[Safety of patient care on an interprofessional training ward in visceral surgery]. / Sicherheit der Patientenversorgung auf einer viszeralchirurgischen interprofessionellen Ausbildungsstation.

BACKGROUND: Interprofessional training wards (ITW) are increasingly being integrated into teaching and training concepts in visceral surgery clinics. OBJECTIVE: How safe is patient care on an ITW in visceral surgery? MATERIAL AND METHODS: Data collection took place from November 2021 to December 2022. In this nonrandomized prospective evaluation study the frequency and severity of adverse events (AE) in 3 groups of 100 patients each in a tertiary referral center hospital for visceral surgery were investigated. The groups consisted of patients on the ITW and on the conventional ward before and after implementation of the ITW. The Global Trigger Tool (GTT) was used to search for AE. Simultaneously, a survey of the treatment was conducted according to the Picker method to measure patient reported outcome. RESULTS: Baseline characteristics and clinical outcome parameters of the patients in the three groups were comparable. The GTT analysis found 74 nonpreventable and 5 preventable AE in 63 (21%) of the patients and 12 AE occurred before the hospital stay. During the hospital stay 50 AE occurred in the operating theater and 17 on the conventional ward. None of the five preventable AE (in 1.7% of the patients) was caused by the treatment on the ITW. Patients rated the safety on the ITW better than in 90% of the hospitals included in the Picker benchmark cohort and as good as on the normal ward. CONCLUSION: The GTT-based data as well as from the patients' point of view show that patient care on a carefully implemented ITW in visceral surgery is safe.

Online KidClot education for patients and families initiating warfarin therapy: The eKITE study.

Anticoagulation with Vitamin K antagonists (VKA) has always posed challenges in terms of monitoring requirements. These challenges were further exacerbated in the setting of the COVID-19 pandemic, with limited access to and/or avoidance of laboratory testing. The importance of utilizing point of care (POC) health technology for individualized patient management is salient. The foundation of effective home INR monitoring is establishing patient knowledge about their therapy and INR testing proficiency. The eKITE series was developed to support patients in establishing foundational knowledge required for VKA (warfarin) management and INR monitoring. The primary objectives were to evaluate eKITE, a patient-oriented innovative online education program for warfarin therapy, participant learning stress, and patient preference for online learning. This multi-center prospective study provided patients access to warfarin online education. Participants were required to complete written quizzes assessing warfarin knowledge of key concepts proficiency and identifying knowledge deficits. Patient preference, evaluating calm (lack of anxiety) while learning, and an INR on a home meter was completed. Participants performed INR tests at home and reported INRs by telephone. The analysis included 144 children and caregivers enrolled at five US and CDN sites. Most indications for anticoagulation were cardiac (congenital or acquired heart disease) with varied INR target ranges. Mean knowledge scores for warfarin and INR self-testing modules were 97%, with low anxiety with TTR of 84%. Patient preferred online learning. eKITE is an effective teaching modality for warfarin/home INR monitoring with safe INR testing and warfarin management that is appropriate for pediatrics and adults alike. PROLOGUE: The whir in the hallways is deafening. Lights bright, alarms are ringing in a chorus of unsynchronized beeps and screeches. It has been more than a week since I have slept. Snuggled beside me is my precious child, whining and equally irritated with the asynchronous symphony, further compounded by anxiety, procedures, and pain. The sun has broken. The staff smiles are welcoming and incessant, as one after one, they approach hurried, urgent, assiduous, their need to coach me for our upcoming departure to the warmth of home. Each provides essential information that I will require to keep my child, my treasure, safe and healthy. Yet, my eyes are heavy, blurred, and my brain foggy, trapped in a dark heavy cloud. How am I to follow? Comprehend? and retain anything? As they instruct, my precious child yearns for loving arms, compassion and love, whining, crying in disquiet. Overwhelmed does not adequately describe my ineffable exhaustion. Amidst this, how am I to learn about warfarin? Such a challenging medication, with so much to know. Concentrate, I tell myself, focus; now is my only opportunity to learn. I must be alert. It seems to be nonsensical.

Primary percutaneous aspiration and thrombolysis for the treatment of acute embolic superior mesenteric artery occlusion.

