[Procedure-specific postoperative gastrointestinal hemorrhage]. / Verfahrensspezifische postoperative gastrointestinale Blutungen.

Gastrointestinal bleeding (GIB) can occur as a complicating issue in the postoperative course after visceral surgery. It can be of varying clinical extent ranging from mild anemia to fatal hemorrhagic shock. Symptomatic manifestations of a GIB are hematemesis, melena and hematochezia. The GIB are fundamentally differentiated into upper and lower GIB. While upper GIB is defined as the occurrence of endoluminal hemorrhage above the ligament of Treitz, correspondingly the definition of lower GIB is intraluminal bleeding distal to the duodenojejunal flexure. Knowledge of their procedure-related incidence during the postoperative course enables a better assessment of the necessary intervention.

[Endoscopic management of complications after laparoscopic sleeve gastrectomy]. / Endoskopisches Komplikationsmanagement nach Schlauchmagenbildung.

Laparoscopic sleeve gastrectomy (SG) is currently the most commonly performed standalone bariatric procedure worldwide. Gastric staple line leakage is the feared immanent complication of the operation, which is difficult to treat and often persists. This article presents the endoscopic treatment options for complications after laparoscopic SG, particularly the treatment of gastric staple line leakage. Most important for a successful treatment is the understanding of the underlying pathophysiological causes, the exact surgical comprehension of the procedure and advanced endoscopic skills. The choice of endoscopic intervention depends on the available strategies as well as on the skills of the executing endoscopist. Currently, internal drainage seems to be the most expedient method.

[Bariatric surgery: Expectations and therapeutic goals-a contradiction?] / Bariatrische Chirurgie: Erwartungshaltung und Therapieziele ­ ein Gegensatz?

In the majority of patients with morbid obesity, metabolic/bariatric surgery leads to relevant and sustained weight loss and improves obesity-related comorbidities, quality of life and functionality. Moreover, the associated reduction of risk factors for cardiovascular events and cancerous diseases has been shown to improve life expectations. Due to its excellent antidiabetic effect, the currently valid national S3 guidelines now recommend metabolic/bariatric surgery in patients who have a body mass index (BMI) ≥30 kg/m2 with poorly controlled diabetes. The Edmonton staging system enables a multidimensional consideration of the severity grade of obesity for each individual patient independent of the BMI. Patients with relevant obesity-related metabolic comorbidities should be prioritized for treatment and if possible before the occurrence of end-organ damage that is at least in some cases irreversible and which also increases the perioperative risk. Therapeutic goals for each individual patient should be carefully defined preoperatively in order to mediate realistic expectations. Unrealistic expectations, such as "surgery solves my problems", "surgery makes me more beautiful", "surgery eliminates stigma", and "surgery guarantees success", are common in bariatric surgery patients. These unrealistic expectations can lead to frustration and to severe psychological decompensation and need to be addressed as early as possible by an interdisciplinary team. Redundancies, conclusive and empathic communication in the team improve therapy adherence, the expectations and therefore the overall outcome.

Active surveillance cultures: comparison of inguinal and rectal sites for detection of multidrug-resistant bacteria.

BACKGROUND: Rectal swabs are the most widely used surveillance technique for detecting multidrug-resistant bacteria colonizing the intestinal tract. Obtaining these samples may cause embarrassment and discomfort to patients. Prior studies indicate that perirectal swabs are as sensitive and specific as rectal swabs with greater patient acceptance. AIM: To compare inguinal and rectal swabs for the detection of multidrug-resistant bacteria colonizing the intestinal tract. METHODS: An epidemiological, comparative, prospective, and controlled study was undertaken with 102 Brazilian patients. Inguinal and rectal swabs were collected for culture and compared. FINDINGS: Compared to rectal swabs, the sensitivity and specificity of inguinal swabs was 91.8% and 88.7%, respectively. Even when there were low colony counts from rectal samples, there were more than 100 colonies from inguinal samples. CONCLUSION: The inguinal region can be considered an acceptable alternative for collecting surveillance cultures for multidrug-resistant bacteria colonizing the intestinal tract. The inguinal swab technique is sensitive and specific for assessing multidrug-resistant micro-organisms, less embarrassing for patients, and simple to implement in hospital practice.

