[Preoperative fasting period of fluids in bariatric surgery]. / Präoperative Flüssigkeitskarenz in der bariatrischen Chirurgie.

BACKROUND: Aspiration of stomach content is a severe complication during general anaesthesia. The DGAI (German Society for Anesthesiology and Intensive Care Medicine) guidelines recommend a fasting period for liquids of 2 h, with a maximum of 400 ml. Preoperative fasting can affect the patients' recovery after surgery due to insulin resistance and higher protein catabolism as a response to surgical stress. OBJECTIVES: The aim of the study was to compare a liberal fasting regimen consisting of up to 1000 ml of liquids until 2 h before surgery with the DGAI recommendation. MATERIALS AND METHODS: The prospective observational clinical study was approved by the ethics committee of the University of Leipzig. In the liberal fasting group (Glib) patients undergoing bariatric surgery were asked to drink 1000 ml of tea up to 2 h before surgery. Patients assigned to the restrictive fasting group (Gres) who were undergoing nonbariatric abdominal surgery were asked to drink no more than 400 ml of water up to 2 h preoperatively. Right after anaesthesia induction and intubation a gastric tube was placed, gastric residual volume was measured and the pH level of gastric fluid was determined. Moreover, the occurrence of aspiration was monitored. RESULTS: In all, 98 patients with a body mass index (BMI) of Glib 51.1 kg/m2 and Gres 26.5 kg/m2 were identified. The preoperative fasting period of liquids was significantly different (Glib 170 min vs. Gres 700 min, p < 0.001). There was no difference regarding the residual gastric volume (Glib 11 ml, Gres 5 ml, p = 0.355). The pH of gastric fluid was nearly similar (Glib 4.0; Gres 3.0; p = 0.864). Aspiration did not occur in any patient. CONCLUSIONS: There is evidence suggesting that a liberal fluid fasting regimen (1000 ml of fluid) in the preoperative period is safe in patients undergoing bariatric surgery.

Micro- and macrovesicular steatotic liver model for transplantation induced by ethanol and protein-deficient diet.

Steatotic liver grafts are associated with a high incidence of primary nonfunction and initial poor function. Due to the increasing number of liver transplant candidates, centers are inclined to accept marginal donors more frequently. For a lack of a reliable fatty liver model, preservation concepts for fatty livers have hardly been evaluated. Moreover, there is an ongoing debate on the relevance and impact of micro- versus macrovesicular steatotic organs. We therefore intended to establish a steatotic liver model in pigs comprising both micro- and macrovesicular steatotic livers. Five groups of pigs received daily 1 to 6 g ethanol/kg body weight and/or a protein-deficient diet for up to 72 days. Liver biopsy was carried out at days 24, 48, and 72. With an increasing amount and duration of ethanol intake, higher levels of microvesicular steatosis were induced. Ethanol and protein deficient diet resulted in more than 60% microvesicular steatosis after 72 days. Exclusively protein-deficient diet without ethanol induced macrovesicular steatosis of more than 70% after 72 days. For the first time, we established a porcine model of hepatic steatosis that comprises both histologic types of fatty liver: micro- and macrovesicular steatosis induced by ethanol and a protein-deficient diet. We would like to conclude that our model is particularly qualified to study new concepts of preservation for steatotic livers to improve on the posttransplant outcome.

[Anaesthesiological management in orthotopic liver transplantation -- results of a survey]. / Anästhesiologisches Vorgehen bei orthotopen Lebertransplantationen (LTX) -- Ergebnisse einer Umfrage.

OBJECTIVE: Since there is no therapeutical standard for the anaesthesiological approach during liver transplantation (LTX) in Germany at the moment, we have evaluated the current anaesthesiological procedures during LTX. METHODS: All departments of anaesthesiology (n = 24) cooperating with transplantation centers in Germany received a questionnaire via mail regarding following complexes: anaesthesiological methods, anaesthetics, blood components therapy, perioperative monitoring, supportive cardiovascular therapy and staff. RESULTS: The answers (n = 16) showed following results: Balanced anaesthesia with continuous application of opioids was the standard method (80 %). Different volatile anaesthetics as well as different opioids were used, isoflurane (66.7 %) and fentanyl (53.3 %) were the most common. Veno-venous bypass was never or occasionally used (86.7 %). The differentiated use of catecholamines, based on discussions in the last years, was also reflected in the results. Dobutamine/noradrenaline as combination seemed to be the first choice (46.7 %). Whereas there was an accordance with the employment of blood components, there was a large variation in the effectively applied blood products. Aprotinin was given in 60 % of all clinics occasionally, in 20 % every time and in 20 % aprotinine was never used. In most departments > or = 2 anaesthesiologists (80 %) and 1 nurse (53.3 %) were needed for intraoperative observation. Postoperative medical attendance was provided on anaesthesiological as well as surgical guided intensive care units (ICU). Generally accepted was an early extubation after arrival at the ICU (86.7 %). CONCLUSION: Even though there was a consensus in the anaesthesiological approach during LTX some departments still use different procedures. This is the first study that will give a basis for discussion of anaesthesiological approaches during LTX.

