Preemptive endoluminal vacuum therapy to reduce anastomotic leakage after esophagectomy: a game-changing approach?

Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien-Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0-26.2). PEVT appears to be a safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.

Endoscopic and histopathologic reflux-associated mucosal damage in the remnant esophagus following transthoracic esophagectomy for cancer-5-year long-term follow-up.

Gastroesophageal reflux is a common problem following esophagectomy and reconstruction with gastric interposition. Despite a routine prescription of proton pump inhibitors, reflux-associated mucosal damage in the remnant esophagus is frequently observed. Purpose of this study is to evaluate mucosal damage in the esophageal remnant during long-term follow-up and to compare the prevalence of this damage between the subgroups of esophageal squamous cell and adenocarcinoma. All patients undergoing transthoracic Ivor-Lewis esophagectomy were prospectively entered in our IRB approved database. All patients underwent a routine check-up program with yearly surveillance endoscopies following esophagectomy. Only patients with a complete follow-up were included into this study. Endoscopic and histopathologic mucosal changes of the remnant esophagus were analyzed in close intervals. A total of 50 patients met the inclusion criteria, consisting of 31 adenocarcinomas (AC) and 19 squamous cell carcinomas (SCC). Mucosal damage was already seen 1 year after surgery in 20 patients macroscopically (43%) and in 21 patients microscopically (45%). At 5-year follow-up the prevalence for macroscopic and microscopic damage was 55% and 60%, respectively. The prevalence of mucosal damage was higher in AC patients than in SCC patients (1y-FU: 51% [AC] vs. 28% [SCC]; 5y-FU: 68% [AC] vs. 35% [SCC], P < 0.05). Newly acquired Barrett's esophagus was seen in 10 patients (20%) with two of those patients (20%) showing histopathologic proof of neoplasia. This study shows a high prevalence of reflux-associated mucosal damage in the remnant esophagus one year out of surgery and only a moderate increase in prevalence in the following years. Mucosal damage was more frequently seen in AC patients and the occurrence of de-novo Barrett's esophagus and de-novo neoplasia was high. Endoscopic surveillance with targeted biopsies seems to be an indispensable tool to follow patients after esophagectomy appropriately.

The cag PAI is intact and functional but HP0521 varies significantly in Helicobacter pylori isolates from Malaysia and Singapore.

Helicobacter pylori-related disease is at least partially attributable to the genotype of the infecting strain, particularly the presence of specific virulence factors. We investigated the prevalence of a novel combination of H. pylori virulence factors, including the cag pathogenicity island (PAI), and their association with severe disease in isolates from the three major ethnicities in Malaysia and Singapore, and evaluated whether the cag PAI was intact and functional in vitro. Polymerase chain reaction (PCR) was used to detect dupA, cagA, cagE, cagT, cagL and babA, and to type vacA, the EPIYA motifs, HP0521 alleles and oipA ON status in 159 H. pylori clinical isolates. Twenty-two strains were investigated for IL-8 induction and CagA translocation in vitro. The prevalence of cagA, cagE, cagL, cagT, babA, oipA ON and vacA s1 and i1 was >85%, irrespective of the disease state or ethnicity. The prevalence of dupA and the predominant HP0521 allele and EPIYA motif varied significantly with ethnicity (p < 0.05). A high prevalence of an intact cag PAI was found in all ethnic groups; however, no association was observed between any virulence factor and disease state. The novel association between the HP0521 alleles, EPIYA motifs and host ethnicity indicates that further studies to determine the function of this gene are important.

Sexual dimorphism in developmental and diet-dependent circulating retinol binding protein 4.