[Anastomosis and suture insufficiency after interventions for bariatric and metabolic surgery]. / Anastomosen- und Nahtinsuffizienzen nach Eingriffen in der Adipositas- und metabolischen Chirurgie.

BACKROUND: Metabolic surgery is internationally well-established for the treatment of obesity and its comorbidities. The numbers of procedures performed is steadily increasing. The results of surgery are superior in comparison to conservative treatment options regarding weight loss and resolution of comorbidities. The insufficiency of suture lines is a well-known and feared complication in the stapling procedures and is associated with an increased morbidity as well as mortality, especially in super obese patients. MATERIAL AND METHODS: The current literature was reviewed and the results are reported within the context of own experience. RESULTS: The most severe complications are staple line leakage after sleeve gastrectomy, leakage of anastomoses after bypass procedures and duodenal stump insufficiency. For the treatment of sleeve leakage various endoscopic procedures, such as over the scope (OTS) clips, stents and endoluminal vacuum therapy are available. Surgical revision, such as oversuturing, drainage and redo surgery are well-established. The management of all other complications is mainly by surgical intervention. Intraoperative standardization of procedures and knowledge of the physical foundations are essential for the prevention of leakage. Several preventive methods are available but randomized controlled trials are missing. CONCLUSION: The therapy of leakages in the field of bariatric surgery is an interdisciplinary approach and dependent on the available resources in the treating hospital. The data reported show good results but the different reports published are inconsistent. Leakages often do not occur in the immediate postoperative period but in the sense of a long-term complication; therefore standardization of procedures and follow-up as well as complication management is mandatory. Randomized controlled studies must be promoted.

Review article: The nutritional and pharmacological consequences of obesity surgery.

BACKGROUND: Obesity surgery is acknowledged as a highly effective therapy for morbidly obese patients. Beneficial short-term effects on common comorbidities are practically undisputed, but a growing data pool from long-term follow-up reveals increasing evidence of potentially severe nutritional and pharmacological consequences. AIMS: To assess the prevalence, causes and symptoms of complications after obesity surgery, to elucidate and compare therapy recommendations for macro- and micronutrient deficiencies, and to explore surgically-induced effects on drug absorption and bioavailability, discussing ramifications for long-term therapy and prophylaxis. METHODS: PubMed, Embase and MEDLINE were searched using terms including, but not limited to, bariatric surgery, gastric bypass, obesity surgery and Roux-en-Y, coupled with secondary search terms, e.g. anaemia, micronutrients, vitamin deficiency, bacterial overgrowth, drug absorption, pharmacokinetics, undernutrition. All studies in English, French or German published January 1980 through March 2014 were included. RESULTS: Macro- and micronutrient deficiencies are common after obesity surgery. The most critical, depending on surgical technique, are hypoalbuminemia (3-18%) and deficiencies of vitamins B1 (≤49%), B12 (19-35%) and D (25-73%), iron (17-45%) and zinc (12-91%). Many drugs commonly administered to obese patients (e.g. anti-depressants, anti-microbials, metformin) are subject to post-operative and/or PPI-associated changes affecting bioavailability and absorption. CONCLUSIONS: Complications are associated with pre-operative and/or post-operative malnutrition or procedure-related changes in intake, absorption and drug bioavailability. The high prevalence of nutrient deficiencies after obesity surgery makes life-long nutritional monitoring and supplementation essential. Post-operative changes to drug absorption and bioavailability in bariatric patients cast doubt on the validity of standard drug dosage and administration recommendations.

