Effect of amodiaquine on gastric histamine methyltransferase and on histamine-stimulated gastric secretion.

1 Amodiaquine was found to be a potent inhibitor in vitro of gastric histamine methyltransferase from human and canine corpus and from pig antrum. The ID50 for the enzyme, purified from pig antrum mucosa by ultracentrifugation and chromatography on DEAE-cellulose, was 2.5 muM. 2 In six dogs with Heidenhanin pouches the maximum secretory response to histamine (40 mug/kg i.m.) was augmented by i.m. injection of amodiaquine. The augmentation depended on the dose of amodiaquine, the optimum effect (40% increase in volume of gastric juice, 80% in acid output) being achieved with 2 mg/kg. The maximum secretory response to betazole was also enhanced by amodiaquine. 3 It was suggested that amodiaquine may enhance the histamine and betazole stimulated gastric secretion by an inhibition of gastric histamine methyltransferase in vivo.

Laparoscopic gastric bypass for morbid obesity with linear gastroenterostomy.

BACKGROUND: Laparoscopic gastric bypass (LGBP) is a well-established procedure for the surgical management of morbid obesity. Most surgeons create the gastroenteral anastomosis by using the circular EEA stapler. We describe an alternative laparoscopic anastomotic technique using the EndoGIA linear stapling device. METHODS: The stomach was proximally transected with a linear stapler (45 mm, Endo-GIA) to create a 15 to 20 ml pouch. Next, an antecolic Roux-en-Y gastroenterostomy was performed, using the 45 mm Endo-GIA. The proximal loop of the intestine was then separated from the anastomotic site by the Endo-GIA. Finally, the Endo-GIA was used for the intraabdominal creation of a side-to-side enteroenterostomy. RESULTS: Between June and August 2001, 5 patients with mean BMI 56.7 kg/m(2)+/-7.3 underwent LGBP. All patients were seen 6 months post-surgery. Operating time was 7.5 and 6.5 hours for the first 2 operations, but was under 4.5 h for the next 3 cases. 1 patient suffered from perioperative hypoxia leading to long-term artificial respiration. 6 weeks after surgery, 1 patient developed obstruction due to torsion of the enteroenterostomy and required open revision. The 3 remaining patients made an uneventful recovery. All patients lost considerable weight (mean 36.5 kg; [range 32 to 45] after 6 months). No stenosis or anastomotic leakage was noted. CONCLUSIONS: A linear stapled anastomosis is an alternative to the use of the circular stapler.

Effects of steroid hormone therapy on primarily xenotransplanted human colorectal adenocarcinomas.

Primary xenotransplantation of six different human colorectal adenocarcinomas onto nude mice yielded a mean tumor take of 85%. Administration of steroid hormones induced tumor remissions in some cases. Neither the stage of the original patient's tumors nor their hormone receptor content seemed to be related to the result of the hormone therapies. It is concluded that some colorectal cancers can be treated as hormone-sensitive tumors.

Protective effect of heat shock pretreatment with heat shock protein induction before hepatic warm ischemic injury caused by Pringle's maneuver.

BACKGROUND: Induction of heat shock proteins is thought to have a > cytoprotective effect against environmental stress and to result in a better ischemic tolerance. The protective ability of heat exposure and heat shock protein 72 (HSP 72) induction before warm ischemia caused by Pringle's maneuver was evaluated in rats. METHODS: Heat exposed rats (HS) were compared with control animals (C). The gene expression (messenger RNA) of HSP 72 and HSP 72 were detected by Northern and Western blot analyses. During 40 minutes of in situ reperfusion, liver energy metabolism and levels of standard liver enzymes were evaluated. The survival rate was determined after postoperative day 7. RESULTS: After heat exposure and recovery, messenger RNA of HSP 72 and HSP 72 can be detected strongly in HS group but not in C group. During reperfusion HS group exhibited a significantly (p < 0.01) improved energy metabolism, and the release of liver enzymes was significantly (p < 0.001) reduced compared with C group. Seven-day survival rate was 100% in HS group but at 50% was significantly impaired (p < 0.05) in C group. CONCLUSIONS: Heat exposure associated with HSP induction has a significant protective effect against warm ischemic liver injury, which results in a relevant improvement of survival rate.