OBJECTIVES: To evaluate technical success rate and clinical outcome of patients with acute embolic superior mesenteric artery (SMA) occlusion who were treated with primary percutaneous revascularization. METHODS: At three medical centers the radiological information system databases were used to identify all patients in whom primary percutaneous revascularization for the treatment of acute embolic SMA occlusion was attempted between 2001 and 2010. Percutaneous treatment was performed in 15 patients (median age 80 years, range 49-88 years). These patients represent the study population. Eleven patients reported abdominal pain. Five patients exhibited peritoneal signs. Revascularization was defined as complete technical success if (1) patency of the SMA with residual stenosis of not more than 30% in diameter and (2) sufficient perfusion of the entire bowel were obtained. RESULTS: Complete technical success was achieved in eleven patients. After percutaneous revascularization laparotomy was performed in six patients and in three of them bowel resection was carried out (length of resected segments 20-80 cm). The 30-day mortality was 33% (five of 15 patients). None of the surviving patients exhibited short-bowel syndrome. CONCLUSIONS: Primary percutaneous aspiration and thrombolysis constitutes a promising alternative to surgical revascularization in selected patients with acute embolic SMA occlusion.

[Surgical anatomy of the abdominal wall]. / Chirurgische Anatomie der Bauchdecke.

Knowledge of the anterolateral abdominal wall anatomy is crucial for a surgical approach to the abdominal cavity and for reconstructive surgery of abdominal wall defects. Furthermore it can help the surgeon ensure optimal surgical results by avoiding anatomical complications. This overview presents the surgical relevant anatomy and emphasizes surgical principles and pitfalls in abdominal wall surgery.

Development of an open prospective observational multicentre cohort study to determine the impact of standardization of laparoscopic intraperitoneal onlay mesh repair (IPOM) for incisional hernia on clinical outcome and quality of life (LIPOM-Trial).

BACKGROUND: Incisional hernias are one of the most frequent complications in abdominal surgery. Laparoscopic repair has been widely used since its first description but has not been standardized. A panel of hernia experts with expertise on the subject "incisional hernia" was established to review existing literature and define a standard approach to laparoscopic IPOM-repair for incisional hernia. All involved surgeons agreed to perform further IPOM-repairs of incisional hernia according to the protocol. METHODS/DESIGN: This article summarizes the development of an open prospective observational multicentre cohort study to analyse the impact of a standardization of laparoscopic IPOM-repair for incisional hernia on clinical outcome and quality of life (health care research study). DISCUSSION: Our literature search found that there is a lack of standardization in the surgical approach to incisional hernia and the use of medical devices. The possibility of different surgical techniques, various meshes and a variety of mesh fixation techniques means that the results on outcome after incisional hernia repair are often not comparable between different studies. We believe there is a need for standardization of the surgical procedure and the use of medical devices in order to make the results more comparable and eliminate confounding factors in interpreting the results of surgical hernia repair. This approach, in our view, will also illustrate the influence of the operative technique on the general quality of surgical treatment of incisional hernias better than a "highly selective" study and will indicate the "reality" of surgical treatment not only in specialist centres. TRIAL REGISTRATION: The LIPOM-trial is registered at www.clinicaltrials.gov, with identifier: NCT02089958.

Evidence for increased nitric oxide production after liver transplantation in humans.

To evaluate the role of in vivo-produced nitric oxide (NO) after orthotopic liver transplantation, nitrate, a stable end product of spontaneous NO conversion in blood, was assayed in plasma samples of 32 patients. In 31 patients, nitrate increased from 36 +/- 2 microM to 137 +/- 8 microM within the first 6 postoperative days. In 11 out of 12 patients with an uneventful early postoperative course, nitrate increased from 33 +/- 2 microM to 70 +/- 8 microM, and returned to baseline levels within 2-3 days. In the remaining 20 patients with episodes of rejection and/or infection, the nitrate peak was augmented and prolonged. Ten patients suffering from these events in the later postoperative course showed a second nitrate elevation. In 31 patients, effective plasma levels of cyclosporine were reached 4-5 days after OLT. The patient without significant elevation in plasma nitrate had effective levels already at day 1. After liver resection or coronary bypass grafting, the median nitrate level remained at 21 microM (range 15-36 microM; healthy persons: median 24 microM, range 18-32 microM). After kidney transplantation nitrate was elevated in the early postoperative course. Thus, NO formation appears to be increased after solid organ transplantation, but not after other surgeries. After OLT, the increase appears to occur (a) in response to rejection and/or infection, and (b) 4-6 days after surgery in the absence of overt complications. In the latter case, NO might be involved in subclinical rejection and its production is possibly dependent upon the effectiveness of the immunosuppressive therapy.

Local and systemic reactions after lung contusion: an experimental study in the pig.

