[Optimization of perioperative management in laparoscopic hernioplasty]. / Optimierung des perioperativen Managements am Beispiel der laparoskopischen Leistenbruchoperation.

INTRODUCTION: Although about 150,000-200,000 hernia repair procedures are performed every year in Germany alone, fast-track concepts are mainly ignored for this type of surgery. Therefore, this study was designed to analyze the perioperative management of patients undergoing laparoscopic hernia repair, performed as transabdominal preperitoneal patch hernioplasty (TAPP). Based on these results, the clinical management was optimized in order to shorten the length of stay without affecting the quality of treatment or the complication rate, and the effects of the optimization strategies were reanalyzed. METHODS: With ethics committee approval 249 patients undergoing TAPP procedures were investigated. In the first two study sections, problems of the perioperative management were identified first retrospectively (n=129) and then prospectively (n=60). Based on these results, the clinical management was then redesigned and optimized. A TAPP score was developed including the parameters age, ASA physical status, extent and severity of the procedure and postoperative pain level. Patients were scored 24 h after surgery, and clear-cut criteria were defined for discharge home on the second postoperative day. Furthermore, all patients received 10 mg of sodium picosulfate to avoid postoperative constipation. In the third study section (n=60) the impact of the optimization strategies on length of stay, need for pain medication, complication rate and patient satisfaction (based on the PPP33 questionnaire) was evaluated. RESULTS: Patients were on average approximately 60 years old (range 22-92 years), and demographic data were comparable within the study sections. As a result of the optimization process, 72% of the patients could be discharged home on the second postoperative day whereas previously that had only been possible in 5%. Accordingly, the postoperative length of stay (including the day of surgery) was significantly reduced from 4.2+/-0.6 to 3.3+/-0.6 days. By the administration of sodium picosulfate, 92% of all patients reported defecation on the first day after surgery, whereas previously the majority of patients (60%) had complained of constipation at this time. No serious complications were observed. The number of minor complications was very low in total and neither complication rate nor patient satisfaction was affected by earlier discharge. The second day after surgery was judged to be the ideal time point for discharge by 81% of all patients. CONCLUSIONS: This study demonstrates that the length of stay after laparoscopic hernia repair can be reduced by one day by relatively simple means without affecting patient satisfaction or the complication rate. Most important is the introduction of clear-cut criteria that allow an early decision-making for discharge home. Moreover, many patients complain of constipation after laparoscopic surgery, and this may prolong the length of stay. This problem can be solved completely by the standardized use of sodium picosulfate, administered on the evening after surgery.

Prophylactic thyroidectomy in 75 children and adolescents with hereditary medullary thyroid carcinoma: German and Austrian experience.

When mutations of the RETproto-oncogene were found in 1993 to account for hereditary medullary thyroid carcinoma (MTC), surgeons obtained the opportunity to operate on patients prophylactically (i. e., at a clinically asymptomatic stage). Whether this approach is justified, and, if so, when and to which extent surgery should be performed remained to be clarified. A questionnaire was sent to all surgical departments in Germany and Austria. All of the patients who fulfilled the following criteria were enrolled: (1) preoperatively proved RET mutation; (2) age

[Local antiseptic and anti-endotoxin measures in intra-abdominal infections]. / Lokale antiseptische und antiendotoxische Massnahmen bei intraabdominalen Infektionen.

With standardized operating strategies, a lethality rate of 10.2% was achieved following intra-abdominal administration of taurolidine in 352 cases of severe intra-abdominal infection. The extent and type of antibacterial therapy were determined on the basis of the clinical severity, the patient's age, and the original site of the infection. Local antisepsis includes tactical surgery and the use of locally and systemically acting taurolidine. Antibiotics were used for systemic antibacterial therapy. After laparoscopical clearance of the focus of infection (appendix, gall bladder) the operating time was significantly extended compared with that required for open surgery, while the postoperative complication rate and the length of stay in hospital were significantly reduced.

[Preventive thyroidectomy in hereditary medullary thyroid gland carcinoma]. / Die prophylaktische Thyreoidektomie beim hereditären medullären Schilddrüsenkarzinom.

Screening for hereditary medullary thyroid carcinoma (MTC) includes both calcitonin stimulation tests and DNA analysis. Positive results of these diagnostic procedures are indicators for the presence of neoplastic C-cell hyperplasia or an asymptomatic MTC. Thyroidectomy and lymphadenectomy of the first compartment are mandatory in both conditions even in young children.

[Differentiated cancers]. / Differenzierte Karzinome.

