Introducing a gatekeeping system for amyloid status assessment in mild cognitive impairment.

BACKGROUND: In patients with mild cognitive impairment (MCI), enhanced cerebral amyloid-ß plaque burden is a high-risk factor to develop dementia with Alzheimer's disease (AD). Not all patients have immediate access to the assessment of amyloid status (A-status) via gold standard methods. It may therefore be of interest to find suitable biomarkers to preselect patients benefitting most from additional workup of the A-status. In this study, we propose a machine learning-based gatekeeping system for the prediction of A-status on the grounds of pre-existing information on APOE-genotype 18F-FDG PET, age, and sex. METHODS: Three hundred and forty-two MCI patients were used to train different machine learning classifiers to predict A-status majority classes among APOE-ε4 non-carriers (APOE4-nc; majority class: amyloid negative (Aß-)) and carriers (APOE4-c; majority class: amyloid positive (Aß +)) from 18F-FDG-PET, age, and sex. Classifiers were tested on two different datasets. Finally, frequencies of progression to dementia were compared between gold standard and predicted A-status. RESULTS: Aß- in APOE4-nc and Aß + in APOE4-c were predicted with a precision of 87% and a recall of 79% and 51%, respectively. Predicted A-status and gold standard A-status were at least equally indicative of risk of progression to dementia. CONCLUSION: We developed an algorithm allowing approximation of A-status in MCI with good reliability using APOE-genotype, 18F-FDG PET, age, and sex information. The algorithm could enable better estimation of individual risk for developing AD based on existing biomarker information, and support efficient selection of patients who would benefit most from further etiological clarification. Further potential utility in clinical routine and clinical trials is discussed.

Use of a gamma-2 herpesvirus as a vector to deliver antibodies to rhesus monkeys.

The gamma-2 herpesvirus of rhesus monkeys, rhesus monkey rhadinovirus (RRV), persists principally in B cells of its host. We constructed recombinant strains of RRV expressing the rhesus monkey-derived anti-SIV monoclonal antibodies 4L6 and 5L7 and compared the RRV-mediated in vivo delivery of these antibodies in rhesus monkeys with previous studies that utilized intramuscular delivery with an adeno-associated virus (AAV) vector. Recombinant RRV-4L6 and RRV-5L7 were both shown to stably produce the antibodies in persistently infected B-cell lines in culture. Two RRV-negative rhesus monkeys were experimentally infected with recombinant RRV-4L6 and two with recombinant RRV-5L7. Following infection, the appearance of the delivered antibody was readily detected in all four animals. However, the levels of the delivered antibody were considerably lower than what has been typically observed following intramuscular AAV delivery. Furthermore, three of the four monkeys had an antibody response to the delivered antibody as had been observed previously with intramuscular AAV delivery of these same antibodies. We conclude that this recombinant herpesvirus has no inherent advantage over AAV for delivery of potentially therapeutic monoclonal antibodies in a rhesus monkey model.

Genome-wide association study of pathological gambling.

BACKGROUND: Pathological gambling is a behavioural addiction with negative economic, social, and psychological consequences. Identification of contributing genes and pathways may improve understanding of aetiology and facilitate therapy and prevention. Here, we report the first genome-wide association study of pathological gambling. Our aims were to identify pathways involved in pathological gambling, and examine whether there is a genetic overlap between pathological gambling and alcohol dependence. METHODS: Four hundred and forty-five individuals with a diagnosis of pathological gambling according to the Diagnostic and Statistical Manual of Mental Disorders were recruited in Germany, and 986 controls were drawn from a German general population sample. A genome-wide association study of pathological gambling comprising single marker, gene-based, and pathway analyses, was performed. Polygenic risk scores were generated using data from a German genome-wide association study of alcohol dependence. RESULTS: No genome-wide significant association with pathological gambling was found for single markers or genes. Pathways for Huntington's disease (P-value=6.63×10(-3)); 5'-adenosine monophosphate-activated protein kinase signalling (P-value=9.57×10(-3)); and apoptosis (P-value=1.75×10(-2)) were significant. Polygenic risk score analysis of the alcohol dependence dataset yielded a one-sided nominal significant P-value in subjects with pathological gambling, irrespective of comorbid alcohol dependence status. CONCLUSIONS: The present results accord with previous quantitative formal genetic studies which showed genetic overlap between non-substance- and substance-related addictions. Furthermore, pathway analysis suggests shared pathology between Huntington's disease and pathological gambling. This finding is consistent with previous imaging studies.