[Long-term results of the anatomic stem "Euroform"]. / Langzeitergebnisse des anatomischen Titanhüftschaftes "Euroform"

PURPOSE: To date there is a lack of long-term results of anatomic hip stems in the literature. In this context we present our 10-year results with the hip stem "Euroform". METHODS: In a retrospective cohort study 90% of the 51 stems implanted in our institute in the years 1993/94 51 stems were reexamined. Of them 39 were implanted cement-free while 11 were cemented. RESULTS: After 10 to 12 years no revision surgery of the cement-free stems was necessary or performed because of stem problems, in one case of a cemented stem revision was done because of cup problems. The survival rate for the complete prostheses was 97.5% after 10 years and 92% after 12 years. The revision surgery was done for cup problems. The satisfaction rate was "1.9" (according to the German school ranking system), the Merle d'Aubigné score was "good" (>10 points). However, one problem was the high rate of PE deterioration which depended on the inclination. CONCLUSION: Both the cemented and the cement-free forms of the "Euroform" stem gives good long-term results. The longevity of the prostheses is limited by polyethylene wear.

Pathophysiological effects of aldosterone in cardiovascular tissues.

The advent of antihypertensive therapy has resulted in a significant decrease in cardiovascular morbidity and mortality. Nevertheless, the incidence of heart failure, stroke and end-stage renal failure continues to increase. This trend suggests that a mechanism, independent of hypertension, is responsible for end-organ damage. Genetic and experimental models of hypertension have demonstrated that excess aldosterone induces severe injury in the heart, brain and kidneys, and that pharmacological antagonism of aldosterone or adrenalectomy markedly reduces myocardial injury, cerebral hemorrhage and renal vascular disease. In clinical studies, plasma aldosterone levels have been shown to correlate with left ventricular hypertrophy, stroke and renal dysfunction. Moreover, aldosterone antagonism has been shown to reduce morbidity and mortality in patients with heart failure. Thus, an increasing body of evidence now indicates that aldosterone is an independent risk factor for cardiovascular disease.

Ifetroban sodium: an effective TxA2/PGH2 receptor antagonist.

This review presents a comprehensive discussion on the chemistry, pharmacokinetics, and pharmacodynamics of ifetroban sodium, a new thomboxane A2/prostaglandin H2 receptor antagonist. Thromboxane A2 is an arachidonic acid product, formed by the enzyme cyclooxygenase. In contrast to other cyclooxygenase products, thromboxane A2 has been shown to be involved in vascular contraction and has been implicated in platelet activation. In general, results of clinical studies and animal experiments indicate that hypertension is associated with hyperaggregability of platelets and increased thomboxane A2 levels in blood, urine, and tissues. The precursors to thromboxane A2, prostaglandin G2, and prostaglandin H2, also bind and activate the same receptors. Thus, a receptor antagonist was thought to be an improved strategy for reversing the actions of thromboxane A2/prostaglandin H2, rather than a thromboxane synthesis inhibitor. This review describes new methods for the synthesis and analysis of ifetroban, its tissue distribution, and its actions in a variety of animal models and disease states. We describe studies on the mechanisms of how ifetroban relaxes experimentally contracted isolated vascular tissue, and on the effects of ifetroban on myocardial ischemia, hypertension, stroke, thrombosis, and its effects on platelets. These experiments were conducted on several animal models, including dog, ferret, and rat, as well as on humans. Clinical studies are also described. These investigations show that ifetroban sodium is effective at reversing the effects of thromboxane A2- and prostaglandin H2-mediated processes.

Effect of preterm formula with and without long-chain polyunsaturated fatty acids on the urinary excretion of F2-isoprostanes and 8-epi-prostaglandin F2alpha.

BACKGROUND: The objective of this study was to evaluate the effect of conventional and long-chain polyunsaturated fatty acids (LCP)-enriched preterm formula on the endogenous formation of F2-isoprostanes and 8-epi-prostaglandin (PG) F2alpha as possible markers of lipid peroxidation in preterm infants during their first weeks of life. METHODS: In a prospective, randomized, double-blind study, infants received either formula enriched with LCP (n = 8), standard preterm formula (n = 7), or (expressed) breast milk (n = 8). Urine was sampled at study entry and after the study period of 3 weeks. The formation of F2-isoprostanes and 8-epi-PGF2alpha was evaluated by measuring the urinary excretion by gas chromatography-mass spectrometry. RESULTS: No differences in the urinary excretion of F2-isoprostanes and 8-epi-PGF2alpha were observed at the end of the study period. CONCLUSIONS: This result suggests that supplementation of a preterm formula with LCP for a period of 3 weeks does not stimulate lipid peroxidation in preterm infants.

