Is Toupet fundoplication the procedure of choice for treating gastroesophageal reflux disease? Results of a prospective randomized experimental trial comparing three major antireflux operations in a porcine model.

BACKGROUND: Gastroesophageal reflux disease (GERD) is among the most common dysfunctions of the upper gastrointestinal tract. It interferes with quality of life and is a risk factor for the development of adenocarcinoma in the lower esophagus. Laparoscopic fundoplication is an effective treatment of GERD, but the physiologic mechanisms of the different available procedures had not been investigated to date. METHODS: In this study, 28 German Landrace pigs underwent baseline manometry and 24-h pH monitoring followed by myotomy to induce reflux esophagitis. After new-onset reflux was proved, the pigs were randomized to groups based on four treatments: total fundoplication, anterior hemifundoplication, posterior hemifundoplication, and control. On days 10 and 60 after the intervention, the effectiveness of the different fundoplication modifications was compared with that of the control subjects by 24-h pH monitoring manometry. Finally, the pigs were killed, after which the minimum volume and pressure required to breach the gastroesophageal junction were recorded. RESULTS: After myotomy, a significant increase in the reflux could be confirmed. The findings after fundoplication showed a significant decrease in the fraction of time that the pH fell below four and an increase in the vector volume compared with the measurement after myotomy. Total fundoplication and posterior hemifundoplication were highly effective, whereas measurements after anterior fundoplication still showed increased fraction times. Pharmacologic stimulation with pentagastrin showed an increase in the vector volume of the esophageal sphincter. CONCLUSIONS: Total fundoplication and posterior hemifundoplication are potent operations for the treatment of GERD. Anterior hemifundoplication reduces the reflux as well, but the effects are significantly less than with total and posterior fundoplication. Pharmacologic stimulation showed excellent results after posterior hemifundoplication, and a tendency to overcorrection was shown after total fundoplication.

Value of repeat resection for survival in pulmonary metastases from soft tissue sarcoma.

BACKGROUND: Pulmonary metastasectomy in soft tissue sarcoma (STS) can lead to long-term survival. The aim of our study was to report on prognostic factors and the value of repeat resection in recurrent disease. PATIENTS AND METHODS: Seventy-eight pulmonary metastasectomies were performed on 42 STS patients from 1990 to 2005. Overall survival time and 3-year survival rate were evaluated. Subgroup analysis was performed on age, primary tumor stage, histological type and grade, occurrence and recurrence pattern, systemic treatment and number of resections. RESULTS: The 3-year actuarial survival rate was 31%. Primary tumor grade and repeat resections were shown to be independent prognostic factors for survival. CONCLUSION: Patients with repeat resections due to recurrent metastasis show a significantly better prognosis than those with only one resection. Thus, lacking randomised controlled data of the natural course of patients with unresected lung metastases to compare these results, metastasectomy in STS patients is also recommended in recurrent disease.

Ileoanal-pouch reconstruction does not impair sphincter function or quality of life.

BACKGROUND/AIMS: A retrospective trial with regard to continence function and quality of life was conducted in patients who had undergone proctocolectomy and ileo-anal-pouch (IAP) reconstruction for ulcerative colitis (UC) or familial polyposis (FAP), and continence function was compared to patients under conservative treatment for UC. The aim of the study was to evaluate, if proctocolectomy and IAP differed in quality of life and sphincter function from those patients with chronic UC who were not operated on. METHODOLOGY: 50 patients were included in this study: 25 patients had undergone proctocolectomy and ileo-pouch-anal-anastomosis (IPAA) for UC (n=13) or FAP (n=12). The control group included 25 patients under medical treatment for UC (n=25). Anal manometry was performed and quality of life questionnaires were evaluated. RESULTS: No significant differences in maximum basal and squeeze pressure were found. There was a significantly later pouch perception in the patient group (55mL in patients vs. 39mL in controls; p = 0.0054) as well as a significantly greater stool frequency (6 vs. 4 per day; p = 0.0018) and a shorter high pressure zone in the patients' group (25 mm vs. 35 mm; p < 0.0001). Patients demonstrated superior but not significantly better values for Gastrointestinal Quality of Life Score (GLQI) and Activity Index (AI). Furthermore, there was a significant negative correlation between perception values and GLQI (p = 0.014) and AI (p = 0.04) in this group, indicating that the later the perception the worse the Quality of Life and Activity Index. CONCLUSIONS: Proctocolectomy combined with IPAA neither deteriorates anorectal function nor quality of life compared to conservatively treated controls. These data support that prophylactic proctocolectomy in patients who are at high risk for the development of colorectal cancer can be performed at an early stage of the disease.