Long-term outcomes after endothoracic sympathetic block at the T4 ganglion for upper limb hyperhidrosis.

BACKGROUND: The aim of this study was to evaluate long-term results, quality of life, satisfaction and compensatory sweating after endothoracic sympathetic block at T4 (ESB4). METHODS: Patients who underwent an ESB4 procedure for palmar or palmoaxillary hyperhidrosis between 2001 and 2008 were included in a prospective study at a university hospital. Questionnaires devised by Keller and Milanez de Campos were applied to evaluate disease-specific quality of life. RESULTS: A total of 189 patients underwent 374 ESB4 procedures. Of 174 evaluated patients, 54 (31·0 per cent) had palmar and 120 (69·0 per cent) had palmoaxillary hyperhidrosis. Median follow-up was 92 months. In both groups, treatment successfully reduced hyperhidrosis (P < 0·001) and quality of life increased significantly after ESB4 (P < 0·001), remaining stable after 5 years. Overall satisfaction rates decreased owing to the development of compensatory sweating and recurrence during follow-up. Compensatory sweating affected 41 patients (23·6 per cent), and was severe in 11 (6·7 per cent) of 163 patients at 5-year follow-up; eight of these 11 patients had been treated for palmoaxillary sweating. The severity of compensatory sweating did not deteriorate with time. The severe recurrence rate increased to 11·0 per cent during follow-up, and was twice as common in patients treated for palmoaxillary sweating as in those treated for palmar sweating (13·2 versus 6·1 per cent respectively). Nine reoperations (5·2 per cent) were performed for persistent sweating, recurrence or compensatory sweating. CONCLUSION: T4 endothoracic sympathetic clip application is safe and effective in patients with upper limb hyperhidrosis, with stable long-term improvements in quality of life.

Changes in drinking behavior among control group participants in early intervention studies targeting unhealthy alcohol use recruited in general hospitals and general practices.

BACKGROUND: This study aims to analyze the influence of setting variables on drinking behavior in patients with unhealthy alcohol consumption recruited proactively in general medical practices (GP) and internal and surgical wards of two general hospitals (GH) assigned to control groups. METHOD: This analysis compared two control groups of RCTs targeting unhealthy alcohol consumption: one outpatient sample (GP; n=99) with one inpatient sample (GH; n=173). Both groups were recruited via systematic screening of all patients aged between 18 and 64 years and were included in the studies if drank above the at-risk criteria of the British Medical Association (20/30 g alcohol/daily) and/or fulfilled criteria of alcohol abuse or - dependence according to DSM-IV. Both samples received a non-alcohol specific brochure on healthy living after study inclusion and were re-assessed 12 months later. RESULTS: GH patients were significantly older, included of more males, had received less schooling and had a higher readiness to change at baseline than GP patients. Groups did not differ concerning alcohol-related diagnoses or smoking status. At the 12-month follow-up, significantly more GH patients revealed abstinence or drinking below the inclusion criteria (50.0% vs. 26.1%, p<.001). In a multivariate analysis, medical setting (GH vs. GP) remained a significant predictor for non-problematic drinking or abstinence even after controlling for baseline differences between groups. CONCLUSIONS: Findings suggest that untreated change from problematic alcohol use may be more intense after non-alcohol-related inpatient treatment than after having been a GP patient. Implications for brief interventions in inpatients are discussed.

[Assessment of problematic alcohol use]. / Erfassung problematischen Alkoholkonsums.

An overview with respect to the identification of patients with risky drinking, alcohol abuse or alcohol dependence is given. As a first step, a simple screening questionnaire should be used. Self-statements in standardized questionnaires are more valid than standard laboratory markers. A useful instrument is for example BASIC. In screening positive patients, an in-depth diagnosis is necessary and helps to distinguish between different forms of problematic alcohol use. Depending on the severity of the alcohol problem, brochures, internet-programs, counselling or referral to treatment services is helpful.

New epidemiological aspects of patients with severe hyperhidrosis presenting for sympathetic surgery.