Evaluation of tomography and mediastinoscopy for the detection of mediastinal lymph node metastases.

In a prospective study of 88 patients seen consecutively with proven or suspected bronchial carcinoma, the validity of x-ray tomography and routine mediastinoscopy was tested for the detection and evaluation of mediastinal lymph node metastases. Positive mediastinum was defined as malignant tissue found in the mediastinum and negative mediastinum as mediastinoscopy with negative results plus a negative intraoperative mediastinal lymph node dissection. Thirty-four patients were eliminated from the analysis because carcinoma was not found or because mediastinal evaluation was incomplete by these criteria. Twenty-eight of the remaining 54 patients had mediastinal metastases. Sensitivity was 67% for tomography and 79% for mediastinoscopy. Specificity was 92% for tomography and 100% for mediastinoscopy. The differences were not significant. Sixty-six of 85 mediastinoscopies were unnecessary or unhelpful in the decision to exclude a patient from surgical intervention. Among 19 patients with lesions presumed to be inoperable based on results of mediastinoscopy (i.e., perinodal metastatic growth suspected by palpation or histologically proven), 14 patients had positive tomographic scans and 1 could not be evaluated radiographically because of right upper lobe atelectasis. We conclude that tomography of the upper mediastinum should be used to select patients for mediastinoscopy.

The European experience with laparoscopic cholecystectomy.

A retrospective survey of 7 European centers involving 20 surgeons who undertook 1,236 laparoscopic cholecystectomies was performed. The procedure was completed in 1,191 patients. Conversion to open cholecystectomy was necessary in 45 patients (3.6%) either because of technical difficulty (n = 33), the onset of complications (n = 11), or instrument failure (n = 1). There were no deaths reported, and the total postoperative complication rate was 20 of 1,203 (1.6%), with 9 being serious complications requiring laparotomy. The total incidence of bile duct damage was 4 of 1,203. The median hospital stay was 3 days (range: 1 to 27 days) and the median time to return to full activity after discharge was 11 days (range: 7 to 42 days).

A rare complication of laparoscopic adjustable gastric banding.

The most common complications of laparoscopic gastric banding (LGB) are band dislocation, port problems, and leakage in the band system. We present a case of an aneurysmal dilatation of the balloon portion of the band by filling as a rare complication of LGB. A 53-year-old male patient with morbid obesity (body mass index 40 kg/m2) was treated with LGB (adjustable Bioenterics gastric band). Six months after the operation there was no evidence of weight reduction. X-ray examination showed the band to be in the correct position. The port punction revealed no spontaneous fluid loss. The contrast filling of band demonstrated no signs of leakage but there was an abnormal dilatation of one part of the balloon. Only one filling segment of balloon was dilatated and the rest was empty. Two and a half years after the initial operation, we carried out laparoscopic band exchange. Six weeks later, the band was adjusted with 2 ml saline, and the patient reported successful reduction of food volume. He had lost 18 kg 3 months postoperatively. We conclude that band function requires careful intraoperative monitoring. In patients who do not lose weight after gastric restriction surgery, uncommon complications must also be considered.

Port function after laparoscopic adjustable gastric banding for morbid obesity.

BACKGROUND: Laparoscopic adjustable gastric banding (LGB) has gained wide popularity, but information on port function is limited. METHODS: In a prospective nonrandomized study, we analyzed port function and related symptoms in 50 consecutive patients with severe obesity. All patients underwent LGP in a five trocar technique. In 11 patients, the port was placed subcutaneously in the subxiphoid region. In 39 patients, the port was implanted in the left upper abdomen. Mean duration of follow-up was 2.8 years. RESULTS: Patients (12 males and 38 females) had an initial body mass index (BMI) of 47.1 kg/m2. Puncturing the subxiphoidal port was without problems in all 11 patients. However, seven women reported pain and inconvenience when wearing a brassiere. Two underwent port reimplantation in the left upper abdomen (one due to infection; one due to pain). Among the 39 patients with abdominal port implantation, nine patients required port correction (two of them twice). The causes were port dislocation (four cases), difficult puncturing (three), tube leakage (three), and infection (one). CONCLUSION: The high number of complications suggests that the port is the Achilles' heel of LGB. Ports at the subxiphoid site were easier to puncture, but frequently caused pain in female patients.