Identification of severe and extensive coronary artery disease by postexercise regional wall motion abnormalities in Tc-99m sestamibi gated single-photon emission computed tomography.

Postexercise wall motion abnormality (WMA) in patients with normal resting myocardial perfusion may represent prolonged postischemic stunning, and may be related to the presence of severe angiographic coronary artery disease (CAD). This study assesses the diagnostic value of postexercise WMA by technetium-99m (Tc-99m) sestamibi gated single-photon emission computed tomography (SPECT) in patients with normal resting perfusion. Ninety-nine patients underwent exercise gated Tc-99m sestamibi/resting thallium-201 SPECT and coronary angiography within 90 days of nuclear testing. All patients had normal perfusion at rest. Multivariate logistic regression analysis demonstrated an incremental value of wall motion and perfusion over perfusion data alone in identifying severe and extensive CAD. Sensitivity for identifying any severely stenosed coronary artery by WMA was significantly higher than by severe perfusion defect (78% vs 49%, p <0.0001). Overall specificities of severe perfusion defect and WMA were 91% and 85%, respectively (p = NS). Thus, postexercise WMA detected by gated Tc-99m sestamibi SPECT in patients with normal resting perfusion is a sensitive marker of severe and extensive CAD.

Aldosterone: a mediator of myocardial necrosis and renal arteriopathy.

To determine the role of aldosterone in mediating cardiovascular damage, we performed ablation/replacement experiments with aldosterone in a rat model of cardiac injury. Administration of angiotensin II and Nomega-nitro-L-arginine methyl ester (L-NAME; nitric oxide synthesis inhibitor) to male rats drinking 1% saline caused hypertension, severe biventricular myocardial necrosis, proteinuria, and fibrinoid necrosis of renal and cardiac vessels. Removal of aldosterone by adrenalectomy or through administration of the selective aldosterone antagonist eplerenone markedly reduced the cardiac and renal damage without significantly altering blood pressure. Aldosterone infusion in adrenalectomized, glucocorticoid-replaced L-NAME/angiotensin II-treated animals restored damage. Thus, we identified aldosterone as a critical mediator of L-NAME/angiotensin II induced vascular damage through mechanisms apparently independent of its effects on systolic blood pressure.

Postexercise lung uptake of 99mTc-sestamibi determined by a new automatic technique: validation and application in detection of severe and extensive coronary artery disease and reduced left ventricular function.

UNLABELLED: This study validated a new automatic algorithm for assessment of lung-to-heart ratio (L/H) of radiotracers in myocardial perfusion SPECT and assessed the diagnostic value of (99m)Tc-sestamibi L/H after exercise. METHODS: The new technique extracts a left ventricular region of interest (ROI) from a summed anterior projection image and generates a lung ROI by reshaping and translating the left ventricular ROI. This algorithm was applied to 230 patients who underwent exercise (99m)Tc-sestamibi SPECT (gated SPECT, n = 88) with first-pass ventriculography. Normal values were established in 26 patients in whom the likelihood of coronary artery disease (CAD) was 5% or less. An abnormality threshold for detecting severe and extensive CAD was defined in a subgroup of 109 patients who underwent coronary angiography and was validated in a prospective group (n = 72). RESULTS: The success rate of the automatic algorithm was 97%. Excellent correlation was found between automatic and manual L/H values (r = 0.95; P < 0.001). The mean L/H was higher in patients with a peak exercise ejection fraction (EF) less than 40% versus 40% or more (0.51 +/- 0.07 versus 0.43 +/- 0.05, P < 0.001) and in patients with a poststress EF less than 40% versus 40% or more (0.50 +/- 0.07 versus 0.44 +/- 0.06, P < 0.01). A threshold of L/H greater than 0.44 yielded a sensitivity and specificity of 63% and 81%, respectively, for identifying severe and extensive CAD in the prospective group and a sensitivity of 86% in identifying stenosis of 90% or more in the proximal left anterior descending artery. CONCLUSION: The new automatic algorithm for assessing L/H correlated well with manually derived L/H for (99m)Tc-sestamibi as well as (201)TI SPECT. An increased postexercise (99m)Tc-sestamibi L/H adds significant diagnostic value to study myocardial perfusion SPECT as a marker of severe and extensive CAD and reduced ventricular function.