OBJECTIVE: Retinol binding protein 4 (RBP4) transports vitamin A (Retinol) in the blood and contributes mechanistically to the linkage between obesity, insulin resistance and associated comorbidities including type 2 diabetes mellitus, coronary artery and neoplastic diseases. Circulating RBP4 levels have variably been associated with body mass and gender differences. Many of these differences have been demonstrated after limited dietary interventions, and/or at single unique time points. This study investigated the impact of sex and age as biologic variables as well as high versus low fat diets on development of obesity, RBP4 levels and insulin resistance in C57BL/6J mice. METHODS: Male and female C57BL/6J mice were fed for 400 days with either low or high fat diets. Female mice were also evaluated on same diets after ovariectomy or sham ovariectomy. Mice were monitored for changes in weight, circulating levels RBP4, glucose and insulin at 100-day intervals and also by 2-hour glucose tolerance tests. RESULTS: All mice on low or high fat diets gained weight. Mice on high fat diets showed significantly greater weight gain than those on low fat. Male mice showed significantly greater weight gain compared with females on corresponding diet. Male mice compared with females already showed significantly higher RBP4 levels even before starting diets. Sex differences were maintained for more than 1 year. Gender differences in RBP4 were associated with significant differences in development of glucose intolerance and insulin resistance. CONCLUSIONS: Male compared with female C57BL/6J mice show significant gender differences in circulating RBP4 levels from 6 weeks of age, extending more than 1 year. Gender differences in RBP4 may be mechanistically associated with protection against glucose intolerance and insulin resistance. Targeting RBP4 pathways could be useful to disrupt gender differences in insulin resistance and disparities in comorbidities.

[Surgical anatomy of the carpal tunnel]. / Chirurgische Anatomie des Karpaltunnels.

The carpal tunnel is the pathway between the flexor compartment of the distal forearm and the midpalmar space of the hand. It contains all the long finger and thumb flexor tendons including the median nerve. In cases of a discrepancy between the volume of the carpal tunnel in relation to its contents, high pressures in this region can result. There is a risk that the median nerve will be sustained by compression. The carpal tunnel is covered by the flexor retinaculum. Length and width of the retinaculum correspond to the extension of the tunnel. Radial und ulnar osseous walls can narrow the tunnel diameter as well as an prominent capitate bone at the floor. The median nerve normally courses the tunnel radially near the middle of the flexor retinaculum far reaching straight to the midpalmar region. Several deviations of its tunnel course, atypical divisions, accessory branches and variations of the ramification of the thenar branch of the median nerve are described.

[Humeroradial plica: frequency and visualization on MRI]. / Plica humeroradialis: Inzidenz und MR-tomographische Darstellbarkeit.

PURPOSE: To determine frequency and size of a humeroradial plica and correlate it with degenerative changes, and to determine frequency of the visualization of a synovial fold on MR-Images (T1-weighted spin-echo and STIR sequences) and correlate it with degenerative changes. MATERIALS AND METHODS: Forty-two elbow specimens were dissected and studied for humeroradial synovial folds (small, medium, large) and degenerative changes (absent, medium, strong), and 88 elbow MR-images were analyzed for a synovial fold (not visible, small, large) and degenerative changes (absent, medium, strong). Comparison was performed using the chi (2) test. RESULTS: Dissections revealed a synovial fold in all cases. The sizes were small in n = 13 (31 %), medium in n = 24 (57 %), and large in n = 5 (12 %). Degenerative changes were absent in n = 9 (21.4 %), medium in n = 29 (69 %), and strong in n = 4 (9.6 %). On MRI the synovial fold was not visible in n = 67 (76 %), small in n = 12 (14 %), and large in n = 9 (10 %). Degenerative changes on MRI were absent in n = 65 (74 %), medium in n = 15 (17 %), and strong in n = 8 (9 %). The size of the fold correlated positively with degenerative changes in the specimen but not with degenerative changes on MRI. The T1-SE sequence was superior to the STIR sequence in revealing the synovial fold. DISCUSSION: A humeroradial plica is a regular finding, but visualized by MRI in only approximately 20 %, probably due to its variable size. Its visualization succeeds best with T1-spin-echo sequences.

[Magnetic resonance imaging (MRI) of the bursa around the knee joint]. / Magnetresonanztomographie (MRT) der Bursae um das Kniegelenk.