Technology assessment of endoscopic surgery.

Endoscopic surgery is considered a milestone in the evolution of surgical technique in nearly all fields of surgery. However, the inappropriate use of the new technology in medicine has also been heavily criticised. Systematic technology assessment of endoscopic surgical techniques is mandatory to prove the real benefits and complications, so defining the indications for their appropriate use. This article describes methods of technology assessment suitable for endoscopic techniques with emphasis on relevant endpoints for surgeons and patients. The general stages of a comprehensive technology assessment include: 1. feasibility (safety and technical performance) 2. efficacy (patient benefits in pioneering places) 3. effectiveness (patient benefits in average hospitals in the community as a whole) and 4. economic evaluation (cost-benefit analyses). We used the example of laparoscopic cholecystectomy to describe the methods of technology assessment. A cohort study on 500 patients revealed that laparoscopic cholecystectomy is as safe as the conventional standard open technique. The results on efficacy strongly support the hypothesis of more comfort and less trauma with the endoscopic technique. Major endpoints evaluated were postoperative pain, convalescence, fatigue and quality of life. Data on effectiveness and economics are still in a "premature" state and should be the subject of further analyses. It is concluded, that other disciplines such as neurosurgery should evaluate their endoscopic surgical techniques according to the rules of technology assessment outlined in this paper.

Quality of life more than 20 years after repair of esophageal atresia.

PURPOSE: To examine the quality of life after repair of esophageal atresia, follow-up studies were performed in 58 of 71 surviving patients (81.7%). METHODS: Fifty patients with primary anastomosis and all eight surviving patients with colon interposition were seen. The mean age was 25.3 years (range, 20 to 31). Symptoms were evaluated by a standardized interview. Quality of life assessment was performed using a visual analogue scale (0 to 100 points), the Spitzer Index (5 dimensions, 10 points), and the Gastrointestinal Quality of Life Index (GIQLI, 5 dimensions, 128 points). RESULTS: After primary anastomosis the estimated meal capacity was unrestricted in 46 patients (92%), but numerous symptoms such as recidivating cough (60%), hold up (48%), and short breath (30%) were reported. All symptoms except cough were seen more frequently in patients with colon interposition, and all of these patients suffered from periods of short breath. Quality of life scores were higher in patients with primary anastomosis compared with colon interposition. The difference in the visual analogue scale score did not reach statistical significance, but the mean Spitzer Index was 9.7 compared with 8.8 after colon interposition (P < .05). The GIQLI after primary anastomosis was similar to that in healthy controls and was significantly lower in patients with colon interposition. This was because of specific symptoms, which scored 49.3 after colon interposition compared with 61.7 after primary anastomosis (P < .05) and to 54.8 (SD 5) in healthy controls (P < .05). Physical and social functions, emotions, and inconvenience of a medical treatment scored similar in patients with primary anastomosis, colon interposition, and healthy volunteers. CONCLUSIONS: The long-term quality of life after primary anastomosis was excellent. Patients with colon interposition suffer more frequently from various gastrointestinal and respiratory symptoms, but they lead an otherwise normal life.

Laparoscopic surgery in children and adolescents with suspected appendicitis: results of medical technology assessment.

Laparoscopy has been performed in 43 patients aged up to 18 years with suspected appendicitis; 20 were children 8-15 years and 23 adolescents 16-18 years of age. Diagnostic laparoscopy was successful in 36 (84%) patients; in 7 (16%) subsequent laparotomy was necessary to establish the diagnosis, in 4 (9%) because the appendix was not visualized. Laparoscopic appendectomy was done in 33 (77%) patients, additional laparoscopic adhesiolysis in four and inversion of a diverticulum in one. Changing to laparotomy during the laparoscopic operation was necessary in one patient because of a technical problem and in another because of bleeding of the appendicular artery. Laparoscopy was totally free of complications in 33 (77%) patients; another 9 (21%) had surgical or technical problems without negative outcome for the patient. In one (2%) patient a wound infection led to a negative outcome; there were no other laparoscopy-related events. The mean intensity of pain on the first day after laparoscopic appendectomy was 31 points (Visual Analogue Scale with 100 points) and decreased to nearly zero on the third day; 37% of patients needed opioids on the first and none on the third day. There was no statistical difference for pain intensity and consumption of analgesics after appendectomy via laparoscopy versus laparotomy. We conclude that diagnostic and therapeutic laparoscopy in children and adolescents with suspected appendicitis is a safe and effective procedure.