Inhibition of NOS enhances pulmonary vascular changes in stroke-prone spontaneously hypertensive rats.

To determine the effects of chronic nitric oxide (NO) blockade on the pulmonary vasculature, 58-day-old spontaneously hypertensive rats of the stroke-prone substrain (SHRSP) and Wistar-Kyoto rats (WKY) received N(omega)-nitro-L-arginine (L-NNA; 15 mg. kg(-1). day(-1) orally for 8 days). Relaxation to acetylcholine (ACh) in hilar pulmonary arteries (PAs), the ratio of right ventricular (RV) to body weight (RV/BW) to assess RV hypertrophy (RVH), and the percent medial wall thickness (WT) of resistance PAs were examined. L-NNA did not alter the PA relaxation, RV/BW, or WT in WKY. Although the PA relaxation and RV/BW in control SHRSP were comparable to those in WKY, the WT was increased (31 +/- 2 vs. 19 +/- 1%). L-NNA-treated SHRSP showed two patterns: in one group, the relaxation, RV/BW, and WT were comparable to those in the control SHRSP; in the other, impaired relaxation (36 +/- 7 vs. 88 +/- 4% for WKY) was associated with an increase in WT (37 +/- 1%) and RV/BW (0. 76 +/- 0.05). Thus the abnormal pulmonary vasculature in SHRSP at <10 wk of age is not accompanied by impaired relaxation in PAs or RVH; however, impaired relaxation is associated with increased WT and RVH.

One year's clinical experience of 18F-FDG PET with a modified SPET camera using molecular coincidence detection.

High-quality positron emission tomographic (PET) cameras are expensive and, therefore, not available in many centres. To allow access to clinical 18F-fluorodeoxyglucose (18F-FDG) PET, we began working with an ADAC Vertex camera equipped with a molecular coincidence detection (MCD) module in February 1997. Here we give a preliminary assessment of the clinical utility of our approach. To date, 109 studies have been performed in MCD-mode using standardized protocols (99 oncology cases, 10 neurology cases). Twenty-eight cardiological and 15 other studies were performed using 511 keV collimators without attenuation correction. The average dose of 18F-FDG for MCD studies was 150 MBq, thus avoiding overloading the detectors; cardiac studies required 370 MBq. The results obtained were carefully compared with computed tomography, magnetic resonance imaging, myocardial perfusion scans, coronary angiography and conventional radiology. The results were compared on a patient basis, including histology, surgical notes, autopsy reports and follow-up data. Oncological studies were performed to assess malignancy in a particular lesion (n = 22), staging of cancer (n = 57) or to evaluate whether therapy had been successful or not (n = 20). Indications for conducting studies were categorized as appropriate (Ia) or adequate (Ib). For Ia category cases, the results were: true-positive = 31, true-negative = 12 and false-positive = 2. For Ib category cases, the corresponding figures were: true-positive = 18, true-negative = 10, false-positive = 3 and false-negative = 1. False-positive studies were a result of inflammatory disease or artefacts. Six cases with temporal lobe epilepsy were correctly identified. In cardiac studies, we also found a good correlation with clinical parameters (i.e. hibernating myocardium or scarred tissue). Altogether, this cost-effective set-up allows nuclear medicine institutions to obtain valuable data in clinical practice with a system used both for single photon emission tomography and PET.

Role of aldosterone in renal vascular injury in stroke-prone hypertensive rats.