INTRODUCTION: Since fluid filled bursae lead to visible structures on MR images it is important to establish criteria to recognize them and to differentiate them from tumorous fluid-like structures. With this study the bursae around the knee joint were analyzed for potential differential diagnostic criteria such as localisation, size and shape. MATERIAL AND METHODS: In a retrospective study of 133 MR exams the frequency, localization and morphology were registered. The frequency of occurrence was correlated with the frequency of an effusion by means of the chi 2 test. RESULTS: The most frequently recognized bursae were bursa subtendinea musculi gastrocnemii medialis (54.9%), bursa musculi semimembranosi (21%), and bursa infrapatellaris profunda (18.8%). 8 different bursae were identified in complete. Size roanged from 2 to 18 mm. The shape was round and ovoid. The bursa subtendinea musculi gastrocnemii medialis and bursa musculi semimembranosi correlated with the occureance of an effusion. CONCLUSION: Bursae around the knee are frequently visualized as asymptomatic fluid like structures. Knowledge of the typical localization, size and contour is important for identification and differentiation diagnosis against ganglia, cysts or joint recesses.

[Distribution of hematopoietic and fatty bone marrow in the proximal humerus and scapula: magnetic resonance tomography and macroscopic anatomy]. / Verteilung von hämatopoetischem und fettreichem Knochenmark im proximalen Humerus und in der Skapula: Magnetresonanztomographie und makroskopische Anatomie.

PURPOSE: To establish the distribution pattern of haematopoietic and fatty bone marrow on MRI of the proximal humerus and the scapula in correlation with age, gender and nutritive factors. MATERIAL AND METHODS: 32 shoulder MR examinations (T1-weighted spin-echo and opposed-phase gradient-echo sequences) from 24 patients and 8 volunteers were analysed retrospectively. The amount of haematopoietic bone marrow within the proximal humerus and scapula was classified into four groups and was correlated with age (H-test), gender (chi 2-Test), and thickness of subcutaneous fat (H-test). The marrow distribution within 10 scapulae of cadavers over 60 years of age at death was studied. RESULTS: With increasing age, the amount of haematopoietic bone marrow in the proximal humeral metaphysis tends to decrease from lateral towards medial (H-test, p = 0.3). Diaphysis and epiphysis did not show haematopoietic marrow. The amount of haematopoietic bone marrow within the paraglenoid region of the scapula also revealed a decrease with increasing age (H-test, p = 0.003). Females had higher amounts of haematopoietic marrow than males (chi 2-test, p = 0.03). The thickness of subcutaneous fat was independent of the marrow distribution. CONCLUSION: The amount of haematopoietic bone-marrow of the shoulder girdle decreases with increasing age. The knowledge of marrow distribution patterns based upon these changes is important for shoulder MRI interpretation to prevent confusion with infiltrative disease.

[Clinical anatomy of the fat body in the forearm and in the palm]. / Klinische Anatomie der Fettkörper am Unterarm und an der Hohlhand.

In the hand the space between the deep flexor tendons and the interosseous fascia is named the midpalmar space, spatium palmare medianum. A fat body, Corpus adiposum palmare profundum, can be found there regularly. Despite the anatomical narrowness in this region, it reaches up into the carpal canal. Also in the deep forearm space there is always a fat body, Corpus adiposum profundum antebrachii, located dorsally to the deep flexor tendons, lying on the palmar fascia of the pronator quadratus muscle. Usually it is not connected to the Corpus adiposum palmare profundum. The regular occurrence of both fat bodies indicates their functional importance. It is to be supposed that they serve as a gliding layer for the deep flexor tendons. Especially the Corpus adiposum palmare profundum may provide an essential protecting function to the dorsally located deep branch of the ulnar nerve and deep palmar arch. In contrast there is a higher risk of mechanical irritation and compression of the deep branches of the ulnar nerve and artery during their more proximal course through the opponens muscle of the little finger ("opponens-canal") and the ulnar marginal septum. Characteristic features of dimensions and location of the Corpus adiposum profundum antebrachii and the Corpus adiposum palmare profundum and of the deep branches of the ulnar nerve and artery are described. The clinical relevance is discussed.