Long-term functional results and quality of life after colon interposition for long-gap oesophageal atresia.

Out of a series of 146 patients with oesophageal atresia 9 (6.2%) underwent colon interposition from 1963 to 1971. All eight surviving patients were seen at follow-up after a mean of 22 years. Three patients were free of specific symptoms according to the criteria of DeMeester, two had moderate and three severe distress. The mean time for consuming a standardized test meal was 15 minutes, compared to 8 minutes in healthy controls. Patients required 1-9 minutes to transport liquid barium through the transplant, compared to < 10 seconds in control subjects. Histological evaluation revealed a normal architecture of the colonic and ileal epithelium in three patients who underwent endoscopy. In none of these patients were contractions in the colon graft related to the act of swallowing recorded on manometry. Unimpaired quality of life was indicated by the Spitzer index which scored a mean of nine out of ten points. However, on a 100point visual analogue scale patients scored their global quality of life 66 and the mean Gastrointestinal Quality of Life Index was 92.2, compared to 107.6 in healthy control subjects (p < 0.05). This impairment was exclusively due to specific symptoms which scored 49.3 in patients and 59 in healthy individuals (p < 0.05). Physical and social functions, emotions, and inconvenience of a medical treatment were similar to control subjects. We conclude that colon interposition for long-gap oesophageal atresia achieves acceptable long-term functional results. However, specific symptoms lead to a considerable impairment in quality of life.

[Risk analysis in surgery. A method of increasing effectiveness and efficiency: a neglected method]. / Risikoanalyse in der Chirurgie. Eine Methode zur Steigerung von Effektivität und Effizienz--eine vernachlässigte Methode.

UNLABELLED: The estimation of risk should be an essential prerequisite for the choice of the correct surgical therapy and also for assessment of the quality of surgical care. The fact is, that many people talk about "risk" but have the wrong idea about this remarkable concept. Too often minutely detailed enumeration of negative events (complications) is mistaken for risk. Risk is the probability that something negative will happen. It is also a fact that risk is always regarded as negative. Another fact is that risk in medicine mostly--or only--describes morbidity and mortality. Even though this is correct and important, it is not enough! Today, risk must include the probability of a therapy option not working, or even the risk of perversion of the therapy intention! Determination of a risk factor is time-consuming. It is a typical example for clinical research. Proceeding stepwise is may-be helpful. I propose seven steps: Step 1 demands that the circumstances, facts, variables like negative events, ability to cooperate, mortality, severeness of sickness, social circumstances, etc. be clarified. Step 2 means collecting and compiling these circumstances assumed to be clinically relevant All sources of information are good, but better is a prospective data collection. Step 3 defines the individual surgical situation, and from this the different circumstances, which could be risk factors. This is regarded as development of hypothesis. In step 4 the probability is determined with which a special condition or a group of circumstances could become a clinically relevant risk factor. This is done in the clinical experiment with the aid of the mathematical models known today, but also with the experience and intuition of the surgeon. In step 5 the individual clinical situation can be determined according to the significance of the risk factors (ranking). Step 6 is intended for handling the known risk factors. How to proceed with the risk factor within the decision finding process at the surgical intervention? Step 7 is the all decisive step. It should supply the unequivocal information as to whether risk analysis in toto will bring any benefit for surgery--even more importantly, for the individual patient at a certain time. There is evidence (external) that the correct handling of the risk analysis brings a significant effect or benefit in surgery, but it still has its limits. It is a fact that risk analysis with the methods used nowadays has an advantage for group analyses, but ist limits are tight for the individual patient. This is especially true for the scores established and used for this. With the risk analysis the decisive risk factors can be recognized and determined and put into order according to their different effect. Whether this fact has a benefit in surgery or even for the individual patient is still without unknown. There is evidence that comparing the quality of surgical treatments in individual clinics without risk analysis is almost naive! This is the case for which risk analysis has proved to be the best! Risk analysis is so far unable to predict the risk of a surgical therapy for an individual patient with sufficient certainty. With a value of 70% certainty, risk analysis is as good--or as bad--as the experienced surgeon for this decisive question. CONCLUSION: Risk analysis has not yet given enough proof of its effectiveness. The method is time consuming and up to now only successful for assessment of groups. Comparison of surgical quality in different clinics is naive without risk analysis. Here its importance has been proved. The risk analyses practised so far have no chance when dealing with the individual patient. It can be recognized that the surgeon is a risk factor. However, in the complex system of different circumstances and mechanisms of a surgical care, he is only one factor even though an important one. Risk analysis is an aspect of clinical research and demands more consideration.