[The new curriculum for surgery in Hamburg, Germany]. / Integrierte operative Medizin: Die studentische Ausbildung in der Chirurgie in Hamburg.

In October 2004, the medical faculty of Hamburg University started a program to restructure completely clinical teaching according to new state regulations of June 2002. In this new curriculum design, the surgical disciplines were horizontally and vertically interconnected and integrated, with a focus on practical training and problem-based teaching. This study describes the concept of clinical teaching and presents the student evaluation results of the first four blocks with a focus on performance in surgical disciplines. There was high student satisfaction with the new program, compared with results before October 2004 and also with respect to other disciplines within the new curriculum. This was especially true for the practical courses in the newly established skills lab. Future developments in e-learning and practical teaching in the skills lab are necessary to overcome restrictions on medical education due to changes in the German health care system.

One year of experience with extended application and modified techniques of split liver transplantation.

As organ donation rates decreased in Europe, the authors started a systematic approach of liver splitting in their center in 1994. During this 1-year experience, 73 cadaveric liver transplantations were performed in 66 patients. Sixteen of these transplantations were the result of split-liver transplantation (21.9% of grafts, 24.2% of patients). Patient and graft survival rates at 3 months were 81.2% and 75%, compared with 89.1% and 76.9 % for whole organs. Two modified techniques were developed, based on the technique of living related liver procurement, and applied in 10 cases. With these new techniques, patient and graft survival rates were 90% and 90%. This systematic approach allowed the total number of transplantations in our program to be maintained, despite the decrease in organ availability.

Ambulatory long-term pH monitoring in pigs.

BACKGROUND: pH monitoring has been established as the "gold standard" in the diagnosis of gastroesophageal reflux. Evaluation of experimental antireflux therapy should therefore also include this technique, but a suitable technique in an experimental model did not exist so far. The aim of our study was to establish a reliable method for the evaluation of an experimental reflux model in pigs. METHODS: A total of 33 German Landrace pigs with an average body weight of 56 (50.2-67.2) kg were included. pH monitoring was performed before and after open cardiomyotomy in each animal. All manipulations were performed under general anesthesia. After manometric localization of the gastroesophageal high-pressure zone, a standard pH probe was inserted into the pharynx through a small needle-punctured canal on the side of the animal's snout and placed under endoscopic guidance with the proximal sensor 3 cm above the lower esophageal sphincter (LES) and the distal sensor in the stomach for reference. The harness to carry the pH recorder on the animal's back consisted of a modified belly strap that enabled the animal to move around without limitation. For analysis the same threshold levels were defined as in humans. Gastroesophageal reflux was induced by cardiomyotomy. RESULTS: The placement of the standard pH probe was possible in all cases. Inserting the probe on the side of the snout left the animals free to nuzzle, which complies with the normal habits of pigs, without breaking the probes and without being compromised in their natural behavior. Repeated punctures for multiple measurements were easily feasible. We performed up to three examinations in each individual animal. Recording was performed for 48 h. A mean number of 67.3 (+/-9.7) acidic refluxes were registered. The mean number of long acidic refluxes was 3.2 (+/-0.75). For an average total time of 75.5 (+/-14.3) min the pH was below 4 accounting for a fraction time pH below 4 of 3.5% (+/-0.68%). Following cardiomyotomy the number of acidic refluxes increased significantly to 166.1 (+/-21.8) and the number of long refluxes to 17.74 (+/-3.35). The total time of pH below 4 increased to 371.3 (+/-62) min so that the fraction time pH below 4 was 14.5% ( p = 0.0006). CONCLUSION: pH monitoring should be mandatory in any investigation of antireflux therapy. Our method is easy and secure to perform. It is suitable for other gastrointestinal investigations (Bilitec, long-term manometry) that could be carried out using the same technique. The described data represent the basis for other investigations of experimental antireflux therapy.