The present study was designed to investigate the consequences of isolated unilateral lung contusion on local alveolar and systemic inflammatory responses in an animal model in the pig. Isolated unilateral lung contusion was induced by bolt shot in eight mechanically ventilated animals under general anesthesia (sham: n=4). Plasma and bronchoalveolar lavage fluid were collected during a period of 8 h following lung contusion. Leukocytes, leukocyte neutral protease inhibitor (LNPI), terminal complement complex (TCC), thrombin-antithrombin-complex (TAT) as well as pulmonary microvascular permeability and surfactant function were determined. Within 30 min, lung contusion was found to cause a significant local and systemic increase in TCC and TAT concentrations and a systemic increase in LNPI concentrations. The latter was accompanied by a sequestration of leukocytes in the contused lung. Complement activation and leukocyte sequestration in the contused lung progressively increased during the investigation period. Although surfactant function decreased in the entire lung 30 min after contusion, TCC, TAT, and leukocyte sequestration was unchanged in the contralateral lung. The first indication of an involvement of the contralateral lung was obtained by an increase in leukocyte sequestration 8 h after lung contusion. Unilateral lung contusion initiates an early systemic activation of humoral and cellular defense systems. Involvement of the contralateral lung appears to be a secondary event caused by a systemic inflammatory reaction.

[Open approach or Veress needle in laparoscopic interventions? Results of a prospective randomized controlled study]. / Offener Zugang oder Veress-Nadel bei laparoskopischen Eingriffen? Ergebnisse einer prospektiv randomisierten Studie.

In a prospective randomized study on 50 patients undergoing laparoscopic surgery, the safety and feasibility of open access laparoscopy was analyzed and compared to the closed Veress needle technique. Open access laparoscopic surgery was performed in half the time needed for the Veress needle technique with equal safety and without complications or technical disadvantages. Furthermore, open access offers economical advantages, as disposable trocars are no longer needed. Therefore the open access technique is recommended as the standard for laparoscopic operations.

[How do general surgery patients experience the intensive care unit? Results of a prospective observational study]. / Wie erleben allgemeinchirurgische Patienten die Intensivstation? Ergebnisse einer prospektiven Beobachtungsstudie.

INTRODUCTION: Subjective experiences of patients during their stay in the intensive care unit (ICU) have so far rarely been described. The aim of this study was to analyze the experiences of patients during their stay in the ICU. METHODS: In a prospective study, 100 general surgical ICU patients were recorded consecutively. A questionnaire that covered a broad range of possible ICU experiences was handed out to patients shortly following their stay in ICU. At the same time, a questionnaire was given to the personnel of the ICU to investigate how well nurses and doctors were able to adopt the patients' perspectives of the ICU experience. RESULTS: Concerning the physical symptoms, insomnia was to the fore (67% of patients). Despite pain medication, 25% of patients reported severe pain. The main psychological symptom was a feeling of helplessness (29% of patients). As a general cause for concern, 48% of patients complained about limited mobility. The patients were critical of the presence of severely ill patients. The standards of nursing and medical attention, however, were judged very positively. The evaluation of the staff differed from the patients' experiences in many respects; the clearest differences concerned the items of pain, sleeping disorders and the observance of privacy. CONCLUSIONS: The study results led to several practical consequences in the quality of management procedure (e.g., the introduction of a thorough night's rest at the ICU, optimized information for patients). Additionally, we initiated further studies concerning the quality of life of ICU patients.

[Translaryngeal tracheostomy. Technique and initial results]. / Die translaryngeale Tracheostomie. Technik und erste Ergebnisse.

Translaryngeal tracheostomy is a new type of minimally invasive technique for bedside tracheostomy in intensive care patients. After percutaneous puncture of the trachea below the first tracheal ring, a conic tracheal cannula is fixed to an orally forwarded guide wire. The cannula is then pulled through in orthograde fashion set up, rotated and pushed forward caudally. Among the first 25 translaryngeal tracheostomies in 24 patients, only two complications appeared: one misplacement of the cannula and one infection of the stoma. During a median apnoea time of about 80 s an average PaCO2 increase of 8.0 +/- 6.8 mm Hg was documented; hypoxias could not be seen. Translaryngeal tracheostomy seems to be an appropriate alternative to established tracheostomy methods.

[Is oncological surgery contraindicated in the older patient?]. / Gastrointestinaler Tumor beim alteren Patienten. Wann lohnt noch die Operation?

Almost three-quarters of patients with cancer of the gastrointestinal tract are more than 65 years of age. In the operative treatment of esophageal pancreatic, hepatocellular and colorectal carcinomas, studies show comparable risks for patients under, and those over, 70 years of age. In terms of morbidity, mortality and 5-year mortality rates, attendant risks in the latter do not generally appear to be greater. An increase in the rate of complications, however, has been observed for palliative interventions in colorectal cancer patients. In particular cardiovascular risk factors play a major role in the over-70-year-olds.

