Presurgical assessment of bariatric patients with the Patient Health Questionnaire (PHQ)--a screening of the prevalence of psychosocial comorbidity.

BACKGROUND: Bariatric surgery has gained increasing relevance due to the dramatic rise in morbid obesity prevalence. A sound body of scientific literature demonstrates positive long-term outcome of bariatric surgery in decreasing mental and physical health morbidity. Still, there is a need for a manageable presurgical screening to assess major mental disorders. The aim of this study was to assess the frequency of common psychiatric syndromes in bariatric surgery candidates using a computerized version of the Patient Health Questionnaire (PHQ). METHODS: In a prospective cohort study from August 2009 to July 2011 morbidly obese individuals seeking bariatric treatment were evaluated for mental health disorders using the PHQ (computerized German version). RESULTS: A total of 159 patients were included in this study. The median age of participants was 42 years, the median BMI was 49 kg/m(2). The PHQ revealed a prevalence of 84 % for mental health disorders, 50 % of the participants had three or more mental health disorders. A high somatic symptom burden (46 %), depressive syndromes (62 %) and anxiety disorders (29 %) were the most frequent psychiatric syndromes. The median number of psychiatric syndromes was 3 for women and 1 for men (p = 0.007). No correlation between BMI and a single syndrome or the sum of syndromes was observed. CONCLUSION: 84 % of the patients seeking bariatric treatment were screened positive for at least one mental health disorder. The computerized PHQ with automated reporting appears to be a useful instrument for presurgical assessment of bariatric patients in routine medical settings.

Diversion stoma after colorectal surgery: loop colostomy or ileostomy?

BACKGROUND: The total rate as well as the clinical outcome of anastomotic leakage in colorectal and coloanal anastomosis necessitates a loop stoma for fecal diversion. The aim of this study was to determine the outcome of loop transverse colostomy compared to loop ileostomy as a temporary defunctioning stoma following colorectal surgery with colorectal or coloanal anastomosis. METHODS: Data of 200 patients between January 2003 and January 2009 were analyzed in this two-center study to determine the surgical outcome in patients with loop colostomy (n = 100) in comparison to loop ileostomy (n = 100) for fecal diversion including outcome of stoma creation and complication rates during stoma reversal. RESULTS: During stoma placement, dermatitis and renal insufficiency occurred significantly more often in the loop ileostomy group than in the loop transverse colostomy group (15% vs. 0%; p < 0.001 and 10% vs. 1%; p = 0.005). During stoma reversal, wound infection occurred significantly more often in the loop transverse colostomy group than in the loop ileostomy group (27% vs. 8%; p < 0.001). Time to first defecation was significantly shorter in the loop ileostomy group after both placement and reversal (4 ± 2 vs. 2 ± 1; p < 0.001 and 3 ± 2 vs. 2 ± 1; p < 0.001). Hospital stay was significantly shorter in the loop ileostomy group than in the loop transverse colostomy group after stoma closure (18 ± 15 vs. 13 ± 6; p < 0.001). CONCLUSIONS: Both methods provide a good operative outcome with low complication rates. We do recommend the loop ileostomy in all patients in which dehydration is not to be expected since wound infection rate is lower and hospital stay is shorter during stoma reversal.

Erythropoietin (EPO) influences colonic anastomotic healing in a rat model by modulating collagen metabolism.

INTRODUCTION: Anastomotic failure is one of the most frequent complications in abdominal surgery. During anastomotic healing. the strength of the intestinal tissue nearby is closely related to the accumulation of collagen in interlinked scar tissue. This in turn is influenced, among other things, by single groups of matrixmetalloproteinases, especially collagenases (MMP-1, -8, and -13) and gelatinases (MMP-2 and -9). EPO is known to induce the expression of tissue-inhibitor-of-matrixmetalloproteinases-1 (TIMP-1) and thereby to down-regulate MMPs. MATERIALS AND METHODS: We used a rat as an experimental model and applied a high dose of EPO (5U/g BW s.c.), one dose 24 h before operation (as pre-conditioning) and one dose directly after performing a colonic anastomosis. After 3 and after 5 d, respectively, immunohistochemical stainings for MMP-2, -8, and -9 as well as TIMP-1 were carried out and evaluated semiquantitatively for each layer of the colonic wall. Sirius-red staining and cross-polarization microscopy were evaluated and the collagen I/III ratio calculated. Anastomotic and colonic tissue distal to the anastomosis were used to determine collagen content. RESULTS: We found increased bursting pressure 5 d post-surgery after applying erythropoietin. It was thus shown that EPO influences collagen metabolism and changes the collagen I/III ratio in the colon distal to the anastomosis. The evaluation of immunohistochemistry did not show the expected ubiquitous up-regulation of TIMP-1 and down-regulation of MMPs. Nevertheless, correlations between TIMP-1, MMP-8, and collagen I/III ratio could only be established after the application of EPO. CONCLUSION: Contrary to our hypothesis, the picture of TIMP-1 and of the regulation of the MMPs after the application of EPO is not as clear as expected. EPO improves anastomotic bursting strength and the correlation of TIMP-1, MMP-8, and collagen type I/III ratio can only be seen after the application of EPO.