Anti-TNF antibody treatment has no positive effect on survival in a model of pneumococcal sepsis in pigs.

Gram-positive organisms causing sepsis have gained more significance in the past years. Especially patients with acquired immunodeficiency have been shown to be at risk for gram-positive infections. The mortality in Streptococcus pneumoniae bacteremia has been shown to be as high as 20%. Tumor necrosis factor-alpha (TNF-alpha) plays a crucial role in the "sepsis cascade." The previously described positive effect of monoclonal TNF antibody (anti-TNF-mAb) in gram-negative sepsis should be controlled in gram-positive pneumococcal sepsis. In a porcine model, pneumococcal sepsis was induced, and the course and outcome of a group treated with anti-TNF-mAb were compared to those of an untreated control. Streptococcus pneumoniae serotype 6 B was isolated from patients with systemic infection. The isolates were prepared, cryopreserved at -80 degrees C, and recultivated in a standardized fashion as needed. Then 10(9) bacteria were injected intravenously. Pigs of the German Landrace type with a weight of 20-30 kg were anesthetized using standardized midazolam and ketamine intravenous anesthesia. After introduction of central venous, arterial, and urinary catheters, bacteria were injected intravenously via the ear vein. In the therapy group, animals were treated with anti-TNF-mAb (5 mg/kg body weight) intravenously immediately prior to pneumococci injection. Survival and survival times were primary endpoints. Biochemical and vital parameters were also compared. In the anti-TNF-mAb group, 4/11 animals died (35%), compared to 6/11 (55%) in the control group. The mean survival times were 11 and 10 h, respectively (n.s.). TNF levels were significantly different. The TNF peak at 90-240 min was not present in the anti-TNF group (340 pg/ml vs. 19 pg/ml, p = .034). Leukocyte counts differed also significantly. After an initial drop in both groups, we observed a leukocytosis of up to 32.8 +/- 5.0 g/L in the anti-TNF-group, while in the control group leukocyte counts remained below 15.0 g/L (13.3 +/- 3.0 g/L, p = .007). All other parameters did not differ significantly. Thus, anti-TNF-mAb effectively suppresses the TNF peak following gram-positive septicemia. In the presented setting, these effects did not influence overall survival or survival times.

["Multimedia symposium wares". An enrichment of medical and graduate education?]. / "Multimediale Symposiumsware". Eine Bereicherung der Aus- und Weiterbildung?

The continual development of the internet has supported the spread of surgical knowledge by electronic means. High quality products have to be offered from a software as well as a contents point of view. The question as to whether these new media and their contents have a real value for efficient and motivating use in medical education needed to be answered by first assessing a quality profile for the development of surgical educational modules which were then evaluated on the basis of so-called "symposia ware". First, the reactions and opinions of physicians at 47 universities were assessed by a standardized questionnaire concerning their demands on multimedia teaching/learning modules. Several different aspects of technique, content, presentation, didactics and background knowledge were analyzed. In a second step, their opinions were evaluated concerning two applications (symposia implemented on CD-ROM as a slideshow with original slides and audio) with surgical and gastroenterological contents by standardized questionnaire. Questions concerning personal background such as educational status and experience with computers, e-mail and the internet on one hand and the CD-ROM itself concerning content, relevance for daily clinical work and continuing medical education as well as the quality of the application on the other hand, were evaluated using marks (1 = best, 6 = worst). A total of 320 physicians participated in the first part of the interview. Of these, 93% were equipped with computers in hospital as well as privately. The Internet was used by 90% of them. The majority declined a full text presentation as well as the application of scroll fields. The participants rather favored the integration of text, pictures, animations and videos. Furthermore, 95% demanded the provision on the internet. Thirty-seven colleagues in their 5th (1-11) year of training were interviewed, and of those, 27 were working in a surgical department and 10 in a medical department. Individual computer knowledge was rated with a median of 3. This revealed that 60% were equipped with computers in hospital as well as at home, the remaining 40% had computers either in hospital or at home. All participants used the internet. In total, 57% had experience with "Symposia ware". The rating of the "Symposia ware" itself was positive. Relevance and applicability of a slideshow for imparting knowledge were rated with a median of 2. This showed that 81% would buy the CD-ROM in principle, and 89% would spent up to 50 EUR. Quality, language, content and user-friendliness were all rated 2. Physicians frequently use computers and the internet. All this indicates a high degree of acceptance of electronic teaching/learning modules in medical education. A uniform structure of contents as well as a platform-independent, web-based presentation is appreciated. To enhance illustration, a picture and video-oriented visualization should be chosen. Overall, "symposia ware" is rated positively. It should cost no more than 50 EUR and it represents a valuable source of information for physicians.