BACKGROUND: Epidemiological data on individuals suffering from severe primary hyperhidrosis are scarce. OBJECTIVE: This study aims to prospectively assess disease-specific characteristics of patients with severe, mostly therapy-resistant hyperhidrosis presenting for sympathetic surgery. METHODS: We evaluated a total of 227 patients (69.6% women) with a mean age of 30 years (standard deviation, 9.5 years) using a standardized questionnaire. Severity of disease was rated on a visual analogue scale (VAS) graded between 0 (no symptoms) and 10 (worst symptom). Age, sex, previous therapies, hormonal therapies and body mass index were analysed for their possible influence on severity of the disease and on hyperhidrosis sites. In addition, allergies were investigated for the first time in this patient population. RESULTS: There was a positive correlation between age of onset and sites of hyperhidrosis. The most commonly affected areas were palmar-axillary-plantar (51.1%) and palmar-plantar (15.0%), with sex-specific differences. Two hundred and twelve patients (93.4%) had previous conservative therapies; 219 patients (96.5%) reported VAS scores between 8 and 10. Female patients stated higher VAS scores for palmar (P = 0.009) and axillary (P = 0.012) sites. Type IV allergies were found to be much higher than in the general Austrian female population. Hormonal therapies and the body mass index had no influence on severity of hyperhidrosis after analysis of VAS scores. CONCLUSION: Sex-dependent aspects can be found in patients strongly affected by primary upper limb hyperhidrosis.

Postoperative pain and quality of life after laparoscopic and open inguinal hernia repair: results of a prospective randomized trial.

BACKGROUND: As part of a large prospective randomized Austrian multicenter trial evaluating recurrence rates and complications of open and laparoscopic unilateral inguinal hernia repairs we assessed postoperative pain and quality of life. METHODS: Approximately 151 patients were randomized to Shouldice repair, Bassini operation, or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). Pain was recorded preoperatively and on the first four postoperative days. Quality of life was recorded preoperatively and 1 month postoperatively. RESULTS: Patients having Shouldice repairs had significantly higher visual analog-scale scores for pain on the fourth postoperative day (P=0.048) and significantly higher scores in McGill pain questionnaires on the first four postoperative days (P=0.046) compared with the other groups. Apart from a significantly lower score in postoperative bodily pain in the Shouldice group (P=0.039), no significant differences in quality of life were apparent among the three methods. CONCLUSIONS: The TAPP and Bassini repairs result in less short-term postoperative pain.

Improved quality of life after sympathetic block for upper limb hyperhidrosis.

BACKGROUND: The aim of the study was to assess two disease-specific quality of life (QoL) instruments after limited endoscopic thoracic sympathetic block (TS) at T4 for upper limb hyperhidrosis. METHODS: : Between 2001 and 2005, 112 patients underwent 223 TS procedures in a prospective study. Some 103 patients (92.0 per cent) had palmar, 87 (77.7 per cent) had axillary and 75 (67.0 per cent) had combined hyperhidrosis. QoL questionnaires devised by Keller et al. and Milanez de Campos et al. were employed before and after treatment. Mean(s.d.) follow-up was 21.9(10.1) months. RESULTS: A total of 106 patients (94.6 per cent) were evaluated. All patients with palmar hyperhidrosis were completely or almost dry after surgery. Side-effects of compensatory sweating and gustatory sweating were observed in 17.0 and 28.3 per cent of patients respectively. QoL improved after TS in 100 per cent (Keller) and 97.3 per cent (Milanez de Campos) of patients illustrated by ameliorated scores of 78.7 and 67.8 per cent, respectively (both P < 0.001). Both questionnaires showed that compensatory sweating resulted in reduced postoperative QoL (P = 0.011, Keller; P = 0.032, Milanez de Campos). CONCLUSION: Endoscopic sympathetic block at T4 leads to improved QoL. Both current questionnaires fulfilled validation criteria for disease-specific QoL instruments in upper limb hyperhidrosis.

The relationship between impaired decision-making, sensation seeking and readiness to change in cigarette smokers.

OBJECTIVE: The study investigated whether impaired decision-making as measured by the Gambling Task and Sensation Seeking, on one hand, and nicotine-dependence and readiness to change, on the other hand, show mutual influences in cigarette smokers. METHODS: Cigarette smokers were classified as dependent or non-dependent smokers. Assessment included stages of change (RCQ), decisional balance (DBS), Sensation Seeking Scale Form-V (SSS-V), and performance on the Gambling Task (GT). RESULTS: With the exception of a significant higher score in the SSS-V subscale Experience Seeking in dependent smokers, correlations between nicotine-dependence and cognitive features were not significant. The directions of the non-significant differences were not consistent. No significant relationship was found between the SSS-V and the GT, on one hand, and the readiness to change smoking behaviour, on the other hand. CONCLUSIONS: The results of the present study suggest that impaired performance on the GT and high scores in Sensation Seeking do not play an important role in nicotine-dependence and readiness to change smoking behaviour or vice versa.