Experimental investigation of the elasticity of the human diaphragm.

BACKGROUND: Traumatic diaphragmatic ruptures affect mainly the left side. In an experimental study in human corpses we examined the stretch behaviour of the left and right diaphragmatic halves. METHODS: In a total of 8 male and 8 female corpses each diaphragmatic half was divided into 4 different segments. Each segments stretch behaviour was investigated. In steps of 2 N the stretch was increased up to 24 N. RESULTS: In the female the left diaphragm showed a stronger elasticity compared to the right. Additionally the left diaphragm in females showed a higher elasticity in comparison to the left in males. Traumatic diaphragmatic ruptures affect mostly the central tendineous part or the junction between tendineous and muscular part of the diaphragmatic muscle. Accordingly we found a lower elasticity in these parts compared with the other diaphragmatic segments. CONCLUSION: In summary it can be said that albeit some restrictions we were able to determine the elasticity of different diaphragmatic segments quantitatively and reproduceably with our presented method. Thereby a comparison of results of different diaphragmatic segments as well as of both diaphragmatic halves and of both genders was possible.

Intraperitoneally applied gentamicin increases collagen content and mechanical stability of colon anastomosis in rats.

BACKGROUND: Anastomotic leakage remains a serious complication in colorectal surgery, and is being caused by a multitude of factors. Recent reports reveal changes of the extracellular matrix as risk factors as well as gentamicin as a potential agent to influence wound healing. This experimental study was initiated to investigate the influence of intraperitoneally applied gentamicin on colonic anastomotic wound healing and in particular on mechanical stability, overall collagen content and collagen type I/III ratio. MATERIALS AND METHODS: Sixty Sprague Dawley rats were randomized to one of two groups. In each animal, a standard transverse colonic end-to-end anastomosis was performed. Immediately postoperative, either 5 ml gentamicin (1 ml/kg bodyweight) or NaCl 0.9% was applied intraperitoneally. On postoperative days 3, 5, and 14, ten of the animals in each group were sacrificed. Measurements of the anastomosis bursting pressure were performed on postoperative days 3 and 5. At each explantation time, the collagen per protein ratio, the collagen types I/III ratio, and both the expression of MMP-2, -9, and Ki67 were analyzed. RESULTS: None of the animals died. None of the rats exhibited clinical evidence of anastomotic leakage. The bursting strength in the gentamicin group was significantly elevated on postoperative day 5. Both the overall collagen content and the collagen type I/III ratio in the gentamicin group were significantly increased 3, 5, and 14 days postoperatively compared to the control group. The expression of MMP-9 was significantly elevated in the gentamicin group both 3 and 5 days postoperatively. In contrast, there were no significant differences in the expression of MMP-9 14 days postoperatively. All investigated samples demonstrated positive staining for MMP-2 and Ki67 without statistically significant differences at any term, respectively. CONCLUSIONS: The present data confirm that intraperitoneally applied gentamicin is able to enhance healing and stability of colonic anastomosis due to an increase of both the overall collagen content and collagen type I/III ratio.

Direct intra-abdominal pressure monitoring via piezoresistive pressure measurement: a technical note.

