ginseng generates the minor ginsenosides of Rg3, F2, Rh2, CK, Rh1, Mc, compound O, compound Y through hydrolysis reactions, and synthetic ginsenosides Rd12 and Ia are produced through glycosylation. This review with respect to the properties of particular ginsenosides could serve to increase the utilization of ginseng in agricultural products, food, dietary supplements, health supplements, and medicines, and may also spur future development of novel highly functional ginseng products through a combination of various processing methods.

Functional Results and Quality of Life Following Magnetic Anal Sphincter Augmentation in Severely Incontinent Patients.

OBJECTIVE: Magnetic anal sphincter augmentation is a novel surgical option in the treatment of severe fecal incontinence. This study aimed to analyze functional results, quality of life, and satisfaction after implantation in the mid-term, and to identify factors associated with success of this new treatment. METHODS: All patients, who underwent magnetic anal sphincter augmentation procedure at a single center between December 2008 and January 2016, were consecutively included. Symptom severity [Cleveland Clinic Incontinence Score (CCIS)], quality of life [Fecal-Incontinence Quality of Life Questionnaire (FIQL)], bowel diary data, and patients' satisfaction were assessed before and after implantation. RESULTS: Forty-five patients (43 female), mean (s.d.) age 66.82 (±10.07), were followed for a median of 36 months (range 6-84). Two patients were explanted and 1 lost to follow-up. On a 3-week diary, major leakage rate significantly improved as did CCIS and FIQL. No significant difference was seen for flatus and minor leaks. Postoperative decrease of CCIS by ≥5.5 points correlated best with satisfaction, expressed by 22 patients (48% in intention-to-treat analysis). An independent predictive factor for success after implantation was no previous fecal incontinence surgical treatment. CONCLUSIONS: Satisfaction, functional, and quality of life outcomes improve significantly following magnetic anal sphincter augmentation.

Obstructed defecation-an enteric neuropathy? An exploratory study of patient samples.

PURPOSE: Although various strategies exist for chronic constipation therapy, the pathogenesis of chronic constipation is still not completely understood. The aim of this exploratory experimental study is to elucidate alterations of the autonomous enteric nervous system at the molecular level in patients with obstructed defecation, who represent one of the most predominant groups of constipated patients. METHODS: Full-thickness rectal wall samples of patients with obstructed defecation were analyzed and compared with controls. Differential gene expression analyses by RNA-Seq transcriptome profiling were performed and gene expression profiles were assigned to gene ontology pathways by application of different biological libraries. RESULTS: Analysis of the transcriptome showed that genes associated with the enteric nervous system functions were significantly downregulated in patients with obstructed defecation. These affected functions included developmental processes and synaptic transmission. CONCLUSIONS: Our results therefore indicate that obstructed defecation may represent an enteric neuropathy, comparable to Hirschsprung disease and slow-transit constipation.

The Effects of Poncirus fructus on Insulin Resistance and the Macrophage-Mediated Inflammatory Response in High Fat Diet-Induced Obese Mice.

Obesity is a chronic low-grade inflammatory condition in which hypertrophied adipocytes and adipose tissue immune cells, mainly macrophages, contribute to increased circulating levels of proinflammatory cytokines. Obesity-associated chronic low-grade systemic inflammation is considered a focal point and a therapeutic target in insulin resistance and metabolic diseases. We evaluate the effect of Poncirus fructus (PF) on insulin resistance and its mechanism based on inflammatory responses in high-fat diet (HFD)-induced obese mice. Mice were fed an HFD to induce obesity and then administered PF. Body weight, epididymal fat and liver weight, glucose, lipid, insulin, and histologic characteristics were evaluated to determine the effect of PF on insulin resistance by analyzing the proportion of macrophages in epididymal fat and liver and measured inflammatory gene expression. PF administration significantly decreased the fasting and postprandial glucose, fasting insulin, HOMA-IR, total-cholesterol, triglycerides, and low-density lipoprotein cholesterol levels. The epididymal fat tissue and liver showed a significant decrease of fat accumulation in histological analysis. PF significantly reduced the number of adipose tissue macrophages (ATMs), F4/80+ Kupffer cells, and CD68+ Kupffer cells, increased the proportion of M2 phenotype macrophages, and decreased the gene expression of inflammatory cytokines. These results suggest that PF could be used to improve insulin resistance through modulation of macrophage-mediated inflammation and enhance glucose and lipid metabolism.