[Promoting the intention to quit smoking among patients in family medicine practice]. / Förderung der Intention zur Tabakabstinenz bei Patienten in der hausärztlichen Praxis.

BACKGROUND: General practitioners can reach large number of smokers. Their good interpersonal relationship with patients promises successful guidance with regard to smoking. However, little is known about the accessibility of smokers to intervention in general practice and about the motivation to abandon smoking. There is a lack of information concerning the GPs' perceived responsibility for smoking counselling. The goal of the study is to examine to what extent smokers can be advised in general practice and how GPs' assess the practicability of such counselling. METHODS: The sample consisted of consecutive general practices patients. A random sample of 39 GPs was drawn and 34 took part in the study. Of 3434 patients, 99.7 % participated in the screening procedure. Inclusion criteria (age 18 to 70 years, admitted smokers), were met by 551 subjects. The participation rate was 81.4 % (n = 449). All GPs received a single training session. Counselling was tailored to the motivation to quit. More than 60 % of the patients were not motivated to stop smoking. RESULTS: Following the study design, 87.8 % of all smoking patients were counselled by GPs. A total of 79.3 % among the GPs considered the intervention to be practicable. CONCLUSIONS: Despite a low motivation to quit smoking in the general practice, 80 % of the smoking patients can be reached by interventions. Furthermore, since the agreement of the GPs concerning practicability was almost 80 %, measures should be initiated to promote counselling for all smokers within the scope of medical consultation.

[Medical care requested by smokers and at-risk alcohol consumers: results of a representative population survey]. / Inanspruchnahme medizinischer Versorgung bei Rauchern und riskant Alkohol konsumierenden Personen: Ergebnisse einer repräsentativen Bevölkerungsstudie.

PURPOSE OF THE STUDY: Due to difficult availability of subjects with substance-related disorders (especially nicotine and alcohol) via the existing specialised treatment services, the impact of proactive early interventions in hospitals and general practitioners is increasingly acknowledged. Only little is known as to known many persons with substance-related disorders are not attainable via this pathway and where such persons could be contacted. In the present study, we analysed the prevalence of substance-related disorders and the motivation to change in subjects drawn from a representative population survey with and without use of medical services during the preceding year. METHOD: The present analysis is based on data from the TACOS ("Transitions in Alcohol Consumption and Smoking") Study (N = 4075) conducted in the town of Luebeck and its environs in Northern Germany. Utilisation of medical services was differentiated in non-utilization (NI), hospital admission during the previous year (KH), at least one visit to a general practitioner (HA), specialist only (FA) and dentist only (ZA). RESULTS: 75% of the population had been to a hospital or their general practitioner in the previous year, a further 18.3% visited a specialist or a dentist only and 4.8% did not contact medical services. Analysis revealed a higher prevalence of smoking and increasing alcohol consumption combined with a higher unemployment rate in NI, followed by KH, HA, FA and ZA. CONCLUSION: The majority of smokers and subjects with at-risk alcohol consumption can be attained via medical services. Additionally, early interventions in dentist practices and employment offices might include further substantial groups of smokers and at-risk drinkers.

Limited endoscopic thoracic sympathetic block for hyperhidrosis of the upper limb: reduction of compensatory sweating by clipping T4.

BACKGROUND: Endoscopic thoracic sympathicotomy of T2 to T4 (ETS 2-4) has evolved into an effective treatment for severe hyperhidrosis of the upper limb. Complications such as bleeding or Horner's syndrome are rare, but side effects such as compensatory and gustatory sweating occur in 30-50% of patients. Following the Lin-Telaranta classification, we aimed to reduce these side-effects by clipping T4 solely [endoscopic thoracic sympathetic block (ESB 4)]. We present our experience and clinical results using this method, with emphasis on patients' quality of life. METHODS: A total of 176 procedures (91 patients) were carried out in the ETS 2-4 group and 103 procedures (53 patients) in the ESB 4 group: 60.4 and 43.4% had palmar hyperhidrosis, 8.8 and 5.7% had isolated axillary, and 30.8 and 50.9% had combined manifestations, respectively. Follow-up was 22.1 months (obtained from 79.1% of patients) for the ETS 2-4 group and 7.5 months for the ESB 4 group (obtained from 88.7%). RESULTS: The success rate was similar for both groups: 87.9 and 64.5% had completely dry limbs, 9.9 and 35.5% ( p < 0.0002) were nearly dry, and 2.1 and 0% remained wet. (ETS 2-4 vs ESB 4). Although the armpits remained slightly humid in more patients in the ESB 4 group, 100% stated full satisfaction. Complications did not differ significantly. However, compensatory sweating (55.6 vs 8.5%, p = 0.0002) and gustatory sweating (33.3 vs 2.1%, p = 0.0019) were markedly reduced (ETS 2-4 vs ESB 4). Quality of life was assessed by a hyperhidrosis index, which significantly improved in most patients. CONCLUSIONS: ETS 2-4 and ESB 4 have similar success rates in the treatment of upper limb hyperhidrosis. The major side effects of compensatory and gustatory sweating were effectively reduced by the limited method of clipping T4, and patients' satisfaction and improvement in quality of life were remarkable.