[Quality control in surgery of inguinal hernias]. / Qualitätskontrolle in der Leistenhernienchirurgie.

Quality assurance is a concept intended to ensure the quality of a surgical therapy on a defined level. But what is "quality" in surgical therapy? Quality can be described in a lot of different ways. Quality has something to do with taste, especially with individual preferences. The testing of the quality of wine is a good example. Even though this is quite difficult, it can still be done and has been done for hundreds of years. In surgery we are still at the beginning. Discussions regarding the definition of quality, the best method of quality assurance and, not least, who is responsibility for its measurement are well-known obstacles on the path to improvement. Quality has basically little to do with research. It is not a matter of finding the right technique, but of ensuring that the right technique, when found, is correctly used. Defined quality standards will allow this. Quality standards in inguinal hernia surgery are: outstanding comfort directly before and after the therapy, few or no side effects troubling the patient, most of all no disastrous side effects, disaster, low rate of relapse and, in our times, decent economy. The question: "Is the target to be oriented on the average or must the standard be brought nearer the best performance?" has to be answered. Surgery and average performance do not match; surgical performance cannot be oriented on the average. The next question is: "Which methods are suitable for this?". The "tracer method" is one method, one aspect within quality assurance methods in general. It is designed for obtaining information on the quality of a clinic/department. The obtained data on complication rates, for example (10%), and their striking points should above all give insight into the complete department, i.e., on complication rates of a surgical department in general. The same counts for infection rates or striking points. The essential question remains: "Who should carry it out?" Bureaucrats lacking expertise will buy it. The principle of autonomy, "expertise connected to competence" has to be kept when answering the question of who should do it and how. The tracer method, using hernia surgery as a tracer, is not necessarily suitable as a measure of the quality of inguinal hernia surgery. Even though it supplies--as a side effect--information about inguinal hernia surgery, like complication rates (10%) and relapse operations (10%), as well as the varying anaesthetic procedures, or the use for changes in therapeutic procedures, the tracer method is not suitable to sufficiently inform about the quality of inguinal hernia surgery in particular. A further essential aspect when analysing quality assurance--showing up clearly at the moment--is the fact, that "another" control will develop if this inactivity remains. In this case the "controllers" will certainly not be the surgeons. The nightmare vision of bureaucrats (insurance companies or other parties) as controllers is in sight. This would be the same situation as if Michael Schumacher's Ferrari were checked by clerks and not by engineers.

[Transposition of the gracilis muscle - an option in the surgical treatment of rectovaginal fistulae]. / Transposition des M. gracilis - eine Option bei der chirurgischen Behandlung rectovaginaler Fisteln.

Rectovaginal fistulae following low anterior resection are rare, but if present therapy is difficult. We report on a 52-year-old patient who was operated upon several times, including an endorectal advancement flap procedure and transperineal repair with levator interposition. Closure was only successful after transposition of the M. gracilis between the vagina and rectum.

[Postoperative pain therapy in inpatient treatment]. / Postoperative Schmerztherapie in der stationären Behandlung.