[Obstructed Defecation: Relevance of Sacral Neuromodulation]. / Obstruktives Defäkationssyndrom: Stellenwert der sakralen Neuromodulation.

After successful implementation of sacral nerve stimulation in the treatment of fecal incontinence, the first cohort studies showed promising results for sacral neuromodulation in the treatment of conservative refractory chronic constipation and obstructed defecation. However, these results have not been confirmed with long-term data or with studies of the highest level of evidence. Randomised trials failed to show any difference between patients with and without sacral nerve stimulation. In the long term, many patients suffer from loss of efficacy or adverse events, leading to high explantation rates. On the basis of existing clinical trials, it cannot be concluded that sacral neuromodulation should be included in the treatment algorithm of chronic constipation and obstructed defecation. So far it is unclear whether and which patient cohort may benefit from sacral nerve stimulation. Therefore further trials are needed to identify possible selection criteria for sacral nerve stimulation in the treatment of chronic constipation and obstructed defecation. The aim of this narrative review is to give an overview of the existing literature on sacral nerve stimulation in chronic constipation and the subgroup of obstructed defecation.

Four Surgical Modifications to the Classic Elastase Perfusion Aneurysm Model Enable Haemodynamic Alterations and Extended Elastase Perfusion.

OBJECTIVE/BACKGROUND: Abdominal aortic aneurysm (AAA) is an individual and socioeconomic burden in today's ageing society. Treatment relies on surgical exclusion of the dilated aorta by open or endovascular repair. For research purposes, animal models are necessary and the elastase induced aneurysm model closely mimics end stage human aneurysm disease. To improve the translational value of this model, four modifications to the classic elastase perfusion procedure (PPE) in relation to human aneurysm morphology were conducted. METHODS: In ten week old male C57BL/6J wild type mice the PPE procedure was modified in four ways using two different techniques. Flow alteration was simulated by partial ligation of the common iliac artery or the distal aorta. Additionally, careful exploration of the abdominal aortic branches allowed PPE induction at the suprarenal and iliac level. Molecular biology, ultrasound, and immunohistochemistry were used to evaluate these pilot results. RESULTS: Two aortic outflow obstructions simulating distal aortic or iliac stenosis significantly increase murine AAA diameter (p = .046), and affect local vascular wall remodelling. Suprarenal aortic dissection allows a juxtarenal aneurysm to be induced, similar to the angiotensin II induced aneurysm model. A separate investigation for canonical activation of transforming growth factor ß in the two embryonically distinct juxtarenal and infrarenal segments showed no distinct difference. Creating an aortoiliac bifurcated aneurysm completes the mimicry of human aneurysm morphology. CONCLUSION: The alteration of the classic PPE aneurysm by outflow modulation and further elastase perfusion to the juxtarenal and aortoiliac segment modifies morphology and diameter, and thus increases the translational value in future research.

Analysis of medical service use of knee osteoarthritis and knee meniscal and ligament injuries in Korea: a cross-sectional study of national patient sample data.