Topographical anatomy of the posterior elbow region during fetal development.

We studied the topography of the elbow region with special regard to the ulnar nerve during fetal life. Plastinated 600 microns thick sections through the right and left arms of ten fetuses with a crown-rump length (CRL) of 105 to 360 mm and of a newborn infant were investigated. The ulnar groove does not appear on the dorsal side of the medial humeral epicondyle earlier than at a crown-rump length of 130 mm. It provides the entrance into a formerly described fibro-osseous tunnel called the cubital tunnel. Its floor is formed by the posterior bundle of the ulnar collateral ligament, which bulges medially on flexion of the elbow joint. Up to 270 mm CRL it is composed of rather loosely arranged connective tissue fibres. Later on, its fibres are densely packed and show a parallel orientation. The ulnar nerve is pushed medially but remains behind the medial epicondyle. None of the specimens showed displacement to the anterior site of the elbow joint. An aponeurotic arch bridging the humerus and ulna and covering the ulnar nerve medially could not be identified. The findings in the newborn infant did not reveal any significant differences compared to the fetal specimens.

Vascularization of the fetal elbow joint.

Unlike the adult tissue, prenatal cartilage may be well vascularized. We studied the prenatal development of vascular channels within the epiphyses of the human elbow joint. Plastinated 200-1000 microns thick sections through the right and left arms of 12 fetuses with a crown-rump-length of 90-360 mm and of a newborn infant were investigated. Cartilage canals first develop within the distal humeral epiphysis, later on within the olecranon process and the radial head. With advancing age, the canals reveal an increasingly complex pattern of distribution. However, a constant basic pattern can be recognized at every developmental stage. The cartilage canals take their origin from the perichondrium. At their point of entrance into the cartilaginous tissue, their walls are often ill-defined and consist of several fibrous layers which gradually irradiate into the cartilage. At the opposite tip, the channel wall is more clearly demarcated. Many cartilage canals contain several vessels forming loops or branching into bunch-like structures at the tip of the canals. The vessels mostly lie adjacent to the canal walls, grouped around a core of loose connective tissue. As a rule different channels run towards the centre of the cartilage and do not form any anastomoses. The vascularization of the epiphyses of the human elbow joint takes place a long time before the secondary centres of ossification develop, which normally appear after birth. Thus, a direct causal relationship seems unlikely.

Clinical anatomy of the subcutaneous veins in the dorsum of the hand.

Ninety adult upper extremities from human cadavers were used to study the patterns of the subcutaneous veins in the dorsum of the hand, with careful dissection and measurement under magnification. In our series, the distribution of the veins was not symmetrical in the dorsum of the hand. In 83.3% of the cases, the veins were arranged in two groups, radial and ulnar, above the transverse midline of the dorsum. The area between these two groups, corresponding to the proximal halves of the second metacarpal bone, the second intermetacarpal space and the third metacarpal bone, might be called "vein lacking area". Crossing branches of veins were found in all cases. There were on average three crossing branches in each case, and their internal diameters were 0.9 +/- 0.2 mm. This study established that the subcutaneous veins in the dorsum of the hand are arranged in two layers. They communicate freely with the veins in the palmar aspect through the intermetacarpal spaces. The average number of perforating branches was 3.9, and their internal diameters were 1.0 +/- 0.4 mm. The perforating branch in the first intermetacarpal space was wide (internal diameter: 1.8 +/- 0.3 mm) and very constant (appearance rate: 100%). This branch may be the most important communication between the superficial and deep veins. We found the venous values in 70.0% of the perforating branches, which prevent the blood flowing from the dorsum to the palm.

[Prenatal development of the radial annular ligament]. / Die pränatale Entwicklung des Ligamentum anulare radii.