Stroke-prone spontaneously hypertensive rats (SHRSP) on 1% NaCl drinking solution and Stroke-Prone Rodent Diet develop severe hypertension and glomerular and vascular lesions characteristic of thrombotic microangiopathy seen in malignant nephrosclerosis. We recently reported that spironolactone, a mineralocorticoid receptor antagonist, markedly reduced proteinuria and malignant nephrosclerotic lesions in these animals. This observation, together with our previous findings that angiotensin-converting enzyme inhibitors prevent the development of vascular damage, suggests that mineralocorticoids, as part of the renin-angiotensin-aldosterone system, play a pathophysiological role in this model. In the present study, we examined whether chronic (2-week) infusion of aldosterone can reverse the renal vascular protective effects of captopril in SHRSP. SHRSP received vehicle (n=8); captopril alone (50 mg. kg-1. d-1, orally) (n=10); aldosterone infusion alone (40 microg. kg-1. d-1, SC) (n=7); or captopril and aldosterone at 20 (n=6) or 40 (n=7) microg. kg-1. d-1. Systolic blood pressure was markedly elevated in all groups. Vehicle- and aldosterone-infused SHRSP developed severe proteinuria and comparable degrees of renal injury (21+/-3% and 29+/-3%, respectively) manifested as thrombotic and proliferative lesions in the arterioles and glomeruli. Captopril treatment reduced plasma aldosterone levels concomitant with marked reductions in proteinuria and the absence of histologic lesions of malignant nephrosclerosis. Aldosterone substitution at 20 or 40 microg. kg-1. d-1 in captopril-treated SHRSP resulted in the development of severe renal lesions (16+/-3% and 21+/-2%, respectively) and proteinuria comparable with that observed in SHRSP given either aldosterone or vehicle alone. These findings support a major role for aldosterone in the development of malignant nephrosclerosis in saline-drinking SHRSP, independent of the effects of blood pressure.

Thallium-201 gated single-photon emission tomography for the assessment of left ventricular ejection fraction and regional wall motion abnormalities in comparison with two-dimensional echocardiography.

Simultaneous assessment of myocardial perfusion and function by gated single-photon emission tomography (GS) after a single tracer injection provides incremental information and is feasible with technetium-99m sestamibi. The present study validated the use of GS with thallium-201 for the assessment of left ventricular ejection fraction (LVEF) and regional wall motion by comparison with two-dimensional (2D) echocardiography (echo), which has not been done before. After injection of 111 MBq 201Tl at peak bicycle exercise (n = 55) or pharmacological stress (n = 17), GS was acquired 15 (post stress) and 120 min post injection (rest) on a double-head camera. An automatic algorithm (QGS) was used for processing. Echo (Acuson Sequoia C256) was performed immediately after rest GS. LVEFs assessed by GS and echo were correlated. The overall and segmental sensitivity and specificity of GS for the detection of regional wall motion abnormalities (WMAs) were calculated, echo serving as the gold standard. Perfusion abnormalities were scored. The success rate of the automatic algorithm was 100%, and visually assessed image quality was good to excellent in 88% of cases. Post-stress and rest LVEF as assessed by GS were highly correlated (r = 0.91). Good correlations were obtained between post-stress LVEF (GS) and rest LVEF (echo) and between rest LVEF (GS) and rest LVEF (echo) (r = 0.76 and 0.86 respectively). In patients with a reduced LVEF of less than 50% (n = 23), these correlations were even better (r = 0.84 and 0.89 respectively). Regional wall motion abnormalities (WMAs) were identified by GS with high sensitivity and specificity (88%-100% and 82%-98% respectively) and were directly related to the extent and severity of stress as well as of resting perfusion defects. It is concluded that GS with 201Tl is a feasible and reliable tool for the evaluation of patients with compromised left ventricular function in the context of coronary artery disease, and thus improves diagnosis and prognostic stratification. Regional WMAs were identified with high diagnostic accuracy and the method may prove helpful for the detection of myocardial viability.