BACKGROUND: Osteoarthritis (OA) and meniscal and ligament injuries of the knee are the two most common knee disorders in Korea. The aim of this study was to analyze the demographic characteristics, medical service use and related costs for these disorders, and the results are expected to help inform practitioners, researchers, and policy-makers. METHODS: The present study aimed to evaluate incidence and patient characteristics, and to assess current medical service use, usual care, and medical expenses of knee disorders by analyzing 2014 national patient sample data from the Korean Health Insurance Review and Assessment Service. Data was extracted using 3% stratified sampling from all Korea national health insurance claims submitted in 2014, and analyzed. Usual care for M17 knee osteoarthritis and S83 knee meniscal and ligament injury codes of the International Classification of Diseases, 10th revision (ICD-10) were determined by investigating total number of patients, sociodemographic characteristics, days in care, number of visits, and expenses. RESULTS: Knee OA showed the highest incidence in females aged ≥60 years, whereas meniscal and ligament injuries of the knee were most prevalent among patients aged <20 years and young adults. Total inpatient care expenses exceeded the cost of ambulatory care for both disorders. Ambulatory care was mainly provided at primary care clinics, with 90% of these visits made to orthopedic specialists. Medical expenses for knee OA and meniscal and ligament injuries were largely due to procedures/surgeries and injections, and procedures/surgeries and hospitalizations, respectively. Total replacement arthroplasty was the most commonly performed surgery for knee OA, while meniscectomy and cruciate ligament reconstruction were the most often performed surgeries for meniscal and ligament injuries. Intra-articular injection rates were 55% in knee OA patients and 3% in meniscal and ligament injury patients. Aceclofenac, diclofenac, and tramadol were the most frequently prescribed analgesics. CONCLUSIONS: The current findings may be used as basic data for establishing medical policies and can benefit researchers and clinicians in recognizing trends and patterns of treatment for knee disorders.

Effects of herbal medicine for dysmenorrhea treatment on accompanied acne vulgaris: a study protocol for a randomized controlled trial.

BACKGROUND: The incidence of preadolescent acne among women is increasing. Acne deteriorates the quality of life; conventional treatment options are limited and have not been effective against acne, particularly acne associated with menstruation. Despite evidence that acne associated with menstruation abnormalities naturally improves when menstruation recovers to normal, there have only been few studies on the effects of dysmenorrhea treatment on acne. Therefore- we designed this study to assess the effects of gyejibokryung-hwan (GBH) and dangguijagyag-san (DJS), which are widely used in dysmenorrhea treatment, on acne associated with menstruation cycle. METHODS: This is a protocol for a randomized, double-blind, parallel-group, placebo-controlled and multicenter trial. One hundred and sixteen participants with dysmenorrhea accompanied by acne vulgaris will be recruited at three centers and randomized into two groups, the herbal treatment group and placebo group. The participants will receive GBH or DJS based on pattern identification or placebo granules thrice daily for 8 weeks, with an 8-week follow up. The primary outcome will be the mean percentage change in the count of inflammatory acne lesions. The secondary outcomes would be based on dysmenorrhea numeric rating scale, verbal multidimensional scoring system for dysmenorrhea, acne numeric rating scale, investigator's static global assessment scale of facial acne vulgaris, and safety testing. Adverse events will also be reported. DISCUSSION: The effects of GBH or DJS used in dysmenorrhea treatment on acne associated with the menstrual cycle will be evaluated. The findings of this trial will provide evidence regarding the effect of herbal medicine in improving acne vulgaris associated with menstruation in women. TRIAL REGISTRATION: Korean Clinical Trial Registry ( http://cris.nih.go.kr ; registration number: KCT0002259). Date of registration: March 10, 2017.

How to Size the Anal Canal Circumference When Implanting a Magnetic Anal Sphincter for Fecal Incontinence. Evolution and Update of a New Surgical Technique.

INTRODUCTION: Magnetic anal sphincter augmentation improves function and quality of life of patients with severe fecal incontinence substantially. Measuring the anal circumference exactly with a sizing tool represents a crucial step of the procedure because it determines the correct size and success of the definite implant. OBJECTIVE: This study aims to illustrate the consequent development of 3 different sizing models and the use of the recent sizing tool. TECHNIQUE: After dissection of a tunnel around the anal canal through a ventral perineal incision, the sizing tool is inserted by using a specially designed introducer to measure the circumference for the appropriate size of implant. First- and second-generation sizing tools could only approximate the final implant size and impeded standardization. The latest sizing model resembles the actual implant with magnetic beads, it is nonstretchable, and it is closable end-to-end. RESULTS: The development of 3 measuring tools has progressively improved the accuracy of estimating the correct size of the definitive implant, and the application of the latest sizer seems easy, comfortable in use, and accurate as experienced in our first cases. CONCLUSION: The latest device contributes to standardization of the procedure and therefore facilitates the learning curve for newcomers of the method and could avoid the need for radiological on-table control in the near future.