BACKGROUND: Piezoresistive pressure measurement technique (PRM) has previously been applied for direct IAP measurement in a porcine model using two different devices. Aim of this clinical study was to assess both devices regarding complications, reliability and agreement with IVP in patients undergoing elective abdominal surgery. METHODS: A prospective cohort study was performed in 20 patients randomly scheduled to receive PRM either by a Coach-probe or an Accurate(++)-probe (both MIPM, Mammendorf, Germany). Probes were placed on the greater omentum and passed through the abdominal wall paralleling routine drainages. PRM was compared with IVP measurement by t-testing and by calculating mean difference as well as limits of agreement (LA). RESULTS: There were no probe related complications. Due to technical limitations, data could be collected in 3/10 patients with Coach and in 7/10 patients with Accurate++. Analysis was carried out only for Accurate++. Mean values did not differ to mean IVP values. Mean difference to IVP was 0.1 +/- 2.8 mmHg (LA: -5.5 to 5.6 mmHg). CONCLUSION: Direct IAP measurement was clinically uneventful. Although results of Accurate++ were comparable to IVP, the device might be too fragile for IAP measurements in the clinical setting. Local ethical committee trial registration: EK2024.

Clinical evaluation of an air-capsule technique for the direct measurement of intra-abdominal pressure after elective abdominal surgery.

BACKGROUND: The gold standard for assessment of intraabdominal pressure (IAP) is via intravesicular pressure measurement (IVP). This accepted technique has some inherent problems, e.g. indirectness. Aim of this clinical study was to assess direct IAP measurement using an air-capsule method (ACM) regarding complications risks and agreement with IVP in patients undergoing abdominal surgery. METHODS: A prospective cohort study was performed in 30 patients undergoing elective colonic, hepatic, pancreatic and esophageal resection. For ACM a Probe 3 (Spiegelberg, Germany) was placed on the greater omentum. It was passed through the abdominal wall paralleling routine drainages. To compare ACM with IVP t-testing was performed and mean difference as well as limits of agreement were calculated. RESULTS: ACM did not lead to complications particularly with regard to organ lesion or surgical site infection. Mean insertion time of ACM was 4.4 days (min-max: 1-5 days). 168 pairwise measurements were made. Mean ACM value was 7.9 +/- 2.7 mmHg while mean IVP was 8.4 +/- 3.0 mmHg (n.s). Mean difference was 0.4 mmHg +/- 2.2 mmHg. Limits of agreement were -4.1 mmHg to 5.1 mmHg. CONCLUSION: Using ACM, direct IAP measurement is feasible and uncomplicated. Associated with relatively low pressure ranges (<17 mmHg), results are comparable to bladder pressure measurement.

Foreign body reaction in vaginally eroded and noneroded polypropylene suburethral slings in the female: a case series.

INTRODUCTION AND HYPOTHESIS: Aim of this study was to investigate the pattern of the foreign body reaction of macroporous polypropylene mesh (MPPM) used in females for the treatment of stress urinary incontinence and to compare this pattern between eroded and noneroded tapes. METHODS: Ten explanted suburethral slings, five eroded and five noneroded, were examined immunohistochemically under light microscopy; the tissue reaction was compared between eroded and noneroded materials. RESULTS: Eroded material showed a significantly higher accumulation of macrophages around the filaments of the mesh. CONCLUSIONS: This is the first study comparing reaction around eroded and noneroded MPPMs and indicates a more intense tissue reaction around eroded mesh, when compared to noneroded material. More studies are needed to prove whether the detected foreign body reaction was the actual trigger for the erosion.

New technical approach for the repair of an abdominal wall defect after a transverse rectus abdominis myocutaneous flap: a case report.

INTRODUCTION: Breast reconstruction with autologous tissue transfer is now a standard operation, but abnormalities of the abdominal wall contour represent a complication which has led surgeons to invent techniques to minimize the morbidity of the donor site. CASE PRESENTATION: We report the case of a woman who had bilateral transverse rectus abdominis myocutaneous flap (TRAM-flap) breast reconstruction. The surgery led to the patient developing an enormous abdominal bulge that caused her disability in terms of abdominal wall and bowel function, pain and contour. In the absence of rectus muscle, the large defect was repaired using a combination of the abdominal wall component separation technique of Ramirez et al and additional mesh augmentation with a lightweight, large-pore polypropylene mesh (Ultrapro). CONCLUSION: The procedure of Ramirez et al is helpful in achieving a tension-free closure of large defects in the anterior abdominal wall. The additional mesh augmentation allows reinforcement of the thinned lateral abdominal wall.