[Is the stapled suture in visceral surgery still justified? A prospective controlled, randomized study of cost effectiveness of manual and stapler suture]. / Ist die Klammernaht in der Visceralchirurgie noch gerechtfertigt? Eine prospektiv kontrollierte, randomisierte Studie zur Kosteneffektivität von Hand- und Klammernaht.

Hospitals are facing increasing economic pressure. It therefore seems necessary to evaluate the efficiency and effectiveness of medical or surgical interventions. In this study 324 anastomoses (167 stapled and 157 hand-sewn) were performed after randomization during 200 elective operations [20.5% gastrectomies, 14% gastric resections (Billroth II), 15% Whipple's procedures, 4% segmental colonic resections, 18% right-sided hemicolectomies, 4% left-sided hemicolectomies, 22% sigmoid- or anterior rectal resections, 2.5% total colectomies with pouch-anal anastomoses] in 200 patients. Postoperative motility (time to full oral diet, time with naso-gastric tube) and hospitalization were comparable in both groups. Anastomotic insufficiency was observed in 2.1% of all patients, five after stapled and two after hand-sewn anastomoses. Hospital mortality was 1.5%. All stapled anastomoses were performed significantly (P < 0.001) faster. However, the cost of material for these anastomoses was significantly (P < 0.001) higher, resulting in significantly higher total costs for reconstruction. The time saving for the reconstruction did not influence the total operative time (except for stapled gastrectomy). Therefore, all operations with stapled reconstruction were more expensive than those with sutured reconstruction. The difference was significant for the gastrectomy (P < 0.01), colonic resection (P < 0.01) and sigmoid and rectal resection (P < 0.001) groups. Stapled and sutured anastomoses are equally effective. Stapled anastomoses are not efficient, however, and should be reserved for individual indications.

Effective treatment of symptomatic gastroesophageal reflux disease by laparoscopic fundoplication.

Full text is available as a scanned copy of the original print version.

[The route of reconstruction following esophagectomy]. / Die Rekonstruktionsroute nach Osophagektomie.

The route of reconstruction following esophagectomy.Retrosternal reconstruction shows an increased rate of postoperative non-surgical complications and a slightly increased mortality compared to posterior mediastinal reconstruction. Radionuclid transit through the gastric tube is significantly longer in either way of reconstruction compared to normal controls. Tracerretention is significantly increased after retrosternal reconstruction. This however has no impact on the patients' quality of life. We therefore recommend posterior mediastinal reconstruction provided that curative resection is definitely achieved in order to avoid possible complications by local recurrence. In the palliative situation we would rather choose the retrosternal route of reconstruction as the functional disadvantages had no negative effect on quality of life and the general disadvantages seem to be neglectable in this situation. The same is true if adjuvant radiation of the tumorbed is planned. Pyloroplasty in our opinion is unnecessary. The presternal route of reconstruction is underrepresented in the literature. In our experience it has no indication.

[Multi-media CD-ROM: a new medium for improving information dissemination]. / Multimedia CD-ROM: Ein neues Medium zur Verbesserung der Wissensvermittlung.