Sphincter-sparing intersphincteric rectal resection as an alternative to proctectomy in long-standing fistulizing and stenotic Crohn's proctitis?

PURPOSE: Long-standing fistulizing and stenotic proctitis (LFSP) in Crohn's disease (CD) indicates the end stage of the disease. Definitive diversion such as proctectomy is considered to be the only surgical option. The impact of intersphincteric sphincter-sparing anterior rectal resection (IAR) as an alternative to proctectomy is unclear. The aim of this study was to evaluate feasibility, morbidity, outcome, and quality of life (QL) in patients with LFSP undergoing intended IAR. PATIENTS AND METHODS: Out of a single institution database, 15 patients with LFSP intended for surgery from 856 patients with CD were selected for follow-up analyses. RESULTS: In 12/15 cases, IAR was carried out while 3/15 patients underwent primary proctectomy due to malignancy (n = 2) or due to patient's wish (n = 1). In one case, IAR revealed unexpected malignancy, which led to secondary proctectomy. In patients with IAR, complete healing of fistulas and stenosis was observed in 46% (n = 5) while 36% (n = 4) of patients showed relapse of fistula and 18% (n = 2) developed restenosis. Ileostomy closure was performed in seven patients from which six patients remained stoma free. QL and fecal incontinence measured by standardized scoring systems were unchanged while stool frequency was reduced after IAR in patients with ileostomy closure. The rate of malignancy in this cohort was 20% (n = 3). CONCLUSION: LFSP in CD was associated with 20% of malignant transformation. Although IAR fails to improve QL, it is a suitable procedure for the treatment of fistulas and stenosis associated with acceptable healing rates and can avoid a permanent stoma.

Neurostimulated levator augmentation--a new approach in restoring continence.

PURPOSE: Restoration of continence remains a major challenge in patients after abdominoperineal rectal excision (APE) or with end-stage fecal incontinence. A new surgical technique, the neurostimulated levator augmentation, was introduced for pelvic floor augmentation using dynamic graciloplasty in order to restore anorectal angulation. The aim of this study was to assess feasibility and efficiency. METHODS: From November 2009 to March 2014, n = 17 patients underwent neurostimulated levator augmentation (n = 10 after APE, n = 5 intractable idiopathic fecal incontinence, n = 2 traumatic anal amputation). Gracilis muscle was transposed through the obturator foramen into the pelvic cavity, positioned in a U-shaped sling behind the rectum, fixed to the contralateral os pubis to restore anorectal angulation, and then conditioned by neurostimulation. Questionnaires analyzing function and quality of life were administered. RESULTS: For neurostimulated levator augmentation, four patients suffered from complications that needed operative intervention (n = 3 wound infection, n = 1 colon perforation); three pharmacological treatment and two complications needed no further invasive intervention. One patient died due to causes unrelated to the operation, and no complication required intensive care management. Fecal incontinence in patients with idiopathic incontinence improved significantly after surgery as well as incontinence episodes, urgency, and disease-specific quality of life through all dimensions. Generic quality of life was significantly better after surgery in all patients. After median follow-up of 17 months (2-45), all but one patient would undergo the procedure again. CONCLUSIONS: Neurostimulated levator augmentation was feasible in all patients with acceptable morbidity. It may represent a new therapeutic option in selected patients with intractable fecal incontinence.

Effects of combined oleic acid and fluoride at sub-MIC levels on EPS formation and viability of Streptococcus mutans UA159 biofilms.

Despite the widespread use of fluoride, dental caries, a biofilm-related disease, remains an important health problem. This study investigated whether oleic acid, a monounsaturated fatty acid, can enhance the effect of fluoride on extracellular polysaccharide (EPS) formation by Streptococcus mutans UA159 biofilms at sub-minimum inhibitory concentration levels, via microbiological and biochemical methods, confocal fluorescence microscopy, and real-time PCR. The combination of oleic acid with fluoride inhibited EPS formation more strongly than did fluoride or oleic acid alone. The superior inhibition of EPS formation was due to the combination of the inhibitory effects of oleic acid and fluoride against glucosyltransferases (GTFs) and GTF-related gene (gtfB, gtfC, and gtfD) expression, respectively. In addition, the combination of oleic acid with fluoride altered the bacterial biovolume of the biofilms without bactericidal activity. These results suggest that oleic acid may be useful for enhancing fluoride inhibition of EPS formation by S. mutans biofilms, without killing the bacterium.