[Spleen ruptures after screening colonoscopy]. / Milzruptur nach Vorsorgekoloskopie.

Splenic injury during colonoscopy is a rare but potentially life-threatening complication. The case of an 82-year-old male patient with a ruptured spleen after screening colonoscopy is reported. The predisposing risk factors for a laceration of the spleen during colonoscopy are discussed as well as the diagnostic and therapeutic approaches.

Gastro-pericardial fistula as an early complication after surgery for combined paraesophageal and hiatal hernia.

Open surgery is still used to treat massive combined paraesophageal and hiatal hernias. The operative principles include repositioning of the stomach in the abdomen, resection of the hernia sac, narrowing of the hiatus, and gastropexy. We report on a case in which a life-threatening, gastro-pericardial fistula was an early complication after open surgical treatment.

The perifollicular and marginal zones of the human splenic white pulp : do fibroblasts guide lymphocyte immigration?

We investigate the white pulp compartments of 73 human spleens and demonstrate that there are several microanatomical peculiarities in man that do not occur in rats or mice. Humans lack a marginal sinus separating the marginal zone (MZ) from the follicles or the follicular mantle zone. The MZ is divided into an inner and an outer compartment by a special type of fibroblasts. An additional compartment, termed the perifollicular zone, is present between the follicular MZ and the red pulp. The perifollicular zone contains sheathed capillaries and blood-filled spaces without endothelial lining. In the perifollicular zone, in the outer MZ, and in the T cell zone fibroblasts of an unusual phenotype occur. These cells stain for the adhesion molecules MAdCAM-1, VCAM-1 (CD106), and VAP-1; the Thy-1 (CD90) molecule; smooth muscle alpha-actin and smooth muscle myosin; cytokeratin 18; and thrombomodulin (CD141). They are, however, negative for the peripheral node addressin, the cutaneous lymphocyte antigen, CD34, PECAM-1 (CD31), and P- and E-selectin (CD62P and CD62E). In the MZ the fibroblasts are often tightly associated with CD4-positive T lymphocytes, whereas CD8-positive cells are almost absent. Our findings lead to the hypothesis, that recirculating CD4-positive T lymphocytes enter the human splenic white pulp from the open circulation of the perifollicular zone without crossing an endothelium. Specialized fibroblasts may attract these T cells and guide them into the periarteriolar T cell area.

[Therapeutic concepts in treatment of circulatory and heart failure in surgery]. / Therapiekonzept zur Behandlung von Kreislaufversagen und Herzinsuffizienz in der Chirurgie.

Perioperative circulatory disorders in patients may take the form of a transitory reduction in oxygen transport to the peripheral tissues (pre-shock), manifest circulatory insufficiency in the presence or absence of concomitant heart insufficiency or general congestive heart failure due to the destabilization of an preexisting heart disease. The least problematical stage in this programme of therapy is the treatment of transitory perioperative circulatory insufficiency by manipulation of the oxygen transport system using the following means: comparative volume optimization [according to the central venous pressure (CVP)], positive inotropic support with dobutamine (5-10 micrograms.kg-1.min-1), monitoring of the blood pressure, heart rate and oxygen consumption and, in severe cases, insertion of a Swan-Ganz catheter. In manifest circulatory insufficiency, sepsis or acute congestive heart failure, the Swan-Ganz catheter seems to be obligatory. In such cases, the positive inotropic therapy is based on catecholamines of medium (dobutamine) or high (epinephrine) positive inotropic efficacy, as a normal pattern and functioning of beta-adrenoceptors can be assumed in such cases if there is no history of cardiac insufficiency. The systemic vascular resistance (SVR) is adjusted to 800-1200 n.s.cm-5 to relieve the working capacity of the heart and to maintain sufficient perfusion pressure by means of constrictors (phenylephrine, norepinephrine) or dilators [nifedipine, nitroglycerin or, if necessary, angiotensin-converting-enzyme (ACE) inhibitors].(ABSTRACT TRUNCATED AT 250 WORDS)

[Auxiliary liver transplantation for acute liver failure after intake of 3,4-methylenedioxymethamphetamine ("Ecstasy")]. / Auxiliäre Lebertransplantation bei akutem Leberversagen nach Einnahme von 3,4-Methylendioxymetamphetamin ("Ecstasy").