Significant symptomatic relief after transoral endoscopic staple-assisted treatment of Zenker's diverticulum.

BACKGROUND: Zenker's diverticulum is associated with characteristic symptoms of progressive dysphagia and regurgitation. As most patients are elderly, the perioperative risk is usually high. We report our clinical experience with the transoral endoscopic staple-assisted method, including a thorough assessment of the symptomatic relief achieved by the procedure. METHODS: 46 consecutive patients (29 m, 17 f) with a median age of 61 years (range, 37-96 years) were treated between 1997 and 2002. The symptoms and their frequency were registered. The follow-up consisted of clinical and radiographic investigations. RESULTS: The median size of the diverticulum was 4 cm (range, 2-12 cm). Transoral treatment was successful in 39 patients; in 7 cases (15.2%) a switch to open surgery was required. The median operating time was 30 min (range, 10-150 min). Mortality rate was nil, while morbidity was 7.7%. The median duration of the postoperative hospital stay was 5 days (range, 1-65 days). After a median follow-up of 11 months (range, 1-40 months), 5 patients had been reoperated on endoscopically due to clinical recurrence. Clinical symptoms were significantly reduced (dysphagia of liquids p

[Transhiatal laparoscopic approach in epiphrenic esophageal diverticulum]. / Transhiatale laparoskopische Divertikelresektion bei einem epiphrenischen Oesophagusdivertikel.

Epiphrenic diverticula are rare. The exact prevalence of this condition is unknown because asymptomatic patients are usually not discovered. Symptoms are more often the result of an esophageal motility disorder than the diverticulum itself and no correlation exists between the size of the diverticulum and the severity of symptoms. We present a patient suffering from dysphagia, chest pain, food retention and regurgitation because of an epiphrenic diverticulum. The current treatment of choice for symptomatic epiphrenic diverticula is diverticulectomy via a left thoracic approach. We performed a successful abdominal laparoscopic approach.

[Nissen and Toupet laparoscopic fundoplication in patients with gastroesophageal reflux and motility disorders of the distal esophagus]. / Laparoskopische Fundoplicatio nach Nissen und Toupet bei Patienten mit gastroösophagealer Refluxkrankheit und Motilitätsstörung des distalen Osophagus.

INTRODUCTION: A Nissen fundoplication for gastrooesophageal reflux disease may more often lead to persistent dysphagia than a Toupet fundoplication. The aim of this study was to assess the results of laparoscopic Nissen versus Toupet fundoplication in patients with reflux disease and impaired distal esophageal motility. PATIENTS AND METHODS: In 15 patients a laparoscopic Nissen and in 17 a laparoscopic Toupet fundoplication was carried out. Criteria for an impaired motility of the distal esophagus were a mean amplitude of < 30 mm Hg of swallow-induced contractions, or > 33% non-propulsive or non-transmitted contraction waves. Before surgery, heartburn, dysphagia, regurgitation and other symptoms were scored and endoscopic, manometric and 24 hour pH-metric investigations performed. Patients were reinvestigated 3 to 30 (median 15) months after Nissen and 3 to 42 (median 7) months after Toupet fundoplication. RESULTS: After Nissen as well as after Toupet fundoplication heartburn was significantly less frequent, whereas dysphagia and all other symptom-scores remained unchanged. In the 26 patients reinvestigated manometrically, the resting pressure of the lower esophageal sphincter was significantly higher following both operations and the residual sphincter pressure upon swallowing higher only after Nissen fundoplication. The amplitude of swallow-induced contractions and the percentages of non-propulsive and non-transmitted contraction waves were not significantly changed after either operation. In the 23 patients restudied pH-metrically, reflux activity was significantly reduced after both Nissen and Toupet fundoplication. CONCLUSION: In patients with reflux disease and impaired distal esophageal motility, laparoscopic Nissen and Toupet fundoplication both yielded satisfactory results and neither operation led to increased dysphagia.