The prenatal development of the annular ligament of the elbow was studied by investigating 600 microns thick plastinated sections through the elbow joints of nine fetuses with a crown-rump-length (CRL) of 105-360 mm. At 105 mm CRL the annular ligament consists of one layer of circular fibres around the circumference of the radial head. At 130 mm CRL it extends further distally to the radial neck. The postero-lateral region exhibits an arrangement of three layers of fibres of different course. Stages later than the 190 mm stage show in the anterior region external fibres arising from the medial periosteum of the ulna. They pass over the anterior surface of the ulna and blend with fibres arising from the anterior margin of the ulna's radial notch to surround the radial head. At 270 mm the articular capsule can be recognized as a strong homogenous layer of fibres. With all stages investigated the annular ligament consists of circular fibres only near the attachment at the posterior margin of the ulna's radial notch. Anteriorly the annular ligament is narrower than posteriorly. With the later stages of 290, 330 and 360 mm CRL a further differentiation of the annular ligament cannot be recognized. Thus, between 105 mm and 270 mm CRL, the annular ligament develops a more and more complex structure similar to that described for the adult joint. We describe several distinct steps of this differentiation during the fetal period which are not mentioned in the literature yet.

Cutaneous ligaments of the human hand.

A topographical study concerning the cutaneous ligaments of adult as well as human fetal hands was performed. In order to be able to preserve the cutaneous ligaments in their entirety two different methods, a careful dissection and a new histological technique, have been employed. The results of these methods are compared and the detailed topography of the different cutaneous ligaments is clarified. In addition to topographical details, the functional co-operation of the ligaments especially in regard to their clinical relevance is reported.

[Surgical anatomy of the distal radio-ulnar joint and the ulno-carpal joint compartment]. / Chirurgische Anatomie des distalen Radioulnargelenkes und des ulnokarpalen Gelenkkompartimentes.

Variations in length ratios of both radius and ulna directly influence the profiles of the distal radioulnar joint. During pronation and supination, joint surface incongruity of the two forearm bones permits rotational and translational movements. The ulnocarpal discuss is the central part of the ulnocarpal complex. Together with radioulnar and ulnocarpal ligaments, the ulnocarpal meniscus, the tendon sheath of the extensor carpi ulnaris muscle, the ulnar collateral ligament, and accessory fiber strands the complex guides movements such as pronation and supination and stabilizes the proximal and distal carpal joint.

[A rare anomaly of the superficial flexor tendons of the little finger]. / Eine seltene Anomalie der oberflächlichen Beugesehnen am Kleinfinger.

A rare anomaly was found in both hands of an eighty-five-year old female. The muscle bellies of the superficial finger flexor muscle for the little finger were absent. Instead of this, a thin tendinous cord arose from the tendon of the flexor superficialis of the ring finger proximal to the carpal tunnel to pass into the radial side of the flexor tendon sheath of the little finger at the level of the annular ligament A 1. Together with an abortive tendon on the ulnar side the tendon inserted into the middle phalanx. The flexor digitorum profundus muscle of the little finger was normal.

[Clinical anatomy of the interosseous arteries of the forearm]. / Klinische Anatomie der interossären Arterien des Unterarmes.

In recent years, several local flaps have been developed, based on the anterior and posterior interosseous arteries and their anastomoses at the wrist (e.g. posterior interosseous flap, pronator quadratus flap etc.). The anatomy of the arterial network supplying the flap is well established in both clinical and anatomical literature. Most authors agree in the constancy of the anastomoses between the interosseous arteries at the wrist and the absence of major anatomical variations excluding the use of the flap. In the present study, which is based on cadaver dissections of 60 preserved specimens, several gross vascular variations of the interosseous arteries have been found. The most frequent types were an additional anastomosis between the posterior interosseous artery and a perforating branch of the anterior interosseous artery in the middle third of the forearm, which was found in 20%. Ring-formations of the palmar and the dorsal branch of the anterior interosseous artery occurred in 5%. The point of perforation of the interosseous membrane by the dorsal branch of the anterior interosseous artery was found to vary in a larger extent, as described previously.