[Detection of Chlamydia pneumoniae in intrathoracic abscesses--a case report]. / Nachweis von Chlamydia pneumoniae in intrathorakalen Abszessen--ein Fallbericht.

The case of a 52-year-old patient with intrathoracic abscesses following a traumatic fracture of the 11th thoracic vertebral body is described. The abscesses were resistant to conventional antibiotic therapy and attempts at local drainage under CT scan control remained unsuccessful. Finally, chlamydia pneumoniae was isolated using an immunofluorescence technique. Subsequent therapy with doxycycline caused complete resolution of the abscesses. We suggest that in cases of atypical pneumonias and abscesses, infection with chlamydia pneumoniae should be taken into consideration.

[New methods for transurethral electroresection of the prostate from the anesthesiologic viewpoint]. / Neue Verfahren zur transurethralen Elektroresektion der Prostata aus anästhesiologischer Sicht.

Intravascular absorption of large volumes of solution without electrolytes is a common problem in transurethral resection of the prostate. In the present study we compared two different methods of resection (TURP vs. Vaporization TURP; 20 patients in each group) regarding fluid absorption and loss of blood. In addition, we report on 60 patients who had Vapo-TURP. The operations were performed by different very experienced surgeons. In both groups, spinal anaesthesia and standard regimes of infusion were used. The amount of fluid absorbed was measured by the ethanol method (2 vol.% ethanol; Widmark-formula). Haemoglobin, haematocrit and electrolytes were determined at set times. Ten of the 20 patients in the TURP group showed blood-alcohol levels > 0.1%/1000. In the Vapo-TURP group, only five of 57 patients (three patients with perforation of the prostate capsula were excluded) showed positive levels of blood-alcohol (< 0.05%/1000; fluid absorption < 150 ml). The difference was statistically significant (p = 0.002). Sixty minutes after the beginning of the procedures, the values of haemoglobin and haematocrit were significantly lower in the TURP group (7.68 +/- 0.41 vs. 7.38 +/- 0.64 mmol/l and 0.36 +/- 0.02 vs. 0.34 +/- 0.03). Regarding absorption of fluid and bleeding, Vapo-TURP was superior. From the anaesthesiological point of view, Vapo-TURP should be the method of choice, especially for the elderly.

[Is fiber optic hepatovenous oximetry useful in patients undergoing elective partial liver resection?]. / Eignet sich die fiberoptische Lebervenenoxymetrie als zusätzliches Monitoring bei Patienten mit elektiven Leberteilresektionen?

The validity of continuous measurement of hepatic venous oxygen saturation using a fibreoptic technique was investigated and set in correlation with intermittent measurements of saturation in hepatic venous blood in patients undergoing elective partial liver resection (pLR). Eleven patients (4 m/7 f, average age: 62.6 +/- 11.6 years) were included in the study after approval by the Ethics Committee of the University of Leipzig. A fibre-optic heparinized flow-directed pulmonary catheter (5.5-F) was inserted through the right internal jugular vein into the hepatic vein after induction of balanced anaesthesia (isoflurane/alfentanil). The position of the tip of the catheter was verified by fluoroscopic guidance. The oxygen saturation in the hepatic vein measured by the fibre-optic method and by blood-gas analysis (ShvO2) was compared at nine defined measuring points after in-vivo calibration (baseline). The ShvO2 decreased nonsignificantly from 84.4 +/- 10.4% to 77.1 +/- 19.1% during occlusion of the vessels in the liver hilus (Pringle's manoeuvre). The ShvO2 measured by the fibre-optic method and by blood-gas analysis correlated well (r = 0.815, p < 0.001). The limitations of the method result from artefacts based on surgical manipulations in the portal region (compression of hepatic veins, luxation of the liver). These artefacts can be differentiated by analysis of the pressure curves in the hepatic vein. Nevertheless, fibreoptic hepatovenous oxymetry seems to be a feasible method for continuous monitoring of the ShvO2 under intraoperative conditions in patients undergoing partial liver resection. Ischaemic situations of the liver can be detected and treated early. Additional information can be obtained from analyses of parameters in the hepatovenous blood.