Efficacy and safety of thoracoscopic sympathicotomy for hyperhidrosis of the upper limb. Results of 734 sympathicotomies.

BACKGROUND: Thoracoscopic sympathicotomy (TS) evolved as treatment of choice in severe hyperhidrosis. The aim of this study was to assess the role of video-assistance in TS (VATS) versus conventional TS (CTS) for primary hyperhidrosis of the upper limb with regard to safety, side-effects and long-term outcome. METHODS: 734 TS were performed from below T1 to T4 in 406 patients. In the CTS and in the VATS group 558 and 176 procedures were performed, respectively. Follow-up was completed in 82% of all patients after a median observation period of 16 years. RESULTS: Dry limbs were immediately achieved in 92% (CTS) and 97% (VATS, p = 0.98). Only one patient (CTS) underwent conversion due to bleeding. In the CTS group Horner's syndrome occurred in 2.2% and rhinitis in 9.9% of procedures. No patient of the VATS group experienced Horner's syndrome (p = 0.025), 3 patients developed rhinitis (p = 0.11). At follow-up compensatory sweating was observed in 67.6% vs. 55.6% (p = 0.051) and gustatory sweating in 50.4% and 33.3% (p = 0.01). There were 5 failures or recurrences (1.9%) in the CTS group and 2 (2.8; p > 0.05) in the VATS group at reevaluation. Overall 6.5% (CTS) and 5.6% (VATS) of patients regret the operation (p = 0.7). CONCLUSIONS: We observed a significant decrease of the incidence of complete or incomplete Horner's syndrome and gustatory sweating when the procedure was guided by video-imaging while success rate was similar when compared with CTS.

[Effect of the learning phase on safety and efficiency of laparoscopic fundoplication]. / Einfluss der Lernphase auf Sicherheit und Effizienz der laparoskopischen Fundoplicatio.

The introduction of laparoscopic techniques into surgical practice has required a learning process on the part of the surgeons involved. The duration, morbidity, and functional outcome of laparoscopic fundoplication were evaluated in our institution's first 146 cases. During a 34-month period the patients underwent laparoscopic Nissen (n = 102) or Toupet (n = 44) fundoplication. Conversion to open access was necessary in 7 cases, re-operation for complications in 2, all among the first 40 cases of the series. The median operating time was 165 min (range 75-375) in the first 40 cases, and 105 min (range 50-235) thereafter (P < 0.001). Body mass index, grade of esophagitis, and the surgeon's experience were independent predictors of the operating time. One hundred and thirty-four patients (92%) could be evaluated for recurrence of reflux, which was encountered in 2 (5%) of the first 40 cases and 8 (8%) of 94 patients in the later group.

[Use of the harmonic scalpel (Ultracision) in laparoscopic antireflux surgery]. / Erfahrungen mit dem harmonischen Skalpell (Ultracision) in der laparoskopischen Antirefluxchirurgie.

Gastroesophageal reflux disease can effectively be treated by laparoscopic fundoplication. A new multifunctional device has recently been introduced, Ultracision (UC), which can be expected to be especially effective in laparoscopy. Since 9/1995 laparoscopic fundoplication is being performed at our institution. We routinely divide the "short-gastric vessels" and have been using clip-appliers and Endo-GIAs before dividing the vessels with endo-scissors. Since 2/1997 we also use the UC, which applies ultrasonic energy to cause denaturing of proteins and subsequent hemostasis and dissection. This open, non-randomized study compares operative time, intra- and postoperative complications and conversion rates as well as costs of both methods. Between 2/1997 and 12/1997 20 consecutive patients received a floppy Nissen fundoplication by 2 surgeons. In 8 patients clips/EndoGIA were used (m:w = 5:3, mean age 52 years [33-69]), in 12 patients UC (m:W = 10:2, 53 years [25-74]) was used. 2 patients in each group had had previous open abdominal surgery. In the first group 2 procedures had to be converted to open surgery (1 bleeding, 1 anatomical problem), median operative time was 214 min (135-360). In the UC group all procedures were completed laparoscopically, median operative time 132 min (75-240). Postoperative major complication and mortality rates were 0 in both groups. Use of the harmonic scalpel reduced operative time and costs without increasing conversion rates and perioperative complications.