[Organization of further education in general and visceral surgery in a specialized hospital]. / Organisation der Weiterbildung in Allgemein- und Viszeralchirurgie in einer Schwerpunktklinik.

BACKGROUND: The newly implemented further education regulations of the Medical Association of the Federal States leads to changes in for residents in training as well as for licensed trainers. OBJECTIVE: The aim is the illustration of the effect on the residency of general and visceral surgery as well as the additional training for specialized visceral surgery from the perspective of a specialized center. MATERIAL AND METHODS: Comparison of the (model) further education regulations 2018 of the Medical Association of the Federal States with the further education regulations 2004 exemplified by the Bavarian Federal Chamber of Physicians. RESULTS: The documentation effort for the continuous acquisition of competences is clearly increased and also the required reference numbers especially for diagnostic skills in the course of the specialist training in visceral surgery as well as the surgical skills for acquisition of the additional designation of specialized visceral surgery. The designation of medical specialist for general surgery was retained. CONCLUSION: Whether the changes due to the new further education regulations, such as increased documentation effort and the rotation of residents in training that is necessary in most hospitals without resource compensation, will lead to an improvement of specialist training and attraction of the profession in the setting of a specialized center remains to be elucidated.

Secondary Primary Cancer Risk After Radiation Therapy in Rectal Cancer: A Population-Based Cohort Study With Propensity Score Matching.

BACKGROUND: It remains unclear whether radiation therapy (RT) has an impact on the development of secondary primary cancer (SC) in rectal cancer (RC) patients, especially within the true pelvis. AIM: To examine the incidence of SC in a population-based cohort of RC after surgical treatment with or without radiation therapy (RT, NRT). PATIENTS AND METHODS: The epidemiological cohort consisting of 13,919 RC patients with primary M0 stage diagnosed between 1998 and 2019 was collected from cancer registry data of Upper Bavaria. Competing risk analyses were conducted regarding the development of SC on 11 687 first malignancies, stratified by RT/NRT. A propensity score (PS) was generated by logistic regression modeling of RT to repeat competing risk analyses on a PS-matched cohort. RESULTS: The median age (interquartile range) of the epidemiological cohort was 68.9 years (60.4-76.7). About 60.8%, were men, 38.7% had UICC III, 35.8% of tumors were localized lower than 8 cm, 41.3% underwent RT. Only 17.1% of patients older than 80 years at diagnosis received RT. In general, RT patients were 5 years younger than NRT patients (65.9 years [58.0-73.0] vs. 71.3 years [62.4-79.2], P < .0001). The 20-year cumulative incidence of SC was 16.5% in RT and 17.4% in NRT patients (P = .2298). Men with RT had a lower risk of prostate cancer (HR = 0.55, 95%CI [0.34-0.91], P = .0168). In the PS-matched cohort, RT patients had a significantly higher risk of bladder cancer during follow-up (10-year cumulative incidence of 1.1% vs. 0.6% in NRT). The direction of the RT effects in men and women and different tumor sites may cancel each other. CONCLUSION: A protective effect of RT in rectal cancer patients on developing prostate SC by half is reproduced. Further analyses studying the long-term SC risks of RT should essentially focus on stratification by sex, and focus on more recent data.

Quality of life after laparoscopic resection rectopexy.