A total of 119 papillary and 67 follicular thyroid carcinomas were subdivided according to the WHO classification of 1988 in the morphological subtypes of occult, encapsulated and invasive carcinomas. The patients were monitored over a followup period of 16 years postoperatively. Initially 10.6% of all patients with early follicular carcinoma had distant metastases and 2 of 19 died of carcinoma. In cases of early papillary carcinoma there were no distant metastases and no deaths. Limited thyroid surgery is recommended as curative surgery only for such patients.

[Systemic antibiotic prophylaxis with metronidazole in elective colonic and rectal surgery. Results of a clinical controlled study and a critical literature review]. / Systemische Antibiotikaprophylaxe mit Metronidazol in der elektiven Kolon- und Rektumchirurgie. Ergebnisse einer klinisch-kontrollierten Studie und kritische Literaturübersicht.

The pathogen spectrum of wound infections in colon surgery is composed almost exclusively of facultatively aerobic and obligatorily anaerobic intestinal flora. A study was performed in which a one-shot prophylaxis was carried out by applying metronidazole, 500 mg i.v., or latamoxef (lamoxactam) 2 g i.v., on induction of anesthesia. The metronidazole group evidenced a 26.3% incidence of infections due exclusively to aerobic pathogens. In the latamoxef (lamoxactam) group, it was possible to achieve a reduction of the postoperative rate of wound infections to 11.1%. The study was prematurely terminated because of the high rate of wound infections in the metronidazole group and the exclusive selecting of aerobic pathogens.

Identification and susceptibility patterns of anaerobic bacteria isolated from clinical specimens during a one-year period.

During the whole of 1983, all anaerobes cultured from clinical specimens were identified using both the Minitek system and gas chromatography. Antimicrobial susceptibility patterns were established using a broth microdilution test. The results show isolation rates for the individual species to be in good agreement with previous studies. Despite widespread use (even for prophylactic purposes), mezlocillin, latamoxef, cefoxitin, metronidazole and clindamycin retained their high activity against anaerobic bacteria and no clusters of resistance were observed. Augmentan also showed excellent in vitro activity. Penicillin was found to be inactive against most gram-negative anaerobic rods while tetracycline showed a rather high degree of resistance.

[Thyroid function after peritoneal lavage with polivinylpyrrolidone-iodine solution in diffuse peritonitis]. / Die Schilddrüsenfunktion nach Peritoneallavage mit PVP-Jodlösung bei diffuser Peritonitis.

In 36 patients, intraoperative peritoneal lavage with PVP-iodine solution (26 patients) or with the iodine free chemotherapeutic agent Taurolin (10 patients) was performed because of peritonitis. Total iodine serum levels increased considerably after peritoneal lavage with PVP-iodine. In the early postoperative phase, the resorbed iodine was mostly present as iodide in serum. Iodine serum values returned to normal after 30 days. A decrease in T4 and T3 could be observed with a concomitant reciprocal increase of rT3 in the acute phase of peritonitis. Normalization of the thyroid hormone took place after 8 days. A stronger increase in T4 occurred temporarily in 2 of 5 patients known to have thyroid function disorders. These changes in thyroid hormone may also be considered as the consequence of the severe primary disease. Normalization of hormone values was clearly delayed after PVP iodine lavage. The possible risk of an iodine-induced thyrotoxicosis after intraperitoneal application of PVP-iodine is pointed out, and objections are made to using this therapy.

Nucleotide sequence of the cytochrome B gene and adjacent regions from rat liver mitochondrial DNA.

The nucleotide sequence of a 1.76 Kbp segment from rat liver mitochondrial DNA has been determined. It contains the gene for the cytochrome b apoprotein and the tRNA genes for threonine, glutamic acid, and proline. The arrangement of these genes in rat liver mitochondria is the same as in human (Anderson et al. 1981) or mouse (Bibb et al. 1981) mitochondria. The comparison of the cytochrome b sequences so far determined, reveals that several regions in these proteins are highly conserved.

Deletions and DNA rearrangements within the transposable DNA element IS2. A model for the creation of palindromic DNA by DNA repair synthesis.

Three derivatives of mutant ga10P-308::IS2-I of Escherichia coli were characterized by DNA sequence analysis. Deletions and DNA sequence rearrangements were observed which apparently were initiated at short A-T rich inverted repeats within IS2. Two of the mutants carried newly synthesized DNA sequences which were inverted copies of already existing IS2 sequences. Thus long stretches with twofold symmetry were formed. It is discussed whether these inverted repeats were formed by DNA repair synthesis which was initiated at the A-T rich palindromes of IS2.