New media can be used in medicine for effective and prompt imparting of knowledge. We present a multimedia CD-ROM providing up to date congress information.

[Intussusception after Billroth II procedure--an uncommon cause of an upper gastrointestinal ileus]. / Invagination der abführenden Schlinge nach Billroth-II-Operation - seltene Ursache eines hohen Ileus.

We present a case of a 73-year-old male patient with Korsakow's disease who was admitted with upper gastrointestinal bleeding and recurrent vomiting. He had received partial gastric resection with Billroth II reconstruction 39 years before for recurrent ulcer disease. At gastroscopy erosive gastritis with no active bleeding and a structure-resembling necrotic mucosa suspicious for intussuscepted small bowel was seen. At exploratory laparotomy jejunogastric intussusception of 50 cm of small bowel through Braun's enteroanastomosis into the gastric remnant was found. After reposition the bowel recovered well and resection was unnecessary. As prophylaxis the bowel was partially attached by sutures in terms of a partial Noble's Operation. The patient's recovery was uneventful after surgery. Jejunogastric intussusception is a rare cause of upper gastrointestinal bleeding and ileus.

How important is the route of reconstruction after esophagectomy: a prospective randomized study.

OBJECTIVE: A prospective randomized trial was performed to compare retrosternal and posterior mediastinal gastric tube reconstruction with regard to postoperative function and quality of life. METHODS: Twenty-six patients were randomly allocated to either retrosternal (n = 14) or posterior mediastinal (n = 12) reconstruction after gastric tube formation. Radionuclide transit studies were applied to obtain objective functional data and a standardized quality-of-life assessment was performed. RESULTS: Retrosternal reconstruction showed an increased morbidity (15 vs 13 major complications) and mortality (14.2 vs 8.3%). Radionuclide clearance in the supine position was delayed in the gastric tube in general, compared with normal controls (retention index > 40% vs < 10%). There was a significantly higher retention (p < 0.005) in the retrosternal group in the middle third of the tube and the whole tube after intake of the liquid tracer. The retention of the first solid tracer was also higher in the retrosternal group in the middle third of the tube (p = n.s.) and was significantly higher in the whole tube after 30 (p < 0.05) and 60 (p < 0.01) s. This had no significant impact on the patients' quality of life. CONCLUSIONS: The posterior mediastinal route of reconstruction is recommended but curative resection (R0) is mandatory to avoid possible complications due to local tumor relapse. After incomplete resection (R1 or R2) we recommend retrosternal reconstruction for better palliation.

Surgical treatment of piles: prospective, randomized study of Parks vs. Milligan-Morgan hemorrhoidectomy.

PURPOSE: The present prospective, randomized clinical trial compares the outcome of surgical hemorrhoidectomy according to Parks and Milligan-Morgan in terms of hospital stay, duration of incapacity to work, symptom relief, length of morbidity, and patient convenience. METHODS: Thirty-four consecutive patients with third or fourth degree internal hemorrhoids were randomly allocated to the two groups. Before surgery, all patients were interviewed using a standard questionnaire, followed by rectal examination. All patients underwent a follow-up interview and examinations 1, 2, 4, 8, and 12 weeks after the operation. RESULTS: No serious postoperative complications were seen. Length of hospital stay (3.2 days for Parks hemorrhoidectomy vs. 4.6 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 0.2 and 2.6, respectively; P = 0.02) and mean duration of incapacity to work (12.3 days for Parks hemorrhoidectomy vs. 20.2 days for Milligan-Morgan hemorrhoidectomy; 95 percent confidence interval, 5.7 and 10.2, respectively; P < 0.001) differed significantly between the Milligan-Morgan and Parks patients. Until two weeks after the operation, Milligan-Morgan hemorrhoidectomy patients experienced significantly more pain. CONCLUSIONS: Our study confirms that both operations are safe, easy to perform, and lead to satisfactory results. However, the Parks procedure is the preferred option, because it minimizes patients' postoperative discomfort, is more economic, has a significantly reduced hospital stay, and has a shorter time for return to work.