PURPOSE: This study evaluated continence, constipation, and quality of life (QoL) after laparoscopic resection rectopexy (LRR) for full-thickness rectal prolapse. Results were compared with existing data after perineal rectosigmoidectomy (PRS). METHODS: From May 2003 to February 2008, consecutive patients suffering from full-thickness rectal prolapse undergoing LRR were retrospectively studied. A standardized questionnaire including the Cleveland Clinic Constipation and Incontinence Scores (CCCS and CCIS) as well as general and constipation-related QoL scores (EQ-5D and PAC-QOL) was administered. Results were compared with those after PRS. For statistic analysis, the Wilcoxon test (EQ-5D and EQ-VAS) and two-sample Student's t test (CCCS, CCIS, and PAC-QOL) were used for LRR, for the comparison of both procedures Mann-Whitney test (EQ-5D) and two-sample Student's t test (EQ-VAS, CCCS, CCIS, and PAC-QOL). RESULTS: Eighteen patients, 15 female, aged 58.1 (±20.2) years underwent LRR. Eleven patients completed follow-up. Postoperatively, neither functional outcome nor QoL improved. Two recurrences occurred, morbidity was n = 2, and mortality n = 1. In comparison, patients after PRS benefit from improved constipation, general QoL measures, status of health, and all dimensions of constipation-related QoL. CONCLUSIONS: Patients after LRR do not benefit from improved general nor constipation-related QoL nor improved functional results compared to PRS.

Early-elective single-incision laparoscopic sigmoidectomy for perforated diverticulitis using a totally reusable single-port device.

BACKGROUND: Single-port access (SPA) is an emerging concept in minimally invasive colorectal surgery. The authors report their experience using SPA sigmoidectomy as an early-elective approach to complicated diverticulitis with paracolic abscess. METHODS: Between September 2009 und April 2010, 4 patients underwent SPA sigmoidectomy for Hinchey-I diverticulitis using the reusable X-Cone device. RESULTS: After a median time of antibiotic treatment of 8 days, SPA sigmoidectomy was performed successfully in all patients. The median operative time was 200 minutes (range, 187-221 minutes). No intraoperative or postoperative complications were recorded; the median postoperative hospital stay was 7 days (range, 5-7 days). No incisional hernias were observed at midterm follow-up (median, 11.5 months; range, 8-14 months). CONCLUSIONS: When performed by an experienced laparoscopic surgeon, early-elective SPA sigmoidectomy is a feasible and safe approach to complicated diverticulitis. The reusability of the X-Cone device ensures that the costs of the procedure are not high.

Fast-track rescue weight reduction therapy to achieve rapid technical operability for emergency bariatric surgery in patients with life-threatening inoperable severe obesity - A proof of concept study.

BACKGROUND AND AIMS: Severe obesity (BMI ≥60 kg/m2) in multimorbid patients can be acutely life-threatening. While emergency weight-loss surgery is urgently needed to preserve life, most patients are in an inoperable state. Pre-surgical bridging therapy is required to achieve technical operability through weight reduction. Standard bridging using an intragastric balloon (IB) can achieve operability in 6 months but is unsuitable for some patients in a critical condition. A non-invasive fast-track rescue therapy to achieve very rapid operability is urgently needed. We investigated whether a rescue weight reduction therapy (RWR) consisting of liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, a leucine-rich amino acid infusion and a hypocaloric diet, can accelerate readiness for emergency surgery in patients with acutely life-threatening severe obesity. METHODS: In this proof-of-concept study, prospective data from patients treated with RWR (intervention group 1, n = 26) were mathematically matched with retrospective biometric data of 26 patients with severe obesity (historic control group 2) who underwent standard 6-month bridging with IB. A rating scale was developed to identify patients needing urgent fast-track bridging. RESULTS: Rapid weight loss was observed in all patients on the RWR therapy. All achieved operability after a mean RWR bridging duration of 20.7 ± 6.9 days. Baseline weight was 236.3 ± 35.8 kg in group 1 compared with 230.1 ± 32.7 kg in group 2. Mean body weight loss during RWR was 27.5 ± 14.1 kg, compared with 20.9 ± 10.5 kg in group 2 (P = 0.0629). CONCLUSIONS: Pre-operative bridging using liraglutide in combination with a leucine-rich amino acid infusion and hypocaloric diet was effective in all cases of acutely life-threatening severe obesity, achieving technical operability within only ca. 2-4 weeks. This therapy has potential as a life-saving rescue therapy for multimorbid patients with severe obesity who were previously untreatable. This study is registered at ClinicalTrials.gov (identifier: NCT02616003).