Pain therapy is a central medical task and a legal duty. Not the anaesthetist but the pain-causing surgeon is responsible for therapy of pain. Pain as a negative sensation is subjective and individual. Postoperative pain is an essential aspect of the topic "pain in surgery". Therapy starts with the awareness of the problem. Effective pain therapy requires clinical competence and application of available therapeutic options. Initial steps of successful pain treatment include: an informative dialogue with the patient, conveying of confidence, and skillful choice of diagnostic and/or therapeutic options. Application of drugs presupposes detailed knowledge of their specific effects. For convincing therapeutic results, one has to analyse different causes of pain. Acute surgical pain is classified and treated according to a three-step scheme: intense pain with strong opioids, intermediate pain with weaker opioids or non-opioids, and slight pain with non-steroidal anti-inflammatory drugs. Opioids are used with caution in abdominal surgery because of their negative effects (obstipation), the same is the case with Novalgin in trauma patients because of its effect on temperature and leukopenia. Patient-controlled analgesia with appropriate devices means further progress for suitable patients. Effective pain therapy within the framework of successful surgery is feasible and influences patients' comfort and possibly even their morbidity and mortality.

[Stapler suture or single button suture? A controlled clinical study on the comparison of both skin closure methods]. / Klammernaht oder Einzelknopfnaht? Eine kontrollierte klinische Studie zum Vergleich beider Hautverschlussmethoden.

In a controlled randomized clinical trial, skin closure with a skin-stapling technique was compared with interrupted sutures on 50 patients (26 sutured and 24 stapled). The two groups were similar in all important respects. The clinical side of the study was to compare 1) the cosmetic results, 2) the time taken to close the skin, and 3) advantages and disadvantages of the two techniques by a questionnaire completed by the clinical staff. The study suggested a cosmetic advantage for the stapling when the results at 6th postop. week were compared. The only significant difference was in cross hatching (22 out of 26 sutured wounds but none of the 24 stapled) which was predominantly visible in sutured wounds. A clear difference was found in operating time. Skin closure with interrupted sutures took 310s, compared with 122s for stapling (alpha = 0,001). Similarly time required to remove the closure material was less with the staples than with sutures. Staples are more expensive than sutures. However the advantage of the staples over the suture in avoiding cross hatching is significant as well as time saving.

[Dynamic gracilis muscle-plasty--a case report]. / Dynamische Gracilisplastik--ein Fallbeispiel.

The feasibility of anal dynamic graciloplasty (transposition of the gracilis muscle and subsequent implantation of a stimulation device) to restore continence, was assessed in a 71 year old patient. Anal dynamic graciloplasty was capable to achieve continence by increasing the sphincter tone from 35 mm Hg without stimulation to 110 mm Hg with stimulation. The clinical results and anal manometry data are described and the pros and cons of the procedure are discussed.

[Mediator systems and infection]. / Mediatorensysteme und Sepsis.

Sepsis is the systemic response of the body to an infection. Sepsis-like conditions with nearly identical body reactions, however, are also seen without any evidence of bacteremia. Sepsis is a disease of the host response (specific and non-specific immune system). Depending on the time of the disease process, different mediators (released or newly formed) are involved. This review summarizes the current knowledge and interactions of different cells, cascade systems and mediators in the pathogenesis of sepsis and gives an overview of the approaches and results of current "anti-mediator strategies" to control or modulate inadequate mediator responses.

[Laparoscopic colorectal surgery--attempt at evaluating a new technology]. / Laparoskopische colorectale Chirurgie--Versuch der Bewertung einer neuen Technologie.

The aim of this study was to access the importance of the laparoscopic colorectal resection. Of 131 patients 80 were operated on laparoscopically. The conversion rate was 14% (13/93). A total of 47 patients suffered from cancer. Curative resection was performed in 41 patients (87%). For comparison, 48 patients who underwent open resection were used. The complication rate was lower after laparoscopy and no reoperation was performed. Patients recovered quicker and their first oral food intake and bowel movement were earlier. Hospital stay was shorter (15.3 vs. 8.1 days), and pain at rest and in motion was significantly reduced. Equal numbers of mesenteric lymph nodes were retrieved; adequate margins of resection could be obtained and the length of resected bowel did not differ. No port metastases were observed. Reduced morbidity, reduced hospital stay, reduced abdominal pain, quicker reconvalescence, and reduced overall health care costs are strong arguments in favor of laparoscopic colectomy.