HISTORY AND CLINICAL FINDINGS: An 18-year-old patient had for 6 days been suffering from right upper abdominal pain, weight loss, vomiting and yellow discoloration of the skin. For the preceding 8 months he had been regularly taking 1-2 tablets of "ecstasy" (3,4-methylenedioxymethamphetamine--MDMA) per week, the last 8 days before the onset of the described signs. Physical examination was unremarkable, except for pain on pressure over the right upper abdomen and the jaundice. INVESTIGATIONS: The activities of SGOT (756 U/I), SGPT (1450 U/I). gamma GT (164 U/I) and lactate dehydrogenase (539 U/I) as well as total bilirubin level (7.5 mg/dl) were elevated. The synthesising functions of the liver were impaired (thromboplastin time 47%, fibrinogen 116 mg/dl). Abdominal sonography was unremarkable. All virological tests (hepatitis A, B, C and D; Epstein-Barr virus; cytomegalovirus; HIV 1 and 2) were negative. TREATMENT AND COURSE: The suspected diagnosis was acute liver failure after "ecstasy" intake. The cholestasis and the parameters of liver synthesis and hepatocellular functions deteriorated under symptomatic treatment. 15 days after onset of the first symptoms progressive hepatic encephalopathy occurred and required heterotopic auxiliary liver transplantation (piggy-back technique). 5 months later hepatobiliary sequential scintigraphy demonstrated regenerating of the patient's own liver an atrophy of the transplanted liver. Immunosuppression with cyclosporin A and prednisolone was gradually reduced, and the transplant was removed 6 months postoperatively because of an abscess in it. 11 months after the transplantation liver functions is normal and the patient well. CONCLUSION: In young patients with jaundice of unknown origin toxic hepatitis after "ecstasy" intake should be considered. Auxiliary liver transplantation can lead to regeneration during temporary relief of the patient's own liver. After its function has been restored immunosuppression is no longer needed.

Stimulated cortisol secretion is not correlated with prednisone dose or with steroid side-effects in children after renal transplantation.

Impairment of adrenocortical function and other adverse effects have to be considered whenever corticosteroids are applied for a prolonged period of time. We hypothesized that the assessment of adrenal function with adrenocortiocotropin (ACTH) stimulation reflects the sensitivity to corticosteroids and would predict the development of side-effects in pediatric patients on triple immunosuppression after renal transplantation.

[The concept of lung and heart-lung preservation within the scope of multiple organ procurement]. / Konzept zur Lungen- und Herz-Lungen-Präservation im Rahmen der Multiorganentnahme.

Preservation of the lung is still one of the most challenging problems, because due to limited procurement time not all organs available can be used. The most common procurement technique is flush perfusion of the pulmonary artery system. Alternative methods in clinical use are either the autologous working heart-lung preparation or donor core-cooling (DCC). The own concept presented here, modified to the special demands of multi-organ-procurement, combines DCC and interstitial equilibration adapted to intracellular ion concentration. DCC is induced by extracorporeal circulation (ECC) using a transportable heart lung machine including a highly effective cooling system: cooling circuit based on two parallel heat exchangers with ice-water cooling produced by a high-pressure overflow of a low-temperature ice block (-40 degrees C). While cooling by ECC stepwise hemodilution is achieved by priming volume and incorporation of the cardioplegic solution (Bretschneider-HTK). The aim of equilibration is to lower the extracellular levels of sodium and calcium, and to increase the level of potassium. Additionally, the buffer capacity of donor blood is increased by the incorporated histidine-buffer system (alpha-stat). To avoid donor organ edema the time of ECC should be as short as possible. Using our system donor organ temperatures below 10 degrees C are reached within less than 30 min. In addition to ECC, lung surface cooling is achieved by external overflow with cold arterial blood (internal mammary artery). Besides lung preservation the main advantage of this concept is the profound precooling of all visceral organs before their individual flush perfusion.

Management of nephroblastoma with intracardiac extension: three case reports and review of the literature.

A single institution's experience of three patients with nephroblastoma extending via the inferior vena cava to the right heart is described. The case reports and the pertinent literature illustrate that preoperative failure to detect the intracardial extension increases the risk of right outflow obstruction and pulmonary embolism during or after surgery. Simultaneous thoraco-abdominal surgery with total circulatory arrest is advocated to remove the cardiac and caval tumor together with the primary tumor in order to prevent sudden hemodynamic and embolic complications. Noninvasive diagnostic methods usually suffice to detect this rare complication of nephroblastoma and to plan an interdisciplinary surgical procedure. The presence of this complication should not worsen the stage- and histology-related prognosis of the patient.