[The metacarpal ligament of the thumb. Topography and functional significance of a heretofore unknown fiber tract of the thumb and its anatomic relationship to the internal interosseus muscle]. / Das Ligamentum metacarpale pollicis. Topographie und funktionelle Deutung eines bisher unbekannten Faserzuges am Daumen und seine Lagebeziehungen zum M. interosseus internus.

During cadaver dissections of the thenar muscles of 81 human hands, we found a distinct ligament at the palmar side of the first metacarpal in 58% ([symbol: see text] 47 hands). This not previously described ligament crosses the princeps pollicis artery regularly. The ligament arises from the base of the first metacarpal bone in 83%. Sometimes (in 15%) it arises from the trapezium or from the middle portion of the first metacarpal bone in one case. The primary insertion of this ligament is the ulnar sesamoid. We have named these fibres "metacarpal ligament of the thumb". It could be classified into five different types. We think that this ligament is helpful in the stabilisation of the ulnar sesamoid. Besides it fixes the princeps pollicis artery to the metacarpal bone and therefore it is possible that it could compress the artery. Maybe the "metacarpal ligament of the thumb" is a rudiment of the interosseous muscles of the thumb or of the deep head of the flexor pollicis brevis muscle or of the oblique head of the adductor pollicis muscle. There is a very close topographic relationship between this ligament and the "internal interosseous muscle" of the thumb which was described by Schmidt and Lanz (1992) and which was mentioned by Henle (1858), who named it "M. interosseus volaris primus" for the first time. We could isolate this muscle in 69%.

[Pulleys of the tendon sheath of the flexor pollicis longus muscle]. / Die Verstärkungsbänder der Sehnenscheide des M. flexor pollicis longus.

The fibrous wall of the flexor tendon sheath of the thumb is reinforced by pulleys similar to those in the fingers. As cited in the literature, there are two annular pulleys A 1 and A 2 and one oblique pulley. On the basis of our investigations, this distribution was found only in 10%. In 90%, the proximal (A 1) and the distal pulley (A 2) can be seen. However, between these two annular pulleys a Y-shaped fiber complex can be dissected at the level of the base and the shaft of the proximal phalanx. This complex can be further divided into an annular part (proximal) and an oblique part (distal). The annular part is associated with the tendon insertion of the adductor pollicis muscle. The oblique part arises distal from the annular part from the ulnar side of the tendon sheath, running to the radial side of the proximal phalanx interwoven with the interphalangeal joint capsule and the palmar plate. Some fiber strands continually pass into the cutaneous ligaments of Cleland. Thin accessory pulley fibers were found between the annular pulley A 1 and the annular part of the Y-shaped fiber complex in 9.5% and in 20.6% between the oblique part and the annular pulley A 2.

[The Architecture of the Fibrous Complex between the Palmar Aponeurosis and the Flexor Retinaculum]. / Zur Architektur des palmaren Faserkomplexes zwischen Palmaraponeurose und Retinaculum flexorum1.

Summary. During cadaver dissections of 34 adult human hands (fixed in formaldehyd solution), we examined a fibrous complex at the distal end of the flexor retinaculum. This fibrous complex was first mentioned by Legueu and Juvara (1892). It is located always ulno-dorsally to the attachment of the palmaris longus tendon into the palmar aponeurosis. Measurements of this special connective tissue show a mean length of 18.6 mm, a mean height of 4.3 mm and a mean width of 3.1 mm.Also, we looked for the fibrous complex in six adult plastinated transverse sections and in 12 fetal hands where it occurred in a constant way. We also found a very close topographic relationship between these oblique criss-crossed fibers and the palmar cutaneous branch of the median nerve. This nerve regularly gives some ulnar branches to the fibrous complex. The clinical relevance of the fibrous complex is discussed in relationship to a carpal tunnel syndrome. The described transverse fibers of the connective tissue complex are in danger as well as the ulnar branches of the palmar cutaneous nerve when releasing the flexor retinaculum during operation.